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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3900
} | Medical Text: Admission Date: [**2182-10-10**] Discharge Date: [**2182-10-18**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a [**Age over 90 **] year-old right-handed Lithuanian only speaking
woman with no significant PMH save for arthritis (per HCP who
goes to [**Name (NI) 48924**] visits with her)who initially presented at
around 11am after taking a fall at home at around 10:30. She
was brought in by EMS and was felt to be neurologically intact
when examined with a Lithuanian interpreter at around 2pm. She
had said "Hospital" in english. She didn't initally know the
date or time. The nurse caring for her did not feel that even
with the interpreter that the patient could ever produce 5
consecutive words. At 2:20pm her BP was 204/60 and she was
given 10mg IV labetolol. Her BP decreased to 180s/60s. She was
then noted by the niece (who just arrived - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 79715**] -
1-[**Telephone/Fax (1) 79716**]) at around 2:30 to be weak in the right hand and
not paying attention to her right. Her verbal output was also
diminished. The nurse was called and the ED physician
[**Name9 (PRE) 31042**] calling [**Name Initial (PRE) **] code stroke at 2:39.
Past Medical History:
Arthritis.
Per the HCP [**First Name5 (NamePattern1) **] [**Name (NI) 79717**] - 1-[**Telephone/Fax (1) 79718**]) the patient had
a major medical workup 1 year ago that didn't reveal CAD (as was
once thought in the ED.) He also denied HTN (also mentioned in
the ED). In fact Mr. [**Name14 (STitle) 79717**] said she has low blood pressure.
Social History:
Lives in [**Location **] with Mr. [**Last Name (Titles) 79717**]. No ETOH, Drugs or tobacco.
Family History:
NC
Physical Exam:
On admission:
Temp: 99.2; BP: 204/60 -> 183/61; HR: 70s; RR: [**10-26**];
SaO2:100%RA
Gen: Alert, elder woman in C-collar. Sclerae anicteric. MMM. No
meningismus.
Lungs clear bilaterally.
Heart regular in rate.
Abd soft, nontender, nondistended. Bowel sounds heard
throughout.
Neuro:
>>MS??????Alert. With niece translating could follow intermittent
commands (looking l/r; lifting left arm; indicating whether she
felt light touch). English speech limited to "ouch" and "yes".
In Lithuanian, pt would repeat questions but not name or follow
multi-step commands.
>>CN??????PERRL. No threat blink on right. No ptosis. EOMI w/ smooth
pursuit. Facial sensation and pterygoid strength intact. Facial
mm intact. Tongue protrudes midline.
>>Motor??????LEFT UE/LE [**5-13**] w/ nl tone. RIGHT UE postures to nox
stim; no spontaneous movement; tone increased. RIGHT LE
withdraws (MRC 3+) to nox stime; no spont movement; tone normal.
>>Sensory??????withdraws/grimaces briskly to nox stim throughout.
>>DTRs??????L/R: bic [**2-9**]+, br [**2-9**], tri [**2-9**]; pat [**2-9**], Ach 0/0. Right
plantar extensor.
>>Coord/Gait??????Not tested.
NIHSS: At : 2:50 pm in the admission - performed with the Niece
in Lithuanian.
Total score 21-22
1a =2
1b =2
1c =2
2 =1
3 =[**1-9**] - unclear if complete or partial hemianopia with blink
only.
4 =0
5a =4
5b =0
6a =3
6b =0
7 =0
8 =0
9 =3
10 =2
11 =1
Repeat NIHSS at 4pm. - performed with the Niece in Lithuanian.
Total score 13-14
1a =2
1b =1
1c =0
2 =0
3 =[**1-9**] - unclear if complete or partial hemianopia with blink
only.
4 =0
5a =4
5b =0
6a =3
6b =0
7 =0
8 =0
9 =2
10 =0
11 =0
Discharge physical exam: awake, interactive, following simple
commands. Simple english naming is intact, answers
appropriately. Dense right hemiplegia, sparing the face.
Pertinent Results:
[**2182-10-10**] 11:30AM BLOOD WBC-5.4 RBC-4.09* Hgb-12.8 Hct-36.9
MCV-90 MCH-31.3 MCHC-34.7 RDW-13.3 Plt Ct-343
[**2182-10-10**] 11:30AM BLOOD PT-13.9* PTT-26.2 INR(PT)-1.2*
[**2182-10-11**] 02:59AM BLOOD Glucose-103 UreaN-23* Creat-1.1 Na-142
K-3.7 Cl-107 HCO3-26 AnGap-13
[**2182-10-11**] 12:05PM BLOOD ALT-14 AST-19 LD(LDH)-202 AlkPhos-73
Amylase-18 TotBili-0.5
[**2182-10-10**] 11:30AM BLOOD Lipase-11
[**2182-10-10**] 09:31PM BLOOD cTropnT-<0.01
[**2182-10-11**] 02:59AM BLOOD cTropnT-<0.01
[**2182-10-11**] 12:05PM BLOOD cTropnT-<0.01
[**2182-10-11**] 02:59AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.6 Cholest-184
[**2182-10-11**] 02:59AM BLOOD %HbA1c-6.5*
[**2182-10-11**] 02:59AM BLOOD Triglyc-107 HDL-42 CHOL/HD-4.4
LDLcalc-121
[**2182-10-10**] 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Relevant lab results for discharge:
[**2182-10-15**] 06:35AM BLOOD WBC-7.5 RBC-3.61* Hgb-11.5* Hct-32.8*
MCV-91 MCH-31.8 MCHC-35.0 RDW-13.7 Plt Ct-345
[**2182-10-15**] 06:35AM BLOOD Plt Ct-345
[**2182-10-15**] 06:35AM BLOOD PT-41.5* PTT-41.6* INR(PT)-4.5*
[**2182-10-14**] 03:29AM BLOOD PT-23.5* PTT-63.9* INR(PT)-2.3*
[**2182-10-13**] 05:13PM BLOOD PT-18.6* PTT-65.7* INR(PT)-1.7*
[**2182-10-15**] 06:35AM BLOOD Glucose-98 UreaN-20 Creat-1.2* Na-139
K-4.3 Cl-106 HCO3-26 AnGap-11
[**2182-10-14**] 03:29AM BLOOD Glucose-143* UreaN-15 Creat-1.1 Na-138
K-4.1 Cl-105 HCO3-26 AnGap-11
[**2182-10-13**] 05:13PM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-142
K-3.5 Cl-112* HCO3-22 AnGap-12
[**2182-10-12**] 10:10AM BLOOD CK(CPK)-101
[**2182-10-15**] 06:35AM BLOOD Calcium-9.2 Phos-3.8 Mg-1.9
Trauma XRay: The examination is limited due to overlying spinal
board and fixators. Within these limitations, there is no
displaced rib fracture or pneumothorax. The lungs are clear. The
cardiomediastinal silhouette appears unremarkable.
Limited assesment due to spinal board. Degenerative changes are
seen at the hip joints. There is no definite fracture
identified.
CTA/CTP [**10-10**]:
CTA: Attenuationa nd markedly decreased caliber of the M1
segment of the left middle cerebral artery with attenuation and
paucity of the M2 branches.
CTP: Large area of elevated MTT in the left MCA territory with
relatively well preserved blood volume in the periphery
indicating ischemia. However, the abnormality extends beyond the
area included on the present study.
Area of low blood volume in the left parasagittal parenchyma in
the higher
slices is not adequately assessed as the abnormality is in the
watershed
zone. Acute infarcts in this location or in areas not included
on the present study cannot be excluded. To consider MR head
with DWI for better assessment.
Echo: Suboptimal image quality - poor echo windows. The rhythm
appears to be atrial fibrillation. The left atrium is mildly
dilated. The right atrium is moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). No masses or
thrombi are seen in the left ventricle. 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 leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Repeat CT of head [**10-12**]: Evolving left anterior cerebral artery
territory infarction without evidence of hemorrhagic
transformation. No new abnormalities identified.
Brief Hospital Course:
Ms. [**Known lastname 79719**] is a [**Age over 90 **]yo Lithuanian speaking RHW without
significant PMH who presented with fall and transient right
sided weakness with recrudescence of weakness noted ~4h later.
It is unclear whether vessel occlusion/weakness prompted the
fall. She was found to have a left ACA occlusion with some left
MCA involvement. Her family declined intervention with IA tPA.
She was admitted to the Neuro ICU initially with a heparin drip
with PTT goal 50~70. She went into atrial fibrillation on HD #2
and thus was maintained on heparin and bridged to coumadin.
There was no past documentation of Afib per history and there
was no evidence of myocardial infarction per EKG or cardiac
enzymes. On [**10-14**], INR was 2.3 and heparin drip was discontinued.
She was started on Diltiazem 30mg [**Hospital1 **] for rate control since
there was a question of severe bradycardia with metoprolol. She
had sustained afib with elevated heart rate up to 160. Diltiazem
was changed to extended release 120mg daily. She received a
couple extra doses on [**10-17**] and had one 3.4sec pause on
telemetry; she then flipped back into sinus rhythm. [**10-15**] INR =
4.5, [**10-16**] INR = 3.5, so coumadin was held; [**2182-10-17**] INR = 3,
coumadin 2.5mg was restarted, but her most recent ([**2182-10-18**])
INR=3.7 and coumadin was again held. INR needs to be followed
and coumadin adjusted in order to establish the correct dose of
coumadin. Her right sided weakness remained unchanged during her
hospitalization.
Medications on Admission:
ASA, meclizine, vicodin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left ACA/MCA stroke
Atrial fibrillation
Discharge Condition:
stable, however with dense hemiplegia over the right side
(excluding the face), not walking
Discharge Instructions:
You were admitted to this hospital because you presented with
weakness over the right side of your body. You had a brain MRI
which showed signs of stroke at the left side of the brain.
While in the hospital we noticed irregularity of your heart beat
called atrial fibrillation, and this is a risk factor for
stroke.
To prevent further episodes of embolism and stroke you neeed to
take coumadin and you need to have your blood checked every
couple of days.
Please return to the emergency department if you have new onset
of weakness, mental status changes, loss of consciousness,
dizziness, loss of balance, or any other concerning symptoms.
Followup Instructions:
You will need to call your primary care physician in [**Name9 (PRE) **] to
set up a follow up appointment with Neurology after your
discharge from Rehabilitation. We sent a copy of your Duscharge
summary to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79720**] in [**Location (un) **]. Telephone #
[**Telephone/Fax (1) 79721**] Fax# [**Telephone/Fax (1) 79722**].
While in [**Location (un) 86**] you can contact [**Name2 (NI) 79723**] office [**Telephone/Fax (1) 657**]
for recommendations if necessary.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3901
} | Medical Text: Admission Date: [**2137-12-23**] Discharge Date: [**2138-1-4**]
Date of Birth: [**2089-11-30**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Biaxin / Levaquin
Attending:[**First Name3 (LF) 1032**]
Chief Complaint:
bilateral leg weakness and numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History and exam obtained with her daughter -in -law (Ms [**First Name8 (NamePattern2) 78403**] [**Name (NI) 78404**]) translating Cambodian.
Ms [**Known lastname **] is a 47 year old right handed woman who is primarily
Cambodian speaking and has a past medical history significant
forneuromyelitis optica (Ab neg) with transverse myelitis
andbaseline RIGHT eye blindness and right sided weakness last
time admitted in [**Month (only) 1096**] (discharged on 12 / 15/ 08 with a new
flare in the context of a UTI w E. Coli: sensitive to
quinilones,
cephalosporines and AMGs). She has been treated with
corticosteroids plus Rituximab (anti CD20 antibody) in the past.
She now presents with worsening right sided weakness and
numbness plus new LEFT sided weakness and numbness and new
urinary/ bowel incontinence.
She started with increasing "numbness" in her RIGHT leg and
newnumbness in her LEFT leg 48h ago. When enquired, she explains
it feels like "pins and needles" around the circumference of her
legs form her toes up to her hip in both extremities. In
addition, she is experiencing the same sensation up to her
umbilicus and in the back (bilaterally). Besides, there is new
onset urinary incontinence (starting on 01/ 24 in the evening).
She does not feel the need to urinate and does not realize she
has urinated till she feels wet. This already happened in her
previous flares. Besides, there is new bowel incontinence.
Again, she does not feel the need to move her bowels or that she
is
doing it. Just realizes an accident has happened. She recalls
more than 7 events per day, although cannot provide an specific
number for th elast 2 days. It is not watery stool, but "loose",
in the context of a patient using 4 medications for her
constipation, which she has stopped. There was no blood or
mucous contents in her stools. There are no sick contacts at
home. No nausea or vomiting.
No cough or dysuria. She has been complaining of "fever" for the
past week. however, when her relatives checked her temperature,
it was whithin normal limits. She has been taking Tylenol. She
admits having a headache when she feels feverish. It has the
same features as her baseline headache. Bifrontal, pressure
quality, without aura. Responds to tylenol.
There are no muscular spasms ongoing. No Lhermitte either. She
refers no phosphene perception. There is pain with ocular
movements (bilaterally) in any direction. Importantly, there is
no shortness of breath.
She was taken to [**Hospital 1121**] Hospital ED. The team at [**Location (un) 12914**] contact[**Name (NI) **] Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **], whom recommended transfer to
[**Hospital1 18**] for admission and further evaluation.
She has completed a Rituximab course recently (cannot recall
when, probably last week). Never on AZA, not on chronic po
corticosteroids.
Baseline (same as at discharge on [**2137-11-11**]): she is
able to lift her left leg off the bed and wiggle vigorously her
ankle and toes. The right leg had minimal movement proximally
and slightly increased movement at the toes. She has a T3 level
bilaterally, though does have intact sensation in the right
leg. She does not have permanent indwelling cathether. She is
wheelchair bound. Requires help to bathe and dress up (given
hervisual impairment: legally blind in the RIGHT eye, decreased
visual acuity in the LEFT eye for which she uses glasses, though
apparently she cannot read). She is FC.
ROS: as above.
She had an MRI of her thoracic spine during this [**Month (only) 1096**]
admission that was remarkable for: extensive areas of edema and
T2 hyperintense lesions in the
thoracic cord, up to the level of T9; these appear to be
slightly
decreased in extent, as seen on the axial T2-weighted images,
accurate
comparison is somewhat difficult, due to the suboptimal quality
of the sagittal
T2-weighted sequence. No abnormal enhancement is noted. Again
noted is
minimal enhancement on the surface of the lower cord, which may
relate to
prominent vessels rather than normal enhancement and is
unchanged. No pre-
or para- vertebral soft tissue swelling or masses are noted.
MRI CNS w/ wo contrast: in [**2137-10-22**]
Evidenced: seven small foci of high T2 signal in the
subcortical, deep, and periventricular white matter of the
frontal lobes, without associated contrast enhancement. Thought
to be of demyelinating origin given the clinical presentation.
Past Medical History:
1. Neuromyelitis optica, NMO titer negative
2. HBV core and surface antibody positive, surface antigen
negative
3. GERD
4. DM.
5. s/p hysterectomy
Social History:
Currently living with her husband and daughter ([**Telephone/Fax (1) 78405**]),,
a
son in-law and three kids. She was born in [**Country **].
Denied EtoH, tobacco or drugs
Family History:
NC
Physical Exam:
Exam on admission:
T 98.9F, BP 132/ 72, HR 78, 16 RR, O2Sat 100% RA
VC: 3l, NIF 60.
Gen: Lying in bed, NAD.
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
Back: No point tenderness or erythema
CV: Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Soft, nontender, non-distended. No masses or megalies.
Percussion within normal limits. +BS. NO dat aof urinary
retention.
Ext: no edema, no DVT data. Pulses ++ and symmetric.
Rectal tone: very mildly decreased, weak wink.
Foley in place.
Neurologic examination:
No meningismus. No photophobia.
Lhermitte: negative
MS:
General: alert, awake, normal affect
Orientation: oriented to person, place, date, situation
Attention: [**Doctor Last Name 1841**] backwards +. Follows simple/complex commands.
Speech/Language: fluent w/o paraphasic errors; comprehension,
repetition, naming: normal.
Memory: Registers [**1-28**] and Recalls [**12-31**] when given choices at 5
min.
Calculus: impaired.
Comprehension: normal.
Similarites: normal.
Praxis/ agnosia: Able to brush teeth. There are field cuts in
all
quadrants in her LEFT eye. Legally blind in her RIGHT eye.
Speed and contents of thought: normal.
No Extinction with tactile stimuli.
CN:
I: not tested
II,III: VFF to confrontation, PERRL 4mm to 2mm on the LEFT eye,
pupillary afferent defect on the RIGHT. Would close her eyes and
not allow for funduscopic exam.
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**4-1**] bilaterally
XII: tongue protrudes midline.
Motor: decreased bulk in both legs.
No tremor, no asterixis or myoclonus. No pronator drift.
Decreased tone in both legs.
Neck flexion and extension [**4-1**].
Delt;C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7
Left 5 5 5 5 5
Right 5 5 5 5 5
Lower extremities:
LEFT: toes wiggle. ANkle dorsiflexion preserved. Rest of muscle
groups: 0/5
RIGHT: 0/5 for all muscle groups.
Deep tendon Reflexes:
Bicip:C5 Tric:C7 Brachial:C6 Patellar:L4 Achilles Toes:
Right 1- 1- 1 - 0 0 Withdraws
Left 1 - 1 - 1 - 0 0 Withdraws
Sensation:
Light [**Known lastname **]: Preserved in the legs. Then, there is anesthesia
from the hip to a T4 LEFT level and T3 RIGHT level.
Pinprick: Patchy: absent below both knees (around the whole leg
circumference), decreased symmetrically up to the hip. From the
hip toward her chest: Absent up to T4 (bl).
Temperature: Difficult to assess. It seems there is a T3 level
bl.
Vibration: Normal in the RIGHT foot. Absent in the LEFT foot.
Propioception: normal bl.
Coordination:
*Finger-nose-finger limited by visual acuity.
*Rapid Arm Movements normal.
*Fine finger tapping: normal.
*Gait/Romberg: unable to asses.
Pertinent Results:
EKG [**2137-12-23**]
Sinus rhythm. Possible inferior wall myocardial infarction of
indeterminate age. Compared to the previous tracing of [**2137-11-11**]
there are lateral ST-T wave changes which are now present.
Cannot rule out new myocardial ischemia. Clinical correlation is
suggested.
[**2137-12-23**] Chest XR
IMPRESSION: No radiographic evidence of pneumonia.
Spine MRI [**2137-12-23**]
FINDINGS: Study is compared with most recent enhanced MR
examination of the thoracic spine dated [**10-28**] and previous study,
dated [**10-21**], as well as enhanced study of the lumbar spine,
dated [**2137-10-20**]. There is a markedly abnormal appearance to the
mid-thoracic spinal cord, which is markedly expanded and
demonstrates ovoid and "flame-shaped" STIR-hyperintensity and
corresponding enhancement, extending from the C7-T1 through the
T4 level. This demonstrates overall predominant thick
rim-enhancement with slight sparing of the central [**Doctor Last Name 352**] matter
within the cord; the process is best demonstrated on 6:8, 23:[**6-5**]
and 24:[**1-14**]. There has been overall improvement in multifocal
T2- hyperintense lesions within the more caudal cervical and
more caudal thoracic cord, with persistent linear hyperintensity
within the central-dorsal cord substance at the T7-T9 level
which demonstrates apparent corresponding linear relative [**Name (NI) **]
hypointensity, without enhancement (5:8, 23:9), and may
represent early hydrosyringomyelia.
No other definite focus of pathologic intramedullary enhancement
is identified through the conus medullaris, which is normal in
morphology and terminates at the superior L1 level, as before.
There is prominent linear enhancement on the surface of the
thoracic cord, not significantly changed, which has been
interpreted to represent prominent superficial vessels. The
examination of the lumbar spine is essentially unchanged from
the earlier study. Specifically, the conus medullaris is notable
only for the prominent superficial enhancement, unchanged from
previous studies, again thought to represent prominent
superficial vessels, rather than true leptomeningeal
enhancement.
Again demonstrated is degeneration of the L5-S1 disc with small
central
annular tear but no accompanying protrusion. There is no canal
or foraminal compromise at any imaged lumbar level. The
thoracolumbar vertebrae are unchanged in height, alignment and
intrinsic signal intensity, without development of bone marrow
signal abnormality on the sagittal STIR sequences. Again
demonstrated is the well-demarcated, round, predominantly T1-
and T2- hyperintense lesion in the dorsal-inferior aspect of the
T11 vertebral body, unchanged, which likely represents an
incidental hemangioma.
IMPRESSION:
1. Extensive segmental region of edema and enhancement involving
the C7-T1
through T4 levels, new since the [**2137-10-28**] study, in this
context,suspicious
for active demyelination.
2. Interval significant resolution of other foci of
demyelination within the cervicothoracic spinal cord; however,
the findings at the T7-T8 level raise the possibility of focal
hydromyelia at site of previous demyelination.
3. Overall unremarkable appearance to the conus medullaris and
cauda equina nerve roots, other than prominent surface
enhancement, not much changed over the series of studies dating
to [**2137-9-9**]. While this has been attributed to venous hyperemia
related to the active demyelinative process; associated
leptomeningeal enhancement has occasionally been reported in
demyelination, and cannot be completely excluded.
[**2137-12-24**]
CT OF THE CHEST WITH IV CONTRAST: No pulmonary nodules or masses
are
detected. Low lung volumes and scattered subsegmental
atelectasis suggest the study was performed during expiration.
There is no pleural effusion or
pneumothorax. The heart and great vessels are normal. There are
no
pathologically enlarged thoracic lymph nodes. The
tracheobronchial tree is
patent to the subsegmental level bilaterally. On this study not
tailored for subdiaphragmatic evaluation no abnormality is
detected of the upper abdomen. A small 7-mm nodule along the
undersurface of the left hemidiaphragm is probably a splenule or
non-pathologically enlarged
lymph node. No lytic or sclerotic osseous lesions are seen.
IMPRESSION: No evidence of pulmonary nodule or mass.
[**2138-1-1**]
RIGHT LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler
son[**Name (NI) 867**] of the
right common femoral, superficial femoral and popliteal veins
were performed. Normal flow, augmentation, compressibility and
waveforms are demonstrated. No intraluminal thrombus is
identified.
IMPRESSION: No evidence of DVT in the right lower extremity.
Brief Hospital Course:
Mrs [**Known lastname **] was admitted to the floor with presumed diagnosis of
new NMO flair and UTI. She received IV solumedrol 250mg q6hours
for 5 days. Dose was decreased to 250mg Q8hours. Her physical
exam remained essentially the same: pt can not move
spontaneously her legs or wiggles her toes and sensory level is
T4.
Plan for steroids: Methylprednisolone Sodium Succ 500 mg/4 mL
Recon Soln Sig: One (1) Recon Soln Injection every eight (8)
hours: Taper by taking one dose off every other day, and then
once on 250mg/day switch to oral prednisone 80mg daily and taper
over 2 weeks. Watch insulin requirements carefully as tapering.
Rituxim infusion was given twice : [**2137-12-26**] and [**2138-1-2**] in the
ICU with Desensitization protocol. Patient tolerated well with
30cc/hour infusion rate.
The neurology team contact [**Name (NI) **] daughters and husband
[**Name (NI) 78406**] to recommend plasmapheresis, but patient did not
give the consent for this procedure.
Resp: no issues.
CV: no issues.
GU: UTI in treatment with Nitrofurantoin FOR 14 DAYS last dose
should be on [**2138-1-6**]
Endocrine: [**Last Name (un) **] center was involved in her care, patient
required high insulin scale dose.
Insulin dose upon discharge:
NPH fixed dose: 40U breakfast - 20U bedtime
Scale: ADJUSTED AFTER MEALS
61-89 ZERO
90-140 - 19U - 14U - 16U - 0
141-180 - 25U - 20 -25U- 4U
181-220 - 28U - 25U - 28 -6U
221-260 - 30U - 30U- 30U - 8U
261-300 - 32U -32U- 32U - 10U
301-340 - 34U-34U-34U-15
341-400 - 38U- 38U-38U- 20U
Medications on Admission:
Home Meds:
NRL/ Psych:
1. Pain management:
*Morphine 15 mg Tablet Sustained Release PO Q12H
*Oxcarbazepine 150 mg [**Hospital1 **], titrate up to 1-2 tabs [**Hospital1 **] as
indicated for squeezing
sensation around chest.
*Gabapentin 300 mg TID
*Amitriptyline 10 mg PO BID
2. Spasticity:
*Baclofen 10 mg Tablet Sig: One (1) Tablet PO BID
*Perphenazine 2 mg [**Hospital1 **]
3. Insomnia: Zolpidem 5 mg HS
GI:
1. Hepatitis B: Lamivudine 100 mg qd
2. GERD: Pantoprazole 40 mg Tablet, Q24H
3. Constipation:
Bisacodyl 10 mg qd
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
Lactulose Thirty (30) ML PO BID
Hem-Onc:
DVT ppx: Heparin sc 5000 units TID
Endocrinology:
DM: Insulin Glargine 18 units Subcutaneous at bedtime.
Insulin Regular ss
51-150 mg/dL 0 Units
151-200 mg/dL 2 Units
201-250 mg/dL 4 Units
251-300 mg/dL 6 Units
301-350 mg/dL 8 Units
351-400 mg/dL 10 Units
> 400 mg/dL Notify M.D.
Discharge Medications:
1. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
2. Oxcarbazepine 300 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for Neuropathic pain.
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for Neuropathic pain.
5. Perphenazine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-29**]
Drops Ophthalmic PRN (as needed).
15. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: Two (2)
Capsule PO QID (4 times a day) for 14 days: last dose [**2138-1-6**].
16. Methylprednisolone Sodium Succ 500 mg/4 mL Recon Soln Sig:
One (1) Recon Soln Injection every eight (8) hours: Taper by
taking one dose off every other day, and then once on 250mg/day
switch to oral prednisone 80mg daily and taper over 2 weeks.
Watch insulin requirements carefully as tapering.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
neuromyelitis optica
Discharge Condition:
stable.
Discharge Instructions:
yourwere admitted to this hospital because you presented
weakness and numbness in both legs up to your chest. You are
known to have neuromyelitis optica and your spine MRI showed
signs of new acute inflamation. You received IV steroids and two
doses of Rituximab with special care, because you had allergic
reaction from the previous infusion. You tolerated well the
infusions.
You had also urinary tract infection treated for 14 days.
Please return to the emergency department if you have any
concerning symptoms.
Followup Instructions:
Please cal Dr [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] office [**Numeric Identifier 78407**] for follow up
appointment
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3902
} | Medical Text: Admission Date: [**2135-10-6**] Discharge Date: [**2135-10-11**]
Date of Birth: [**2073-6-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
Cardiac Catherization [**2135-10-6**]
Off pump Coronary artery bypass graft x5 (left internal mammary
artery > left anterior descending artery), saphenous vein graft
Y> right coronary artery > Diagonal, saphenous vein graft >
obtuse marginal, saphenous vein graft > RAMUS)[**2135-10-7**]
History of Present Illness:
62 yo M with crescendo angina->10/10 chest pain. Went to OSH ED
where he developed ventricular fibrillation where he was shocked
and loaded with amiodarone and received aspirin, plavix and
heparin. He was transferred here for cath which showed
multivessel disease.
Past Medical History:
HTN, Anxiety, Hyperlipidemia
Social History:
2 etoh/day
quit tobacco 32 years ago
lives with wife
works as heavy equipment operator.
Family History:
NC
Physical Exam:
hr 62 rr 18 BP 108/60
Well appearing
Admission exam umremarkable
Pertinent Results:
[**2135-10-11**] 07:25AM BLOOD WBC-4.9 RBC-2.54* Hgb-8.6* Hct-24.1*
MCV-95 MCH-33.9* MCHC-35.7* RDW-15.3 Plt Ct-136*#
[**2135-10-11**] 07:25AM BLOOD WBC-4.9 RBC-2.54* Hgb-8.6* Hct-24.1*
MCV-95 MCH-33.9* MCHC-35.7* RDW-15.3 Plt Ct-136*#
[**2135-10-10**] 07:35PM BLOOD Hct-25.7*
[**2135-10-6**] 02:30AM BLOOD WBC-6.6 RBC-4.07* Hgb-14.2 Hct-38.7*
MCV-95 MCH-34.8* MCHC-36.7* RDW-13.1 Plt Ct-146*
[**2135-10-11**] 07:25AM BLOOD Plt Ct-136*#
[**2135-10-6**] 02:30AM BLOOD PT-12.8 PTT-119.9* INR(PT)-1.1
[**2135-10-6**] 02:30AM BLOOD Plt Ct-146*
[**2135-10-11**] 07:25AM BLOOD Glucose-114* UreaN-17 Creat-0.9 Na-141
K-3.8 Cl-103 HCO3-28 AnGap-14
[**2135-10-6**] 02:30AM BLOOD Glucose-162* UreaN-22* Creat-1.1 Na-143
K-3.6 Cl-108 HCO3-25 AnGap-14
CHEST (PA & LAT) [**2135-10-11**] 1:28 PM
FINDINGS: In comparison with study of [**10-10**], no definite pleural
line is appreciated in the right apex. However, a residual tiny
pneumothorax cannot be unequivocally excluded.
The appearance of the heart and lungs are otherwise unchanged.
CHEST (PORTABLE AP) [**2135-10-10**] 11:50 AM
AP UPRIGHT CHEST RADIOGRAPH: The cardiomediastinal silhouette is
unchanged with improved perihilar opacities. There is platelike
atelectasis. There are chest tubes, one within the right base,
the other within the left base. A left-sided effusion has
increased in size, now small-to-moderate.
IMPRESSION:
Mild CHF with increased left pleural effusion.
Echo [**10-6**]
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with mild basal inferior
hypokinesis (c/w RCA disease). The remaining segments contract
normally and the overall LV systolic function is relatively
preserved (LVEF = 55%). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Trace 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 mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic function,
c/w CAD. Mild pulmonary hypertension. Mildly dilated thoracic
aorta.
Brief Hospital Course:
He was taken to the operating room on [**10-7**] where he underwent
an off pump CABG x 5. He was transferred to the ICU in critical
but stable condition and was started on levophed and pitressin.
He remained intubated overnight and was transfused 2 units of
PRBCs. He was extubated and his drips were weaned on POD #1. He
was transferred to the floor on POD #2. His chest tubes and
pacing wires were discontinued, and he developed a right apical
pneumothorax had essentially resolved. He was ready for
discharge home on POD #4.
Medications on Admission:
lisinopril, hctz, lexapro
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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. 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:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days: please see pcp prior to completion of lasix.
Disp:*10 Tablet(s)* Refills:*0*
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day for 10 days.
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p off pump CABG
Preoperative ventricular fibrillation
Hypertension
Anxiety
Hyperlipidemia
Depression
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Dr [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr [**Last Name (STitle) 53759**] in 1 week
Please call and have Dr [**Last Name (STitle) 53759**] refer you to a cardiologist as
we discussed
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2135-10-11**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3903
} | Medical Text: Admission Date: [**2181-3-14**] Discharge Date: [**2181-3-21**]
Date of Birth: [**2122-8-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient had a routine medical appointment here at the
hospital earlier today. On his way home, he was involved in a
lateral impact MVC. The patient lost consciousness and was
transported to an outside hospital where a CT scan of the head
and plain films of the chest and C-spine were obtained. The head
CT revealed a small intraparenchymal hemorrhage and the patient
was transferred
here for further evaluation.
Past Medical History:
-Hep C cirrhosis and HCC s/p liver [**First Name3 (LF) **] [**4-1**]
-Hernia repair and lysis of adhesions [**12-2**] with liver bx showing
F2 fibrosis 6 months after transplantation.
-Liver bx on [**2179-6-15**], showing mild mixed inflammation, no
evidence of rejection, focal bile duct epithelial damage, mild
centrivenular hemorrhage and congestion, mild mixed steatosis,
consistent with recurrent viral hepatitis C and no significant
change in the grade of inflammation.
-DM, on insulin, being titrated down due to wt loss s/p
[**Date Range **]
-s/p right colectomy [**12-29**], for toxic colitis
-Herpes simplex 1, pt unsure of this hx
-hx of EBV
-s/p appendectomy
-hyptertension
Social History:
Married. Lives with wife and 13 y.o. son from a prior
relationship. Is a Jeweler. No tobacco use. Very occasional beer
use. No current drug use, but had used drugs as a young adult.
Family History:
no liver disease in family
Physical Exam:
Temp:98.5 HR:80 BP:152/80 Resp:20 O(2)Sat:100 Normal
Constitutional: Uncomfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact
Oropharynx within normal limits, C-spine nontender
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, mild left upper quadrant
tenderness to palpation. There are no peritoneal findings.
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Speech fluent, moves all extremities
Psych: Mental status somewhat diminished according to the
patient's wife
Pertinent Results:
[**2181-3-14**] 02:30PM WBC-1.1* RBC-3.22* HGB-10.3* HCT-32.8*
MCV-102* MCH-32.1* MCHC-31.5 RDW-14.7
[**2181-3-14**] 02:30PM NEUTS-70.4* LYMPHS-16.0* MONOS-6.5 EOS-6.9*
BASOS-0.2
[**2181-3-14**] 02:30PM PLT COUNT-64*
[**2181-3-14**] 02:30PM PT-12.4 INR(PT)-1.0
[**2181-3-14**] 02:30PM tacroFK-5.3
[**2181-3-14**] 02:30PM UREA N-24* CREAT-0.9 SODIUM-134 POTASSIUM-4.9
CHLORIDE-101 TOTAL CO2-25 ANION GAP-13
[**2181-3-14**] 02:30PM ALT(SGPT)-37 AST(SGOT)-27 ALK PHOS-94 TOT
BILI-0.4
[**2181-3-14**] 02:30PM ALBUMIN-3.7 CALCIUM-8.2* PHOSPHATE-2.9
MAGNESIUM-1.9
[**2181-3-14**] 08:35PM WBC-2.6*# RBC-2.98* HGB-9.8* HCT-29.4*
MCV-99* MCH-32.8* MCHC-33.2 RDW-15.4
[**2181-3-14**] Head CT :
1. Trace SAH in left parietal region.
2. Small amount of intraventricular hemorrhage in right
occipital [**Doctor Last Name 534**].
[**2181-3-14**] CT Torso :
1. Left rib fractures, detailed above. Left distal clavicle
fracture.
2. Small amount of hemoperitoneum, source unclear though
possibly from subtle splenic injury.
3. Liver [**Month/Day/Year **], with hepatosplenomegaly, extensive varices,
and
gallbladder fossa seroma.
4. Increase in supraumbilical ventral hernia, containing
transverse colon
without evidence of obstruction.
[**2181-3-15**] Head CT :
Unchanged appearances of the intracranial hemorrhage compared to
the prior CTA examination of [**2181-3-14**]. No new hemorrhage or
hydrocephalus seen.
[**2181-3-15**] Left shoulder :
Non-displaced fracture distal left clavicle. Acromioclavicular
joint intact.
[**2181-3-17**] Head CT :
Stable right parietooccipital subarachnoid hemorrhage with
possible slight
redistribution. A hyperdense focus in the left frontal lobe is
unchanged and could be a small focus of intraparenchymal
hemorrhage, which is unchanged. No new worrisome findings.
Brief Hospital Course:
Mr. [**Known lastname 43406**] was evaluated by the Trauma team in the Emergency
Room and his imaging was reviewed. He was also seen by the
Neurosurgery service as he had a SAH and a right occipital IVH.
He was admitted to the hospital for further observation and
testing.
He was treated prophylactically with Keppra for a 10 day course
and had no seizure activity. He had 2 subsequent Head CT's
which showed no interval change in his intracranial hemorrhages
but his wife felt that he was not at his baseline mental status.
He was evaluated by the Occupational Therapy service on
multiple occasions and they found deficits in memory and recall
and felt that he would benefit from both a short term rehab and
a follow up visit with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Cognitive
Neurology.
[**Last Name (NamePattern1) 1326**] surgery was following the patient during his
hospitalization and made recommendations regarding his
immunosuppressive regimen.
He underwent pulmonary toilet specifically incentive spirometry,
to ensure deep breathing and coughing and prevent pneumonia due
to his multiple rib fractures. He needed much encouragement but
was compliant. The Physical Therapy service concurs that a short
term rehab prior to returning home would be helpful for
increasing mobility safely as well as stamina.
Medications on Admission:
Ribavirin 200 mg Tab 3 tablets in the am and 2 in the evening
Procrit 40,000 unit/mL Injection inject 1mL once a week
Neupogen 300 mcg/mL Injection 300mcg weekly
Infergen 15 mcg/0.5 mL Sub-Q 15mcg once a day in place of
pegasys
Viagra 100 mg Tab 0.5 (One half) Tablet(s) by mouth as needed
Citalopram 20 mg Tab 1 Tablet(s) by mouth once a day
Prograf 1 mg Cap, twice daily 2 Capsule(s) by mouth twice a day
ergocalciferol (vitamin D2) 50,000 unit Cap once a week
sulfamethoxazole-trimethoprim 400 mg-80 mg Tab
1 Tablet(s) by mouth once a day NOT TAKING for now while on
interferon and Ribavirin
Lisinopril 5 mg Tab daily
Amlodipine 10 mg Tab once a day
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): thru [**2181-3-24**].
Disp:*14 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
9. insulin regular human 100 unit/mL Solution Sig: home dose
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
Neuro-Rehabilitation Center - [**Location (un) 7740**]
Discharge Diagnosis:
S/P MVC
1. L parietal SAH
2. Tiny IVH in R occ [**Doctor Last Name 534**]
3. Mildly diplaced left lateral 9th rib fx
4. Nondisplaced left 4th-8th rib fx
5. Intraabdominal hemorrhagic free fluid
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive (fluctuating).
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* Your injury caused rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
* You bled into a portion of the brain and a repeat Head CT
showed no extension. The Occupational Therapist recommends that
you follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Cognitive
Neurology for a full evaluation. In the mean time you are on
Keppra which is a drug to prevent seizures. You will stay on
that for a total of 10 days for prophylaxix.
* If you develop any new symptoms that concern you please call
your doctor or return to the Emergency Room.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**12-28**] weeks.
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1669**] for a follow up appointment in 8
weeks with a repeat Head CT. The secretary can arrange that for
you.
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Cognitive Neurology at
[**Telephone/Fax (1) 1690**] for a follow up appointment in [**1-26**] weeks.
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2181-4-25**] 1:40
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
ICD9 Codes: 5715, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3904
} | Medical Text: Admission Date: [**2170-1-22**] Discharge Date: [**2170-2-1**]
Date of Birth: [**2111-4-20**] Sex: M
Service: Neurosurgery
CHIEF COMPLAINT: Syncope.
HISTORY OF THE PRESENT ILLNESS: The patient is a 58-year-old
male with a past medical history for vasovagal syncope status
post pacemaker placement in [**2154**], pacemaker removal in [**2165**]
secondary to infection, who presents with an episode of
syncope while urinating.
The patient was in his usual state of health when he awoke at
5:00 a.m. this morning to urinate. He found that he had
difficulty getting up because of his left leg weakness. His
wife noted that he was able to walk but had slurring of
speech. He went to the bathroom where he experienced roughly
one minute of unresponsiveness. Per the report of his wife,
there was no seizure activity, no urinary or bowel
incontinence, no biting of tongue. He went back to sleep and
woke up at 8:00 a.m. without his leg weakness, normal speech,
but tingling sensations persisted. He presented to the ED
and was essentially asymptomatic. The vital signs were
stable. Review of symptoms were negative.
In the Emergency Room, he was evaluated by Neurology who felt
that he had a transient ischemic attack versus seizure.
During workup, there was an observed episode of slurred
speech, left facial, arm, and leg tingling. On evaluation,
the blood pressure was 121/76, heart rate 50. He had left
facial weakness with only a mild left hemiparesis with ataxia
out of proportion to his weakness that lasted 15 minutes and
resolved. The vital signs remained stable. The CTA was
negative for acute intracranial bleeding or abscess. The
patient states that he was continued on his normal dose of
Dilantin 200 mg p.o. b.i.d. for seizure prophylaxis secondary
to an AVM repair in [**2128**].
The patient and the PCP report five such episodes of
left-sided weakness, tingling, and dysarthria have occurred
since pacemaker implantation, although current episode of
syncope was void of such symptoms. Denied fevers, chills,
anesthesia, illness, lightheadedness, visual changes,
postictal state, chest pain, nausea, vomiting.
PAST MEDICAL HISTORY:
1. As above, a pacemaker, single-chamber, inserted in [**2154**]
for vasovagal syncope which was explanted in [**2165**] secondary
to cellulitis.
2. AVM resection in [**2128**]. The patient was on Dilantin and
phenobarbital from [**2128**] to [**2146**] for seizure prophylaxis, was
taken off AEDs in [**2146**], recently restarted on Dilantin three
weeks ago.
3. Gout, last flare in [**2165**] with right metatarsal head
inflamed, currently stable.
4. Hypertension.
5. Hypercholesterolemia.
ADMISSION MEDICATIONS: Dilantin 200 mg p.o. b.i.d.
ALLERGIES: Codeine.
FAMILY HISTORY: No history of stroke or seizure. Positive
for chronic atrial fibrillation in a younger brother.
Maternal grandmother has type 2 diabetes, no CAD, colon
cancer, skin cancer.
SOCIAL HISTORY: The patient is a self-employed contractor.
Denied smoking, drugs. Occasional alcohol use. No substance
abuse.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient
was afebrile at 97, heart rate 59, blood pressure 173/85.
Orthostatics checked on the floor were negative, breathing at
a rate of 16, 98% on room air. HEENT: NC/AT, MMM, PERRLA,
EOMI, fields full, no nystagmus. Neck: Supple. No
adenopathy. No carotid bruits appreciated. Cardiac: Regular
rate, no murmurs, rubs, or gallops. Lungs: Clear to
auscultation bilaterally. Abdomen: Soft, nontender,
nondistended, normoactive bowel sounds. Extremities: No
clubbing, cyanosis or edema. Capillary refill less than two
seconds. Neurologic: Mental status-alert and oriented times
three. Speech appropriate, fluent, naming and repetition
intact, comprehension intact. Cranial nerves II through XII
without deficits. Tongue midline. Palate elevation normal.
Face symmetric. Motor: No tremor. Normal bulk, tone. No
pronator drift, midline. Strength was symmetric and full on
both sides. Sensory: Intact to light touch, pinprick,
temperature, vibration, and proprioception. Reflexes were 3+
in the right upper extremity, 3+ in the left upper extremity,
3+ right lower and left lower extremities. The toes were
downgoing bilaterally. Coordination: Finger-to-nose no
ataxia, rapid finger tapping intact bilaterally. Gait:
Romberg negative, narrow base stance. No difficulty with
tandem gait.
LABORATORY/RADIOLOGIC DATA: Pertinent for a creatinine of
1.1 which is his baseline, glucose 103, calcium 8.7,
phosphorus 3, magnesium 2. CK troponin negative. TSH 2.7.
Homocysteine 14. Triglycerides 326, HDL 42, LDL 190. White
count 6.3, hematocrit 42, platelets 179,000. Prothrombin
time 11, Partial thromboplastin time 25.
The patient had a CTA and could not undergo MRI due to right
craniotomy clips as well as retained ventricular pacing wire.
No evidence of acute intracranial hemorrhage. Scattered
calcifications in the left internal carotid and left
vertebral body with mild midbasilar narrowing, no aneurysm
identified.
EKG showed sinus bradycardia, borderline left axis deviation,
RSR pattern in V1 with normal QRS duration.
The patient's workup for both presentations of syncope and
[**Doctor First Name **] observed in the Emergency Room with stable vital signs.
The Stroke Team, Cardiology, Electrophysiology, and
Neurosurgery were consulted for appropriate workup. The
patient remained on telemetry and the vital signs were stable
throughout. An EEG had been performed prior as an outpatient
which was negative for seizure which was low on the
differential.
TEE and TTE with bulbar study were negative for ASD or PFO.
It was felt that this was less likely to represent embolic
phenomenon.
Carotid ultrasounds were negative. It was felt that
angiography would be the best to apprise posterior
circulation. Angiography was performed by Dr. [**Last Name (STitle) **] which
revealed a stenosis of the left vertebral artery at its
origin as well as a midbasilar stenosis of approximately
70-80%. At that time, the decision for intervention was made
on the left vertebral artery on the basis of providing the
most flow to the already stenotic basilar lesion.
HOSPITAL COURSE: The patient was started on aspirin, Plavix,
as well as risk factor modification with B12, B6, and folate
administered due to elevated homocysteine. Lipitor was
started given prior elevated lipid panel. The patient
underwent uncomplicated stenting of the origin of the left
vertebral artery with good distal flow, no focal neurologic
deficit. The patient remained free of syncopal and
dysarthria, left-sided weakness, or neurologic sequelae
throughout.
In discussion with Cardiology and Neurology, at this time,
episodes likely represent dual episodes of vasovagal syncope
and TIA. Transient ischemic attacks are being addressed with
antiplatelet therapy of aspirin and Plavix as well as
decreasing lipid profile and addressing homocysteine
elevation. If the patient experiences further vasovagal
episodes, this would warrant implantation of the pacer. It
was felt that pacemaker placement right now was not
sufficient enough to fully address his known basilar
stenosis.
At this time, the risks and benefits were in favor of holding
pacemaker placement and continue with a trial of medical
management and observation post left vertebral stenting.
DISCHARGE MEDICATIONS:
1. Dilantin 100 b.i.d. This is to be tapered per PCP until
off as no history nor likelihood of seizure disorder.
2. Aspirin 325 mg p.o. b.i.d.
3. Plavix 75 mg p.o. b.i.d.
4. Folic acid one tablet p.o. q.d.
5. Vitamin B12 and B6 p.o. q.d.
6. Lipitor 10 mg p.o. q.d. pending further LFT checks.
Statin dose should be maximized given the patient's severe
atherosclerotic risk.
FOLLOW-UP: The patient is to follow-up in one to two weeks
with Dr. [**Last Name (STitle) 93686**], his PCP, [**Name10 (NameIs) **] appraise neurologic
examination, monitor for signs of further syncopal episodes
and/or TIA episodes. Possible initiation of low-dose ACE
inhibitor if blood pressure and heart rate stable.
DISPOSITION: The patient was discharged to home in stable
condition without neurologic deficits on antiplatelet therapy
post stenting of the left vertebral artery.
Dictated By:[**Last Name (NamePattern1) 972**]
MEDQUIST36
D: [**2170-2-2**] 03:39
T: [**2170-2-3**] 19:26
JOB#: [**Job Number 93687**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3905
} | Medical Text: Admission Date: [**2142-3-30**] Discharge Date: [**2142-4-3**]
Date of Birth: [**2078-6-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 year old Male with history of type 2 diabetes, CKD, who
presents with lethargy and hypotension. History of recent
admission (including MICU stay) in [**1-/2142**] indicated for
acidosis, hyperkalemia, and acute kidney injury. Patient
presented to his outpatient physician today with altered mental
status and was discovered to have hypotension. Was subsequently
referred to the ED.
In the emergency department vitals were: T 97.8, HR 49, BP
93/46, RR 20, O2Sat 100% 2L NC. Patient had Cr up to 5.7 from
recent baseline of 2.8 at discharge from [**Hospital1 18**] in 3/[**2141**]. Also
with K up to 6.3 and EKG with peaked T waves. Received
kayexylate, insulin, and glucose. Also, due to relative
hypotension, was given Vancomycin and Zosyn. Patient received 4L
NS IVF in the ED. He had a U/A measured without any evidence of
UTI. CXR showed pulmonary vascular congestion, similar to prior
imaging. Head CT was without acute abnormality. Vitals prior to
transfer to the MICU were: T 96.1, HR 45, BP 107/56, RR 16,
O2Sat 100% 2L NC.
Upon arrival to the MICU patient reports some nausea, but denies
chest pain, thirst, dysuria.
REVIEW OF SYSTEMS:
(+)ve: fatigue, malaise, confusion, nausea, vomiting
(-)ve: fever, chills, night sweats, loss of appetite, chest
pain, palpitations, rhinorrhea, nasal congestion, cough, sputum
production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, diarrhea, constipation, hematochezia, melena, dysuria,
urinary frequency, urinary urgency, focal numbness, focal
weakness, myalgias, arthralgias
Past Medical History:
1) CAD with [**2134**] PTCA/stenting of PDA
2) Diastolic dysfunction
3) Hypertension, severe
4) Diabetes mellitus, type II c/b retinopathy, nephropathy, and
neuropathy
6) Chronic infected diabetic ulcer
7) PAF on coumadin
8) Obstructive sleep apnea
9) Peripheral edema
10) Hyperlipidemia
11) Obesity
12) GERD
Social History:
Retired; formerly worked as bus driver with [**Company 2318**]. Girlfriend
reportedly passed away suddenly recently.
TOBACCO: denies
ETOH: denies
ILLLICTS: denies
Family History:
Brother with diabetes mellitus
Physical Exam:
On Admission:
VS: T 94.8, HR 43, BP 102/52, RR 12, O2Sat 99% 2L NC
GEN: Somnolent
HEENT: right surgical pupil, left pupil 3 mm and reactive, oral
mucosa moist
NECK: large circumference, no JVP elevation
PULM: CTAB with attenuated breath sounds
CARD: Bradycardia, nl S1, nl S2, no M/R/G
ABD: BS+, non-tender, non-distended
EXT: BLE woody edema
SKIN: BLE with heaped verrucous skin changes and ulcerations
NEURO: Oriented to self and place though cannot report date
correctly without prompting, nonfocal motor exam
On Discharge:
VS: T 97, HR 64, BP 150/76, RR 20, O2Sat 94% RA
GEN: alert, awake, interactive
HEENT: right surgical pupil, MMM
PULM: CTAB
CARD: Regular rate and rhythm, nl S1/S2, no m/g/r
Abd: + bs, distended, soft, non-tender
EXT: BLE woody edema in dressing
SKIN: BLE with heaped verrucous skin changes and ulcerations
NEURO: alert and oriented x 3
Pertinent Results:
Admission labs:
[**2142-3-30**] 11:45AM BLOOD WBC-7.8 RBC-3.66* Hgb-10.0* Hct-32.4*
MCV-89 MCH-27.4 MCHC-30.9* RDW-16.5* Plt Ct-144*
[**2142-3-30**] 11:45AM BLOOD PT-45.3* PTT-40.3* INR(PT)-4.7*
[**2142-3-30**] 11:45AM BLOOD Glucose-88 UreaN-111* Creat-5.7*# Na-134
K-7.3* Cl-109* HCO3-10* AnGap-22*
[**2142-3-30**] 11:45AM BLOOD Calcium-8.2* Phos-8.2*# Mg-2.0
[**2142-3-30**] 07:21PM BLOOD Type-[**Last Name (un) **] Temp-35.3 pO2-72* pCO2-28*
pH-7.18* calTCO2-11* Base XS--16
Discharge labs:
[**2142-4-3**] 05:35AM BLOOD WBC-8.0 RBC-3.35* Hgb-9.1* Hct-27.7*
MCV-83 MCH-27.3 MCHC-33.0 RDW-16.1* Plt Ct-127*
[**2142-4-3**] 05:35AM BLOOD PT-19.8* PTT-32.6 INR(PT)-1.8*
[**2142-4-3**] 05:35AM BLOOD Glucose-87 UreaN-62* Creat-2.9* Na-140
K-4.4 Cl-110* HCO3-20* AnGap-14
[**2142-4-3**] 05:35AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8
Chest PA/Lateral:
IMPRESSION: Bibasilar atelectasis. No new areas of focal
consolidation
identified.
Abdominal ultrasound:
IMPRESSION:
1. No hydronephrosis.
2. Increased resistive indices, with essentially no diastolic
flow identified on either the right or left. This is a
non-specific finding suggesting a broad differential of medical
renal disease.
ECHO:
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. 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). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg).
Doppler parameters are most consistent with Grade II (moderate)
left ventricular diastolic dysfunction. The right ventricular
cavity is dilated with depressed free wall contractility. 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. No mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate-to-severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild concentric left ventricular hypertrophy with
preserved regional/global systolic function. Moderate diastolic
dysfunction with elevated PCWP. Right ventricular dilation and
dysfunction. Moderate to severe pulmonary hypertension. Moderate
tricuspid regurgitation.
CT HEAD W/O CONTRAST ([**2142-3-30**]): No acute intracranial process.
RENAL U.S.; DUPLEX DOPP ABD/PEL ([**2142-3-30**]): No hydronephrosis.
Increased resistive indices, with essentially no diastolic flow
identified on either the right or left. This is a non-specific
finding suggesting a broad differential of medical renal
disease.
Brief Hospital Course:
63 yo M with history of diabetes, CKD, who presented with
lethargy and hypotension. Found to have increased Cr up to 5.7
from recent baseline of 2.8.
#. Acute Renal Failure, Chronic Kidney Disease Stage 3:
- Patient with Cr up acutely to 5.7 after it had stabilized at
2.8 prior to [**1-/2142**] discharge from hospital. In past, [**Last Name (un) **] was
attributed to over-diuresis. Is possible that patient is again
over-diuresed, though given hypotension with lack of response to
4 L fluid resuscitation, will also consider that unintentional
overdose of home anti-hypertensives are contributing to poor
renal perfusion. No history of urinary retention or BPH in past
and patient had renal ultrasound that showed no evidence of
obstruction or hydronephrosis. Checked a serum osmolar gap which
was normal at 9.
- Patient's home furosemide and anti-hypertensives were
initially held. His FeUrea was 14% indicating pre-renal
etiology. The renal team was consulted and the patient received
1L D5 with 3 amps HCO3 and 1 L NS for poor urine output. The
renal team recommended no diuresis and found no indications for
urgent HD. The patient's creatinine trended down to 5.3 before
he was called out from the medical ICU.
- On the floor, his renal function continued to improve, and was
back at baseline of 2.9 prior to discharge. Patient maintained
good urine output. Bilateral venous mapping of the upper
extremities were performed in preparation for potential
hemodialysis. Patient restarted on furosemide 40 mg po qd
(previously 80 mg [**Hospital1 **]) per renal consult recommendations.
#. Hyperkalemia:
Likely secondary to acute kidney injury as described above. Had
peaked T waves on precordial leads in ED and received insulin,
D50, and kayexylate. K improved from 6.3 to 5.8 with those
interventions in the ED. Patient's potassium remained stable
throughout remainder of the hospital course.
#. Bradycardia / Hypotension:
- Patient with history of hypertension and is on metoprolol,
isosorbide mononitrate, furosemide, and hydralazine. It is
possible that he either has impaired renal clearance or an
accidental overdose of blood pressure medications are to blame
for patient's hypotension and bradycardia. Also may be some
component of hypothermia contributing to hypotension and
bradycardia, though body temperature was only mildly depressed
at 94.8 and body temperature alone does not likely explain
hemodynamics. Is concerning that BNP elevated to [**Numeric Identifier 3301**]. Patient
was initially treated with vancomycin and zosyn for empiric
sepsis coverage given hypotension, but these were stopped as
patient had negative culture data while in ICU. All of
patient's home blood pressure medications were initially held.
- On the medicine floor, hydralazine and isosorbide mononitrate
were restarted at home dose. Metoprolol was slowly titrated up
as blood pressure/heart rate tolerated to 50 mg po BID (home
regimen 100 mg po BID). Restarted on furosemide 40 mg po qd
(previously 80 mg [**Hospital1 **]) per renal consult recommendations.
#. Hypothermia:
- Patient's temperature upon presentation to the MICU was 94.8.
Given temperature upon presentation to the ED was normal at
97.8, is possible that 4L NS in ED may be contributing.
Normoglycemia at presentation, so that does not seem to be cause
of hypothermia. Patient without a history of hypothyroidism and
TSH was normal. Patient initially received warming blanket and
his temperature improved and remained stable throughout
remainder of hospital stay.
#. Type 2 Diabetes Uncontrolled with complications:
- Checked QID fingersticks and gave carbohydrate controlled
diet.
#. Atrial Fibrillation:
Patient presented in sinus bradycardic with INR up to 4.7 which
then continued to trend up to 8.9, most likely from antibiotics
administered in the ICU. He was treated with vitamin K. Warfarin
was held until INR drifted down to 1.8 and then restarted at
previous dose of 3 mg po qd. Patient will follow-up in [**Hospital 197**]
clinic one day post discharge. Rate control with metoprolol as
above.
Medications on Admission:
1) Simvastatin 80 mg PO DAILY
2) Calcium acetate 667 mg PO TID
3) Vitamin D 50,000 unit PO QWEEK
4) Lasix 80 mg PO TWICE DAILY
5) Hydralazine 75 mg PO THREE TIMES DAILY
6) Ipratropium-albuterol DAILY:PRN dyspnea or wheezing
7) Isosorbide mononitrate 30 mg EXT release PO DAILY
8) Metoprolol succinate 100 mg PO TWICE DAILY
9) Omeprazole 20 mg PO DAILY
10) Warfarin 3 mg PO DAILY
11) Aspirin 81 mg PO DAILY
12) Ammonium lactate 12 % Topical [**Hospital1 **]
13) NPH insulin 16 units before breakfast and dinner
14) Novolog 12 units with each meal
Discharge Medications:
1. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
2. calcium acetate 667 mg Tablet Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
6. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) treatment Inhalation once a day as
needed for shortness of breath or wheezing.
7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
12. ammonium lactate 12 % Lotion Sig: One (1) application
Topical twice a day.
13. NPH insulin human recomb 100 unit/mL Suspension Sig: Sixteen
(16) units Subcutaneous before breakfast and dinner.
14. insulin aspart 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous with each meal.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute on chronic kidney disease
Hyperkalemia
Hypotension
Diabetes Mellitus
Atrial fibrillation
.
SECONDARY DIAGNOSES:
Coronary artery disease
Chronic diastolic congestive heart failure
Obstructive sleep apnea
Hyperlipidemia
Benign Prostatic Hyperplasia
Gastric reflux disease
Elephantiasis verrucosa nostra
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the [**Hospital1 69**]
because you were confused. We found that your kidney function
had worsened, your potassium level was very high, and you blood
pressure was low. You were initially in the ICU, but you
improved and was tranferred to the regular medicine floor. Your
coumadin level also became very high. Fortunately, your kidney
function, blood electrolyes levels, coumadin level, and blood
pressure all got better.
.
We are discharging you on 3 mg of coumadin a day which is the
dose you used to be on. You need to go to [**Hospital 197**] clinic on
[**2142-4-4**] to have your level checked and dose adjusted.
.
You should go to the lab at [**Hospital1 **]
on [**2142-4-6**] to have your electrolytes checked when you go for
your wound care appointment. The order has already been placed
in for you and your primary care doctor will be expecting the
results.
.
We also made follow-up appointments with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) **] for you (see below). It is very
important that you make these appointments. It is also very
important that you take your medications as instructed.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
Medications:
ADDED: none
CHANGED:
- DECREASED metoprolol to 50 mg three times a day
- DECREASED furosemide to 40 mg once a day
REMOVED: none
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 28551**]
Appointment: Tuesday [**4-10**] at 3:40PM
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 125**] [**Last Name (NamePattern1) **] MD
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: [**Location (un) 4363**] [**Location (un) 86**], [**Numeric Identifier 4364**]
Phone: [**Telephone/Fax (1) 2263**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) 86557**]
within 1-2 weeks. You will be called at home with the
appointment. If you have not heard from the office within 2 days
or have any questions, please call the number above.
Completed by:[**2142-4-3**]
ICD9 Codes: 5849, 2767, 4280, 3572, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3906
} | Medical Text: Admission Date: [**2149-4-1**] Discharge Date: [**2149-4-8**]
Date of Birth: [**2100-1-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Darvocet-N 100 / Aspirin / Amitriptyline /
Wellbutrin
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
DOE/fatigue
Major Surgical or Invasive Procedure:
AVR(#21 [**Company 1543**] Mosaic)[**4-1**]
History of Present Illness:
49 yo F with a history of a bicsupid aortic valve followed by
serial echocardiograms. Recent echo revealed RV dysfunction with
increased MR, Ai and AS. She was referred for surgery.
Past Medical History:
PMH:
- Crohn's disease since age 19, no surgeries, treated with
prednisone off and on
- prednisone induced hyperglycemia
- COPD - PFTs in [**6-20**] showed FEV1/FEV 87% predicted
- Aortic Stenosis (moderate,per echo [**1-20**])
- hypertension
- high cholesterol
- gastritis/GERD, h/o GI bleed
- one seizures in the setting of emesis in [**12-20**], no AEDs
- skin cancer on nose
- inflammatory [**Last Name **] problem periodically
- pyoderma gangrenosum-on L calf and R ankle, tx with Prednisone
- osteopenia
- all teeth extracted secondary to prednisone
- right arm arterial bypass when she presented with right arm
pain and pulselessness
Social History:
completed 12th grade, currently on disability but formerly
worked in an airplane factory, divorced, lives with son, active
[**Name2 (NI) 1818**] - 1-1.5 ppd x 32 years. No drinking or drug use (IVDA).
Family History:
mother deceased age 62 of stroke, HTN, high chol, father
deceased age 56 of MI and also had low back pain, sisters x 4
one with diabetes and neuropathy, one brother deceased (in
army), and another alive with HTN, high chol, and prostate
cancer, one son healthy.
Physical Exam:
Admission:
HR 80 NSR RR 20 BP 140/80
NAD
Lungs Mild Rhonchi
Heart RRR 3/6 SEM
Abdomen obese, benign
Extrem warm, 1+ edema
No Varicosities
Discharge:
VS T 97 BP 105/56 HR 65 SR RR 18 O2sat 94%/3LNP
Gen NAD
Neuro Alert, non focal exam
Pulm CTA bilat
CV RRR, no murmur. Sternum stable, incision CDI
Abdm Soft, NT/+BS
Ext warm, [**1-15**]+edema bilat
Pertinent Results:
[**2149-4-1**] 12:23PM GLUCOSE-127* NA+-136 K+-3.0*
[**2149-4-1**] 12:12PM UREA N-9 CREAT-0.7 CHLORIDE-114* TOTAL CO2-24
[**2149-4-1**] 12:12PM WBC-18.4* RBC-3.49*# HGB-9.7*# HCT-29.2*#
MCV-84 MCH-27.8 MCHC-33.1 RDW-15.1
[**2149-4-1**] 12:12PM PLT COUNT-187
[**2149-4-1**] 12:12PM PT-13.8* PTT-38.8* INR(PT)-1.2*
[**2149-4-8**] 05:20AM BLOOD WBC-9.6 RBC-3.33* Hgb-9.4* Hct-28.8*
MCV-87 MCH-28.3 MCHC-32.7 RDW-15.4 Plt Ct-233
[**2149-4-8**] 05:20AM BLOOD Plt Ct-233
[**2149-4-8**] 05:20AM BLOOD PT-11.8 PTT-20.9* INR(PT)-1.0
[**2149-4-7**] 06:20AM BLOOD Glucose-76 UreaN-11 Creat-1.0 Na-141
K-3.7 Cl-99 HCO3-40* AnGap-6*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2149-4-6**] 10:47 AM
CHEST (PA & LAT)
Reason: pna /plueral [**Hospital 18440**]
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with cosistanlt requiring O2, low BP post cabg
REASON FOR THIS EXAMINATION:
pna /plueral effussion
CHEST RADIOGRAPH
INDICATION: Oxygen requirement, rule out of pneumonia and
pleural effusion.
COMPARISON: [**2149-4-4**]. As compared to the previous
radiograph, the lung volumes have increased. Due to the
increased lung volumes, band-like opacities in both lung bases
are better seen than on the previous radiograph. These opacities
could correspond to plate-like atelectasis, old post- infectious
scars or cryptogenic organizing pneumonia. The remaining
differential diagnosis could be further worked up by CT. There
is unchanged subtle blunting of the right costophrenic angle,
suggestive of either a small pleural scar or a small pleural
effusion. No newly occurred opacities. No evidence of
hyperhydration or cardiac failure. The size of the cardiac
silhouette is slightly above the normal range.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 18441**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 18442**]
(Complete) Done [**2149-4-1**] at 8:34:23 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2100-1-23**]
Age (years): 49 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Left ventricular function.
Preoperative assessment.
ICD-9 Codes: 440.0, 424.1
Test Information
Date/Time: [**2149-4-1**] at 08:34 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW4-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aortic Valve - Peak Gradient: *40 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 16 mm Hg
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Bicuspid aortic valve. Moderately thickened aortic
valve leaflets. Systolic doming of aortic valve leaflets.
Moderate AS (AoVA 1.0-1.2cm2) Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is bicuspid. The aortic valve leaflets are
moderately thickened. There is systolic doming of the aortic
valve leaflets. There is moderate aortic valve stenosis (area
1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POSTBYPASS
Biventricular systolic function is preserved. There is a well
seated, well functioning bioprosthesis in the aortic position.
There is trace perivalvular AI. MR remains mild. The study is
otherwise unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2149-4-1**] 15:54
Brief Hospital Course:
She was a direct admission to the operating room on [**2149-4-1**]
where she underwent an AVR, please see OR report for details. In
summary she had AVR with 21mm [**Company 1543**] Mosaic valve, her bypass
time was 102 min with cross clamp of 75 minutes. She tolerated
the operation well and was transferred to the ICU in critical
but stable condition. She was extubated on the morning of POD #1
and later in the day was transferred to the floor. Once on the
floors she had an uneventful post-operative course. Her chest
tubes were removed late on POD1 and epicardial wires were
removed on POD3. Her activity was advanced by nursing and PT. On
POD4 she was transfused with PRBC's for a HCT of 22. her HCT
stayed stable over the next 2 days and on POD6 she was
transferred to rehabilitation at Lifecare of [**Location (un) 5165**].
Medications on Admission:
Prednisone 10', Albuterol, Lipitor 20', Budesonide 6', Pletal
100", Duloxetine 30", Chantix, Lasix 40", Folate 1', Boniva
150'Qmo,
Lisinopril 20', Ativan 0.5", Methadone 5 Q6/prn, Percocet
5/325-prn, Donnatal 16.2'/prn, Lyrica 150", Protonix 40",
Carafate 1", Sulfasalazine 1000", Spiriva 18', Trazadone 300/hs,
ASA 81', Calcium 500", Vit B12 100', MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Methadone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO bid ().
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Sulfasalazine 500 mg Tablet Sig: 1-2 Tablets PO TID (3 times
a day).
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
16. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
18. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
20. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): 14mg/day x 1 week then 7mg/day patch.
21. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
22. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain.
23. Boniva 150 mg Tablet Sig: One (1) Tablet PO once a month.
24. Donnatal 16.2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for diarrhea.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
AS/AI now s/p AVR
PMH: HTN,^chol,COPD,PHTN,PVD,Crohn's, s/p GIB,Gastritis,GERD,
Depression,CHF,Skin CA s/p excision(nose),L ear
chrondrodermatitis,osteopenia,restless leg,C-sectionx2,R arm
bypass/embolectomy,L caf debridement
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Already scheduled appointments:
Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 18443**] [**Name12 (NameIs) 815**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2149-4-14**] 1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2149-4-14**]
3:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2149-6-30**]
10:20
Completed by:[**2149-4-8**]
ICD9 Codes: 496, 4019, 2720, 4168, 4280, 311, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3907
} | Medical Text: Admission Date: [**2177-8-31**] Discharge Date: [**2177-9-4**]
Date of Birth: [**2143-4-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
fever and diarrhea
Major Surgical or Invasive Procedure:
R IJ central line placement
History of Present Illness:
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**] ([**Hospital1 778**])
.
HPI: 34 year old male with HIV (last CD4 of 356, VL of 3000; not
on HAART), a h/o skin abscesses presents with fever, diarrhea,
dysuria and generalized body aches.
.
Patient was in his USOH until yesterday when he developed a
transient headache. The morning PTA, he felt febrile, had chills
and developed generalized body aches, neck stiffness, diarrhea
and dysuria. He had 3-4 episodes of watery/bloody diarrhea
associated with mild, diffuse, intermittent abdominal pain that
did not radiate and was dull in nature. No N/V but no PO intake
since Saturday. He denies any sick contacts, recent or remote
travel, or intake of unusual foods or unwashed salad.
Further workup in the ED included a head CT which did not show
any significant findings. An LP was performed given his nuchal
rigidity. Protein, Glucose and cell count in CSF were
unrevealing. CSF cultures were sent off. He initially received
ceftriaxone, ampicillin and vancomycin for antibiotic coverage.
Later during his ED stay, he was also administered one dose of
levo and flagyl for abdominal coverage. Finally, a CT of the
abdomen and pelvis was performed to search for an abscess or
other infectious source. It showed signs compatible with mild
colitis and patient was admitted to the ICU for further workup
and treatment.
.
ROS: Mild SOB, no CP, no cough or nightsweats. Otherwise
pertinent positives and negatives as above.
Past Medical History:
- HIV (dx in [**2174**]; acquired via sex with his ex-boyfriend; not
on HAART; last CD4 count 356, last VL 3000 - both from [**2176-11-20**]
per PCP. CD4 never below 200 and VL never above [**Numeric Identifier 961**] per
patient)
- frequent skin abscesses ([**11-22**] MRSA nose infection; [**12-23**]
hospitalized for buttock abscess; '[**75**] leg abscess; [**6-26**] penile
shaft abscess)
Social History:
Cigarette smoking: 1ppd for 10 yrs, no alcohol, no IV drug use
but Ecstasy, Ketamine, Crystal meth (not recently). Works as
political consultant.
Family History:
non-contributory
Physical Exam:
VS: Temp: 97.4, BP: 101/62, HR: 88, RR: 15, O2sat 100% on RA
GEN: athletic male lying relatively comfortable in bed
[**Name (NI) 4459**]: [**Name (NI) 2994**], EOMI, anicteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, sparse b/s, soft, diffusely tender with guarding but no
rebound, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. 5/5 strength throughout.
RECTAL: guaiac negative in the ED
Pertinent Results:
[**8-31**]
Labs in the ED:
128 92 20
===========121
3.8 25 1.4
.
Ca: 8.4 Mg: 1.7 P: 2.3
ALT: 22 AP: 76 Tbili: 1.1 Alb: 4.0
AST: 20 LDH: Dbili: TProt:
[**Doctor First Name **]: 48 Lip: 13
.
WBC 11.2 (down to 5.5 after IVF), Hct 42.6, Plt 283
N:35 Band:32 L:17 M:4 E:0 Bas:0 Atyps: 2 Metas: 8 Myelos: 2
.
Lactate 2.7 --> 1.1
.
CSF Studies:
- Appearance was clear and colorless.
- CSF Chemistry: Protein 37, Glucose 74
- CSF Cell count: WBC 4, RBC 4, Poly 0, Lymph 87, Mono 13
MICROBIOLOGY
[**8-31**] URINE CULTURE- NO GROWTH
[**8-31**] BLOOD CULTURES-
[**9-1**]- FECAL CULTURE-PENDING; CAMPYLOBACTER CULTURE-PENDING; OVA
+ PARASITES-FINAL {BLASTOCYSTIS HOMINIS}; FECAL CULTURE - R/O
VIBRIO-PENDING; FECAL CULTURE - R/O YERSINIA-PENDING; FECAL
CULTURE - R/O E.COLI 0157:H7-PENDING; MICROSPORIDIA STAIN-FINAL;
CYCLOSPORA STAIN-FINAL; Cryptosporidium/Giardia (DFA)-FINAL;
CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL; VIRAL CULTURE-PENDING
[**2177-9-1**] BLOOD CULTURE -
[**2177-9-1**] URINE CULTURE-
IMAGING
[**8-31**] CXR PA/LAT No acute intrathoracic process, specifically no
evidence of pneumonia.
CT HEAD W/O CONTRAST [**2177-8-31**] 6:19 PM No acute intracranial
hemorrhage or mass effect.
[**2177-9-1**] Radiology CT ABD/PELVIS W/CONTRAST No prior imaging is
available for comparison.
IMPRESSION:
1. Colitis affecting the majority of the colon as detailed
above. Likely differential considerations include infectious
etiologies given the patient's clinical history. Recommend
clinical correlation.
Brief Hospital Course:
34 year old male with HIV (last CD4 of 356, VL of 3000; not on
HAART), a h/o skin abscesses presents with fever, diarrhea,
dysuria and generalized body aches, admitted to the ICU for
sepsis.
.
# Fever/hypotension: Met SIRS criteria during initial
presentation in ED. Lactate was initially 2.7. WBC with marked
left-shift. Broad ddx for infection given HIV infection. Head CT
and LP were unrevealing. No cough and CXR unremarkable. Dysuria
but negative UA. Diarrhea and initial abdominal rigidity in the
ED pointed towards GI source. LFTs and pancreatic enzymes were
negative. Abdominal CT showed signs of mild colitis. Pt received
a total of 6L IVF in the ED and was started on broad spectrum
abx and levophed. Received CTX, ampicillin, Vanco, Levo and
Flagyl in the ED. Continued levo/flagyl for abdominal coverage
in ICU. A CVL was placed. CVP was 10 on admission. UOP and O2
sats were stable. Pt weaned off levophed in am of [**9-1**], received
1.5L NS in ICU on admission night, lactate trended down, and
remained hemodynamically stable, and transferred to a general
medical floor.
# Diarrhea: Acute onset, bloody diarrhea with marked bandemia
pointing towards bacterial etiology. No recent travel, sick
contacts or unusual food intake. CT abdomen/pelvis with signs of
mild colitis. Broad ddx in HIV patient, initial stool studies
were negative, however, the lab reported shigella on hospital
day 4, just after the patients discharge. The patient had
already improved clinically, was tolerating a regular diet,
ambulating, and had been on 4 days of appropriate
antimicrobials. Efforts were made to contact the patient, to
inform him of the final diagnosis, however attempts were
unsuccessful as the patient could not be reached at contact
numbers in the chart and the patient splits his time between
[**Location (un) **] and phoenix.
#+CSF cultures -an lp was performed in the ED upon admission.
WBC was 4, no poly's, protein glucose were normal. On hospital
day 3 the lab called that coag negative staph and strep species
were growing in the csf and deemed most likely a contaminant by
the lab. By this point the patient was afebrile, ambulating and
had no symptoms of headache, meningismus, visual changes, fever,
or any other symptoms to suggest an active csf infection. He was
instructed upon discharge to return or seek medical attention if
he experienced any recurrence of headache, fever, or any other
questions or concerns.
.
# HIV: Followed at [**Hospital 778**] Clinic. Not on HAART; last CD4 count
356, last VL 3000 - both from [**2176-11-20**] per PCP. [**Name Initial (NameIs) 23198**] CD4
nadir (per pt never below 200). He Should have CD4 count and VL
checked when clinically improved (either before discharge or as
outpatient). He expressed wanting to be established with a new
provider either here or in phoenix. An appointment was made for
a new provider here at [**Hospital1 18**] to discuss initiating HAART.
Medications on Admission:
none (Wellbutrin in the past - not recently taken)
Discharge Medications:
1. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
3. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
4. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for 3 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
gastroenteritis
acute colitis, likely bacterial
Discharge Condition:
improved
Discharge Instructions:
complete antibiotics as prescribed. seek medical attention if
worsening symptoms, inability to keep adequatly hydrated,
worsening headache, fever >100.5, or any other concerns or
questions.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2177-10-3**] 9:00
[**Hospital **] clinic for new provider [**Name Initial (PRE) 648**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2177-9-9**]
ICD9 Codes: 2761, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3908
} | Medical Text: Admission Date: [**2159-9-22**] Discharge Date: [**2159-9-28**]
Service:
HISTORY OF PRESENT ILLNESS: This is an 83-year-old man with
a history of end-stage renal disease on hemodialysis, CAD,
atrial fibrillation on digoxin, congestive heart failure,
transferred from rehabilitation for chest pain and
bradycardia. The patient had three hospital admissions over
the last month for increased gait disturbance thought to be
secondary to worsening spinal stenosis, increased confusion,
bowel incontinence, was stabilized and sent to rehabilitation
each time without definite diagnosis. He did receive
intravenous antibiotics several times and steroid injections
for spinal stenosis. At rehabilitation he was doing well,
alert and oriented x 3, when he complained of chest pain and
diaphoresis on the morning of admission. The patient was
given his AM cardiac medications and later found to have a
heart rate of 20s to 30s, did not have loss of consciousness.
In the ambulance he was given atropine, external pacing was
started, and he was given Versed 2 mg. In the Emergency
Department he had a heart rate of 26, blood pressure of
90/40. He was given 1 mg of atropine, 1 amp of bicarbonate,
2 mg of Versed x 2. Heart rate increased to 50s to 60s,
pacing was able to be stopped. He received EP evaluation who
felt bradycardia was likely due to digoxin toxicity. He
received a renal evaluation and urged to check digoxin level.
He was scheduled for hemodialysis on the day of admission,
and he was to have medical intensive care unit monitoring.
PAST MEDICAL HISTORY: 1. End-stage renal disease on
hemodialysis Tuesday, Thursday, and Saturday, for two years.
2. Coronary artery disease status post myocardial infarction
12 years ago. 3. Congestive heart failure, left ventricular
ejection fraction of 40%. 4. Paroxysmal atrial fibrillation.
5. Hypertension. 6. Diabetes mellitus type 2. 7.
Cerebrovascular accident with residual difficulty swallowing.
8. Anemia on Epogen. 9. Benign prostatic hypertrophy. 10.
Peripheral vascular disease. 11. Spinal stenosis with
steroid injections. 12. Ischemic colitis. 13. History of
positive palpated.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: 1. LAntus. 28 q.h.s. 2.
Regular Insulin sliding scale. 3. Nephrocaps 1 q.d. 4.
Megace 20 cc q.d. 5. Digoxin 0.125 mg q.o.d. 6. Coreg 6.25
mg b.i.d. 7. Tums one tablet t.i.d. 8. Diltiazem 90 q. 6
hours. 9. Lipitor 10 q.h.s. 10. Magnesium oxide 400 b.i.d.
11. Coumadin 2 q.h.s. 12. Epogen q. hemodialysis.
PHYSICAL EXAMINATION: On admission his vital signs were
pulse 73, blood pressure 141/59, respiratory rate 20, oxygen
saturation 96% on 100% nonrebreather. In general he was an
elderly man, somnolent, opened eye to voice. HEENT: Pupils
were equal, round, and reactive to light, oropharynx dry.
Neck: No jugular venous distension, no bruit.
Cardiovascular: Normal S1 and S2, regular rate and rhythm.
Lungs: Decreased breath sounds at the bases with rales left
greater than right, diffuse expiratory wheezing. Abdomen:
Softly distended, positive bowel sounds, nontender.
Extremities: Left chest tunneled catheter and no edema.
LABORATORY DATA: Admission white count was 21.3, hematocrit
30.0, hemoglobin 10.0, MCV 103, platelet count 230. Sodium
133, potassium 5.9, chloride 92, CO2 19, BUN 91, creatinine
7.0, glucose 285, 71% neutrophils, 18 lymphocytes, 9
monocytes, 0.3 eosinophils, 0.4 basophils. INR was 3.5, PT
23, PTT 36.5. Digoxin level was 2.7. CK 557, troponin T
3.8, calcium 9.0, phosphate 8.7, magnesium 2.0.
Chest x-ray was significant for minimal upper zone
distribution, right pleural effusion.
EKG showed atrial fibrillation at 55 beats per minute, normal
axis, no P wave. Q waves in 2, 3 and aVF, V4 through V6.
HOSPITAL COURSE: 1. Bradycardia: The patient's digoxin,
calcium channel blocker, and beta blocker were all held. His
digoxin level was decreased to 1.4 the day prior to
admission. Digoxin was not to be restarted. Calcium channel
blocker was not restarted. Beta blocker was restarted. The
patient tolerated metoprolol. It was titrated up and was
sent out on Coreg 6.25 b.i.d. as outpatient regimen. His ACE
inhibitor was restarted and controlled his blood pressure at
a dose of 25 mg p.o. q.i.d. of captopril. The patient had no
more episodes of bradycardia. Heart rates were in the 60s to
80s and he was taken off telemetry.
2. Pleural effusion, right: The patient had a chronic right
pleural effusion that was documented by several x-rays. The
patient had an elevated white count. Pleural effusion
resolved post dialysis and was not tapped, not felt to be
related to the white count.
3. Elevated white count: The patient had an elevated white
count in the 15-20 range over the past month or two. Work-up
for infection has been negative. The patient will most
likely need a bone marrow biopsy as an outpatient when he
stabilizes.
The patient's INR was 3.5 on admission. Coumadin was held
and the INR came down to 1.4 with anticipation of
thoracentesis. Thoracentesis of the pleural effusion was not
performed, and Coumadin was restarted to titrate up with a
goal of [**3-12**] due to atrial fibrillation.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Bradycardia.
2. Digoxin toxicity.
DISCHARGE MEDICATIONS:
1. Nephrocaps 1 capsule p.o. q.d.
2. Calcium carbonate 500 mg p.o. t.i.d.
3. Ranitidine 150 mg p.o. q.d.
4. Enteric-coated aspirin 81 mg p.o. q.d.
5. Atorvastatin 10 mg p.o. q.d.
6. Insulin sliding scale.
7. Colace 100 mg p.o. b.i.d.
8. Senna 1 tablet p.o. b.i.d. p.r.n.
9. Captopril 25 mg p.o. q.i.d.
10. Carvedilol 6.25 mg p.o. b.i.d.
11. Warfarin 2 mg p.o. q.d., please check INR for goal of
[**3-12**].
FOLLOW-UP PLANS: The patient will follow up with his primary
care physician, [**Name10 (NameIs) **] renal doctor, GI, cardiology with one to
two weeks.
DISPOSITION: The patient will be discharged to [**Location (un) 620**]
nursing facility at [**Street Address(2) 49790**]. Needs to be
rescreened.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (STitle) 49791**]
MEDQUIST36
D: [**2159-9-28**] 10:36
T: [**2159-9-28**] 11:08
JOB#: [**Job Number 49792**]
ICD9 Codes: 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3909
} | Medical Text: Admission Date: [**2110-5-9**] Discharge Date: [**2110-5-13**]
Date of Birth: [**2054-5-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 yo M with history of DM, HTN, high cholesterol presented to
the ED with sevedral days of nausea and vomiting. The patient
reports being in his USOH until Monday, 5 days prior to admssion
when he developed malaise, rigors, and myalgias. He did not
check his temperature. He then developed nausea, vomiting,
non-bilious, non-bloody. He reports not being able to tolerate
any po's since Monday. He reports 5-6 episodes of emesis daily.
He said he stopped taking all of his usual medications,
including insulin on Monday because he was not sure what was
going on. He had been taking Advil with relief in symptoms. He
denies diarrhea, abdominal pain, cough, chest pain before coming
to the ED (developed non-productive cough in the ED). No sick
contacts.
.
ED course: VS on admission T 100.7; HR 119; BP 184/77; RR 30; O2
98% RA. Labs were significant for WBC of 17, Cr 2.5, K 3.2,
serum glucose 474, presence of urine glucose 1000; urine ketones
15. AG =19 initially. Lactate 1.6. Trop 0.12; CK [**2049**]; MB 9 on
presentation (with Cr 2.5. Trop went up to 0.38. EKG sinus rate
104; new ST depression in aVL on this am's EKG.
.
Patient resuscitated with 2L NS. In the ED the paitent was also
given:
Acetaminophen 1000 mg x 2, Insulin Human Regular 6 units IV and
8 units SC; Ondansetron 4 mg IV x 2; Levofloxacin 750mg; Aspirin
325mg.
.
By the time the patient arrived to the floor, he felt improved.
Continues to have nausea. Denies CP or any other symptpoms. He
has nver had DKA before.
Past Medical History:
1. HTN
2. DM type 2
3. Hypercholesterolemia
4. Hepatitis C
5. PUD
6. R cranial nerve palsy
7. Erectile dysfunction
8. Prostatitis
9. BPH
10. L renal cell carcinoma
11. LLL radiculopathy
12. Microalbuminuria
Social History:
Lives with wife. [**Name (NI) **] children. Quit smoking 20 y ago. No alcohol
Family History:
Noncontributory
Physical Exam:
VS: 100.9 95 156/94 27 97% RA
General: resting in bed; pleasant; alert and oriented x 3; NAD;
breathing comfortably
HEENT: OP clear; no scleral icterus; MM sl dry
Neck: no JVD, no bruits
Heart: regular, nl S1S2, no m/rubs/gallops
Lungs: soft crackles at left base
Abd: + BS, soft, NT, ND
Ext: no edema, palp pulses throughout
Pertinent Results:
[**2110-5-8**] 11:00PM URINE GRANULAR-0-2
[**2110-5-8**] 11:00PM URINE RBC-[**1-27**]* WBC-[**5-4**]* BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2110-5-8**] 11:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2110-5-8**] 11:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2110-5-8**] 11:30PM PT-11.1 PTT-27.2 INR(PT)-0.9
[**2110-5-8**] 11:30PM PLT SMR-NORMAL PLT COUNT-337
[**2110-5-8**] 11:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2110-5-8**] 11:30PM NEUTS-94.9* BANDS-0 LYMPHS-3.2* MONOS-1.9*
EOS-0.1 BASOS-0
[**2110-5-8**] 11:30PM WBC-17.3*# RBC-3.50* HGB-10.7* HCT-29.6*
MCV-85 MCH-30.5 MCHC-36.0* RDW-14.4
[**2110-5-8**] 11:30PM CK-MB-9 cTropnT-0.12*
[**2110-5-8**] 11:30PM CK(CPK)-[**2049**]*
[**2110-5-8**] 11:30PM estGFR-Using this
[**2110-5-8**] 11:30PM GLUCOSE-474* UREA N-41* CREAT-2.8* SODIUM-134
POTASSIUM-3.6 CHLORIDE-93* TOTAL CO2-22 ANION GAP-23
[**2110-5-8**] 11:48PM GLUCOSE-446* LACTATE-2.0 K+-3.6
[**2110-5-9**] 01:44AM LACTATE-1.6 K+-3.2*
[**2110-5-9**] 01:44AM COMMENTS-GREEN TOP
[**2110-5-9**] 04:00AM CK-MB-11* MB INDX-0.6 cTropnT-0.33*
[**2110-5-9**] 04:00AM LIPASE-41
[**2110-5-9**] 04:00AM ALT(SGPT)-37 AST(SGOT)-73* CK(CPK)-1705* ALK
PHOS-64 TOT BILI-0.4
[**2110-5-9**] 04:00AM GLUCOSE-298* UREA N-39* CREAT-2.5* SODIUM-133
POTASSIUM-3.2* CHLORIDE-98 TOTAL CO2-24 ANION GAP-14
[**2110-5-9**] 05:45AM CK-MB-10 MB INDX-0.5 cTropnT-0.38*
[**2110-5-9**] 05:45AM CK(CPK)-1828*
[**2110-5-9**] 10:29AM PLT COUNT-291
[**2110-5-9**] 10:29AM WBC-14.1* RBC-3.01* HGB-9.0* HCT-26.1* MCV-87
MCH-29.8 MCHC-34.3 RDW-14.4
[**2110-5-9**] 10:29AM CALCIUM-8.0* PHOSPHATE-2.6*
[**2110-5-9**] 10:29AM CK-MB-12* MB INDX-0.7 cTropnT-0.58*
[**2110-5-9**] 10:29AM ALT(SGPT)-39 AST(SGOT)-87* CK(CPK)-1776* ALK
PHOS-64 TOT BILI-0.5
[**2110-5-9**] 10:29AM GLUCOSE-303* UREA N-35* CREAT-2.3* SODIUM-135
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13
[**2110-5-9**] 11:15AM URINE OSMOLAL-430
[**2110-5-9**] 11:15AM URINE HOURS-RANDOM CREAT-63 SODIUM-23
[**2110-5-9**] 06:30PM PLT COUNT-321
[**2110-5-9**] 06:30PM WBC-14.5* RBC-2.36* HGB-7.1* HCT-19.5*#
MCV-83 MCH-30.0 MCHC-36.3* RDW-14.5
[**2110-5-9**] 06:30PM CALCIUM-7.8* PHOSPHATE-1.5* MAGNESIUM-1.8
[**2110-5-9**] 06:30PM CK-MB-9 cTropnT-1.14*
[**2110-5-9**] 06:30PM GLUCOSE-113* UREA N-32* CREAT-2.2*
SODIUM-131* POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-21* ANION
GAP-12
[**2110-5-9**] 10:00PM PLT COUNT-269
[**2110-5-9**] 10:00PM WBC-11.4* RBC-2.67* HGB-7.9* HCT-22.4* MCV-84
MCH-29.6 MCHC-35.2* RDW-14.7
[**2110-5-9**] 10:00PM CALCIUM-7.7* PHOSPHATE-2.3* MAGNESIUM-1.8
[**2110-5-9**] 10:00PM GLUCOSE-113* UREA N-32* CREAT-2.2* SODIUM-133
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-22 ANION GAP-11
.
[**2110-5-9**]: Sinus tachycardia. There is a late transition with tiny
R waves in the anterior leads consistent with possible prior
anterior wall myocardial infarction. Minimal ST segment
elevation in the inferior leads consistent with possible
ischemia or infarction. Clinical correlation is suggested.
Compared to the previous tracing left ventricular hypertrophy is
no longer apparent and ST segment elevation is new.
.
[**2110-5-9**] AXR: Fidnings suggestive of mild partial or early small
bowel obstruction. If clinically indicated, continued monitoring
is advised.
.
[**2110-5-9**] CXR: Left lower lobe pneumonia.
.
[**2110-5-10**] Echo: Mild left ventricular cavity enlargement with
moderate global hypokinesis suggestive of a diffuse process
(toxin, metabolic, etc. - though cannot fully exclude
multivessel CAD).
.
[**2110-5-9**] EKG: Sinus tachycardia. Left axis deviation. Late
transition with tiny R waves in the anterior leads consistent
with possible prior anterior wall myocardial infarction. Minimal
ST segment elevation in the inferior leads with diffuse ST-T
wave changes consistent with possible ischemia or infarction.
Clinical correlation is suggested.
.
[**2110-5-9**] EKG: Sinus tachycardia. Probable left ventricular
hypertrophy. Non-specific ST-T wave changes. Compared to the
previous tracing of [**2110-5-9**] no change.
.
[**2110-5-10**] EKG: Sinus rhythm. Compared to the previous tracing the
rate is slower.
.
[**2110-5-11**] CXR: Sinus rhythm. Compared to the previous tracing the
rate is slower.
.
[**2110-5-11**] EKG: Sinus rhythm. Occasional atrial premature beats.
Leftward axis. Intraventricular conduction delay. Non-specific
ST-T wave changes. Compared to the previous tracing of [**2110-5-10**]
atrial ectopy is new. The QRS duration is similar.
.
[**2110-5-12**] CXR: Consolidation in the left lower lobe, not
significantly changed since the prior radiographs.
Brief Hospital Course:
Mr. [**Known lastname **] is a 55 year old man with diabetes, hypertension,
and hyperlipidemia, who presented with fever, nausea, and
vomiting, and who was found to be in DKA with infiltrate on CXR,
now positive for Legionella. His brief hospital course, by
problem:
.
#) Pneumonia. Urinary Legionella antigen positive, treated
empirically for CAP for 3 days with levofloxacin. Afebrile,
leukocytosis resolved, satting well on room air. CXR showed that
pneumonia unchanged. He was given a total 14-day course of
levofloxacin.
.
#) NSTEMI. Subendocardial ischemia in the setting of acute
demand from difficult-to-control hypertension/fever/pneumonia.
Non-specific EKG changes. Enzymes trending down. He will get a
P-MIBI once pneumonia has resolved and blood pressure is better
controlled; it was scheduled for [**6-4**]. Continued aspirin,
statin, beta blocker, [**Last Name (un) **]. Blood pressure was aggressively
controlled, and the patient was discharged on many blood
pressure medications (see med list).
.
#) Anemia. Received 2 units of pRBC's in MICU. Hematocrit
remained stable.
.
#) Hypertension. Has been difficult to control, requiring
esmolol and nitro drip for control. Blood pressure on floor has
been 142-180 systolic. Titrated medications to max dose; the
patient has follow up appointment with his PCP next week for
further titration of blood pressure medications.
.
#) Elevated blood glucose. Likely high in the setting of
infection. Initial anion gap closed quickly. Blood sugars have
been well controlled since transfer. He was continued on Lantus
while inpatient, and his outpatient oral hypoglycemic
medications were restarted at the time of discharge.
.
#) Nausea. Resolved.
.
#) Metabolic acidosis/resp alkalosis. Anion gap is 12. [**Month (only) 116**] have
respiratory alkalosis from pneumonia, with compensatory renal
acidosis. Mildly elevated anion gap (12) was concerning given no
clear source (lactate WNL, blood glucose has been well
controlled, ? renal failure). It resolved by the time of
discharge.
.
#) Renal failure. s/p left nephrectomy with rising creatinine
over the past few months (appears baseline is 1.6-2.0 or so).
MRI in [**12/2109**] showed widely patent R kidney vasculature.
Creatinine was monitored and remained stable.
Medications on Admission:
Aspirin 81mg daily
Neurontin 300mg [**Hospital1 **]
Vytorin 10-40mg daily
Glipizide 10mg [**Hospital1 **]
Metoprolol 50mg [**Hospital1 **]
Prilosec daily
Glucophage 1000mg [**Hospital1 **]
Levirmir Pen 10mL at bedtime
Norvasc 5mg daily
Doxazosin 2mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
Disp:*180 Tablet(s)* Refills:*2*
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO once a day.
8. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
9. Neurontin 300 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
13. Levemir Flexpen 100 unit/mL Insulin Pen Subcutaneous
14. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Type 2 diabetes
Hypertension
Demand ischemia
Discharge Condition:
Stable, blood pressures improved,
Discharge Instructions:
You were admitted with high blood pressure, high blood sugars,
and pneumonia. You are being treated with many new blood
pressure medications and antibiotics for the pneumonia. Please
take all of the new medications as prescribed, and complete the
entire course of the antibiotics.
.
If you develop nausea, vomiting, dizziness, chest pain,
shortness of breath, high fevers, or other concerning symptoms,
please seek medical attention immediately.
Followup Instructions:
You have been
Chest X-ray: To be scheduled by Dr. [**Last Name (STitle) 5717**]
Stress Test: Tuesday, [**2110-5-27**], at 10am. [**Location (un) **] of
[**Hospital Ward Name 23**] Building on [**Hospital Ward Name 516**] of [**Hospital1 18**].
- No smoking or eating for 2 hours prior to the test
- No caffeine or decaffeinated products for 12 hours prior to
the test
- They will send a letter
Please follow up with Dr. [**Last Name (STitle) 5717**] as previously scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2110-5-22**] 9:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2110-5-23**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2110-6-10**] 9:10
ICD9 Codes: 5849, 486, 5859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3910
} | Medical Text: Admission Date: [**2192-12-21**] Discharge Date: [**2192-12-22**]
Date of Birth: [**2124-12-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 nursing home resident with h/o AF, CVA, prostate CA, HCC,
+MRSA screen, found unresponsive and hypotensive at his nursing
home in respiratory distress with SaO2 76%, increasing to 92%
with "high flow O2". VS in the field were T 100.9F, BP 70/40, HR
110, SaO2 78% RA. He had been noted the previous night to have
some respiratory distress. The next morning, this was again
seen, along with congestion. A CXR was done which was reportedly
read as normal. He was transported to [**Hospital3 1196**],
where he was intubated with etomidate/succinylcholine. CXR
demonstrated LLL and RLL infiltrates, mod pulmonary edema. Also
noted to be hypernatremic at 157. He was given vancomycin 1gm
and moxifloxacin 400mg IV. He was started on peripheral dopamine
for hypotension. He was send to [**Hospital1 18**] ED, where initial VS were
BP 108/59, HR 151 in AF, RR 14, satting 100% on AC 500 x 14/ 5 /
100%. ABG: 7.24/47/210. A RIJ was attempted, but unsuccessful,
and was coverted to a R femoral TLC and switched from dopamine
to levophed. He was given 5L NS, flagyl 500mg IV, and ativan 2mg
IV, and send to the floor for further management.
Past Medical History:
1) AF
2) HTN
3) h/o CVA
4) prostate CA
5) "liver cancer"
6) h/o aspiration PNA, chronically NPO with PEG
7) Major depression
8) +MRSA screen
Social History:
3 children and several step children living with wife.
Separated. 10yr [**Name2 (NI) **] h/o, denies etOH or drugs.
Family History:
nc
Physical Exam:
T: 97.8F BP: 129/70, HR 139, RR 21, SaO2 98% on AC 500x28, PEEP
10, 60% FIO2.
Gen: Ill-appearing man, ventilated, not opening eyes to command.
HEENT: PERRL, OP dry
CV: Tachycardic, [**Last Name (un) 3526**] [**Last Name (un) 3526**], no m/r/g
Chest: Coarse BS anteriorly, crackles in bases laterally
bilaterally
Abd: Obese, soft, NT/ND, +BS
Extr: No LE edema, 1+ DPs
Neuro: no gross facial assymmetry, PERRL, oculocephalics intact.
1+ DTRs LUE, [**Name2 (NI) **], 2+ RUE, RLE, toes equivocal bilaterally.
.
Pertinent Results:
[**2192-12-21**] 12:30AM BLOOD WBC-5.7 RBC-3.55* Hgb-11.4* Hct-34.0*
MCV-96 MCH-32.1* MCHC-33.5 RDW-14.8 Plt Ct-324
[**2192-12-21**] 03:36AM BLOOD WBC-5.5 RBC-2.86* Hgb-9.1* Hct-27.7*
MCV-97 MCH-31.9 MCHC-33.0 RDW-14.7 Plt Ct-273
[**2192-12-21**] 12:30AM BLOOD Neuts-54 Bands-8* Lymphs-29 Monos-8 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2192-12-21**] 03:36AM BLOOD Neuts-75.4* Bands-0 Lymphs-22.0 Monos-2.0
Eos-0.3 Baso-0.2
[**2192-12-21**] 01:35AM BLOOD PT-14.0* PTT-31.0 INR(PT)-1.2*
[**2192-12-21**] 12:30AM BLOOD Glucose-121* UreaN-62* Creat-1.3* Na-159*
K-4.0 Cl-128* HCO3-21* AnGap-14
[**2192-12-21**] 12:30AM BLOOD CK(CPK)-353*
[**2192-12-21**] 12:30AM BLOOD CK-MB-3 cTropnT-0.13*
[**2192-12-21**] 12:30AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.7*
[**2192-12-21**] 03:14PM BLOOD Cortsol-27.1*
[**2192-12-21**] 12:36AM BLOOD pH-7.26* Comment-GREEN TOP
[**2192-12-21**] 08:46AM BLOOD Type-ART pO2-103 pCO2-45 pH-7.27*
calTCO2-22 Base XS--5
[**2192-12-21**] 12:36AM BLOOD Glucose-117* Lactate-2.0 Na-159* K-3.9
Cl-125*
.
Head CT: IMPRESSION:
1. No hemorrhage.
2. Large right chronic MCA infarct and chronic left basal
ganglia lacunar infarct.
3. Mucosal thickening of the ethmoid air cells.
MRI with diffusion-weighted images is more sensitive in the
detection of acute infarct.
.
CT chest: IMPRESSION:
1. Dense consolidation in the left and right lower lobes.
Multifocal nodular and parenchymal opacities consistent with
infection, which may be bacterial or atypical in origin.
Peripheral based opacities are likely an extension of the
infectious process. Septic emboli are less likely.
2. No pulmonary embolus.
Brief Hospital Course:
68M with h/o CVA, AF, prostate CA, and hepatic CA, presenting
with shock and respiratory failure, most likely [**1-18**] PNA.
.
Plan:
1) Septic shock: Blood and sputum cultures pending. After
speaking with pt's wife (separated) and legal guardian, decision
made to focus on comfort measures only, due to critical illness
complicated by RVR from AF in patient with already profoundly
deteriorated functioning following recent stroke with small
probability of returning even to previous baseline function.
Guardian and wife agreed to extubation and withdrawal of
pressors. Placed on morphine gtt and scopolamine patch for
comfort
Pt died at 9:51pm on [**2192-12-22**].
.
2) AF with RVR: Refractory to IV boluses and metoprolol and
diltiazem. Likely exacerbated by infection and
dopamine/levophed.
.
3) Comfort care
- Morphine gtt
- Scopolamine patch
Medications on Admission:
Digoxin 250mcG qD via PEG
ASA 325mg PO qD via PEG
Diltiazem 60mg qid via PEG
Metoprolol 75mg qid via PEG
Neurontin 200mg/200mg/300mg via PEG
Seroquel 37.5mg qAM, 112.5mg qHS via PEG
Percocet 1 tab qid via PEG
MVI 5L PO qD via PEG
Thiamine 100mg qD via PEG
[**Name (NI) 10687**], MOM
[**Name (NI) **] 500mg q6h prn via PEG
Guiatuss 10mL 16h prn via PEG
Jevity TF 360cc 5x/day
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
pneumonia
septic shock
history of cerebrovascular accident
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2192-12-23**]
ICD9 Codes: 0389, 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3911
} | Medical Text: Admission Date: [**2168-9-6**] Discharge Date: [**2168-9-28**]
Date of Birth: [**2142-10-11**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Oxycodone / Demerol / MS Contin / Penicillins /
Fentanyl / Bactrim / Tamiflu / Keflex
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Left chest Port-A-Cath removal
Insertion and subsequent removal of right-sided PICC
History of Present Illness:
Ms. [**Known lastname **] is a 25F with IDDM1 c/b chronic pancreatitis and
gastroparesis with chronic g-j tube, depression, and borderline
personality disorder who p/w with abdominal pain since the
evening PTA. She reports abdominal pain [**9-16**] in intensity and
similar to previous pancreatitis pain, radiating to the back "a
little," in association with T to 101, chills/sweats,
nausea/vomiting, and loose stools. She denies hematemesis or
melena/BRBPR. She also endorses chest pain and shortness of
breath, but denies joint pains, rashes, or dysuria. She
indicates that she has been compliant with her insulin regimen
at home. Of note, she has had repeated admissions for similar
symptoms, most recently in [**7-19**], when she was found to have DKA.
In the ED, she was found to be in DKA with glucose of 595, AG of
27 with uncorrected Na of 132, and UA with 40 ketones and 1000
glucose. She received 2L IVNS and was started on an insulin gtt
at 7u/hour. On exam, her lungs were clear, and UA was otherwise
negative for infection. VS on transfer were: 98.0, 107, 122/78,
18, 100% RA. Of note, she has a h/o multiple ED visits for
chronic abdominal pain and remains on a strict narcotics
contract, including 6mg PO Dilaudid q3h prn pain. On arrival to
the MICU, VS were as follows: 98.5, 99, 108/62, 14, 97% RA. She
was crying and requesting medication for abdominal pain.
Past Medical History:
IDDM1 c/b gastroparesis with chronic g-j tube (though most
recent gastric emptying study in [**4-17**] was normal)
Chronic abdominal pain presumed to be chronic pancreatitis
(narcotics contract with [**Hospital1 **] PCP; reportedly receives weekly
prescription on Tuesdays, though she reports she is no longer
seeing her [**Hospital1 **] PCP)
- pancreatic divisum (fibrosis and calcification in the pancreas
as well as 2 completely separate pancreatic ducts on ERCP)
- ampullary stenosis s/p stenting
Depression and borderline personality disorder with h/o cutting
behavior and suicide attempts
Asthma
H/o urinary retention
PUD due to H. pylori
Gastritis
Iron deficiency anemia
R adnexal cyst
S/p Cholecystectomy
Social History:
She was born in the [**Country 13622**] Republic and moved to the United
States as a child. She has a sister, who is married with a
child/children. She has a strained relationship with other
relatives, most notably her father, against whom she has a
restraining order. She lives with her husband in a multi-bedroom
apartment in [**Location (un) 686**], where she feels unsafe due to the
presence of weapons in her landlord's room, as well as a prior
attempt by her landlord to harm/threaten her by slashing her
Port. She reportedly works at an electronics store in [**Location (un) 14307**] as a technician. Endorses intermittent cigarette smoking.
Denies EtOH or illicit/IVDU.
Family History:
Mother, grandmother, and uncle with DM. Uncles with chronic
pancreatitis. No family h/o diabetic gastroparesis.
Physical Exam:
On admission:
VS: 98.5, 108/62, 99, 14, 97% RA
General: Alert, oriented, crying, but with very flat affect and
voice
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, TTP over RUQ, only mild TTP with deep palpation
over epigastrium and elsewhere, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
At discharge:
Afebrile/AVSS.
General: Lying comfortably in bed
CV: RRR, no m/r/g
Lungs: CTAB
Chest: Mild TTP at former L chest Port site with stable
keloiding and stable palpable fluid collection with minimal
erythema and no drainage
Abdomen: NTTP, no guarding/rebound
GU: No foley
Ext: Warm, well perfused, 2+ pulses, R PICC with stable
ecchymosis
Neuro: AOx3, appropriately interactive, CNs [**4-18**] intact, moving
all 4 extremities
Head: No focal contusion/stepoff
Pertinent Results:
Admission labs:
CBC: 13.1/47/367
Lytes: 132/4.7/94/19/0.6/595 AG 24
LFTs: 30/19/223/0.6
Lipase 13
Discharge labs:
CBC: 5.8/30.8/244
Lytes: 135/4.3/104/27/18/0.5/177
[**9-8**]: HBsAg negative, HIV Ab negative, HCV Ab negative
-
BCx ([**9-10**]) in [**5-11**] bottles:
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Port-A-Cath wound Cx swab ([**9-11**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
Port-A-Cath wound Cx swab ([**9-15**]): STAPHYLOCOCCUS, COAGULASE
NEGATIVE. SPARSE GROWTH.
Port-A-Cath wound Cx foreign body at removal ([**9-16**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
Port-A-Cath wound Cx swab at removal ([**9-16**]): STAPHYLOCOCCUS,
COAGULASE NEGATIVE. SPARSE GROWTH.
-
Portable CXR ([**9-6**]): Left Port-A-Cath terminating within the
right atrium. No focal consolidation, pneumothorax, or effusion.
Portable CXR ([**9-10**]): There are low inspiratory volumes. Allowing
for this, no significant change is detected compared with [**9-6**], [**2168**]. No CHF, focal infiltrate, effusion, or pneumothorax is
detected. A left-sided
indwelling catheter tip overlying the SVC/RA junction or upper
RA is
unchanged.
Portable KUB ([**9-10**]): Non-obstructive bowel gas pattern. No free
air identified. Stool present in the colon.
LUE US ([**9-14**]): No e/o LUE DVT.
Chest wall US ([**9-14**]): No e/o fluid collection or abscess near L
port site.
Portable CXR ([**9-20**]): In comparison with study of [**9-10**], there are
continued low lung volumes. No evidence of acute pneumonia or
vascular congestion. Tip of the PICC line is in the lower
portion of the SVC.
L chest soft tissue US ([**9-22**]): 3 cm left chest wall fluid
collection, most consistent with hematoma.
Noncontrast head CT ([**9-22**]): No acute intracranial hemorrhage or
fractures.
Brief Hospital Course:
Ms. [**Known lastname **] is a 25F with IDDM1 c/b chronic pancreatitis and
gastroparesis with chronic g-j tube, depression, and borderline
personality disorder who p/w abdominal pain since the evening
PTA and was found to have DKA, since resolved, and later
developed Klebsiella bacteremia and coagulase negative Staph
Port-A-Cath pocket infection, now s/p Port removal and treatment
with vancomycin/ciprofloxacin.
#IDDM1 c/b DKA: DKA was attributed to medical noncompliance,
though patient reported adherence to insulin regimen as
prescribed. She was started on IVF and insulin gtt and
transitioned to home insulin after AG closed. CXR, UA, and
lipase were normal on admission. She subsequently revealed that
she had been injecting insulin into the deltoid and was
counseled on proper administration, though it was not clear that
she planned on changing her behavior. Home [**Known lastname 8472**] was uptitrated
incrementally from 40 to 80u qhs and later qpm due to
hyperglycemia intermittently to the 400s without AG in the
setting of infection, surreptitious consumption, and insulin
resistance, with simultaneous increase in Humalog insulin SS and
subsequent addition of NPH. Due to her profound insulin
requirement, she was ultimately discharged on insulin U500
regular 70u at breakfast, lunch, and dinner, with close PCP
[**Name9 (PRE) 702**] arranged.
#Klebsiella bacteremia/coagulase negative Staph Port-A-Cath
pocket infection: On HD5, patient developed T to 103 with HR to
140s attributed to ciprofloxacin-sensitive Klebsiella bacteremia
presumed secondary to her L chest Port-A-Cath, which she
reportedly had been chewing, with a 2-week course of IV
ciprofloxacin ([**Date range (1) 68146**]) initiated at that time. CXR, KUB, and
UCx were negative. When the Port was found to be draining
purulent material, wound Cx demonstrated coagulase negative
Staph, prompting Port removal and R-sided PICC placement, given
difficult peripheral access, under general anesthesia. Wound Cx
from the time of removal confirmed the presence of
vancomycin-sensitive coagulase negative Staph, prompting a
19-day course of IV vancomycin ([**Date range (1) 68147**]). She remained largely
afebrile with intermittent low-grade temperatures in the setting
of self-disconnecting IV antibiotics and HD stable without
leukocytosis on vancomycin/ciprofloxacin without recurrent
bacteremia on surveillance BCx. US of her L chest pre- and
post-Port removal were negative for soft tissue abscess. Patient
declined Port replacement, and R-sided PICC was removed prior to
discharge.
#Behavioral complications: Patient with known depression,
borderline personality disorder, and h/o aggressive behavior
became uncooperative, and threatened care team (MDs and RNs) and
posed challenges to her own care by self-disconnecting IV
antibiotics and reportedly chewing on/manipulating her
Port-A-Cath and other lines and consuming carbohydrate-[**Doctor First Name **]
foods surreptitiously outside of her restricted diabetic diet,
prompting involvement by psychiatric nurse specialists, to whom
she is well-known, and ultimately security on multiple
occasions, followed by transient physical/chemical restraints
with permission of her legal [**Doctor First Name 18297**] and subsequent seclusion
under 1:1 security sitter surveillance for the duration of her
admission.
#Chest pain: Patient reported chest pain pre- and post-removal
of her L chest Port-A-Cath, with L chest US negative for soft
tissue abscess both pre- and post-removal, though the latter US
was notable for a small hematoma. EKGs demonstrated no acute
ischemic changes, and the appearance of her L chest remained
stable with minimal erythema and no purulent drainage
post-procedurally. Although pain control became a flash point in
the setting of her strict narcotics contract, her pain was
ultimately well-controlled on regularly administered PO Dilaudid
6mg q3h.
#Soft blood pressures: Patient demonstrated intermittently soft
blood pressures, SBP to 90s, unassociated with fevers or
localizing symptoms in the setting of regular Dilaudid use and
likely intravascular volume depletion due to limited fluid
intake and hyperglycemia, with universal fluid responsiveness
and return to baseline SBP of 100s-120s.
#Abdominal pain: Patient with known h/o chronic abdominal pain
presumed [**3-10**] pancreatitis p/w epigastric pain c/w baseline.
Lipase was normal on admission. IV pain medications were
initiated per previously documented care plan, with transition
to PO pain medications once tolerating POs, also as per care
plan. Patient became uncooperative and threatening to care team
(MDs and RNs) on transition to PO medications, prompting
involvement of security and psychiatric nurse specialists, with
subsequent deescalation. In this setting, she removed her g-j
tube; reinsertion was deferred, given ability to tolerate POs,
in consultation with her PCP.
#Fall: Patient fell and struck her head on the front desk while
playing around when not confined to her room. Noncontrast head
CT was negative, and she displayed no LOC or focal neurologic
deficits throughout admission.
#Depression and borderline personality disorder: She received IV
Ativan and Benadryl initially as per documented care plan, with
transition to PO psychiatric medications once tolerating POs.
Patient declined psychiatric involvement, with the exception of
psychiatric nurse specialists, on this admission.
#Asthma: Home albuterol, ipratropium, and Advair were continued.
#PUD: She received IV pantoprazole initially, with transition to
home omeprazole once tolerating POs.
#Transitional issues:
-IDDM1: Patient was started on a new insulin regimen consisting
of tid insulin U500 regular at discharge due to profound insulin
resistance and will need close follow-up in the outpatient
setting.
-Access: On admission, patient had L chest Port-A-Cath, given
difficult peripheral access and frequent admissions for DKA.
Port was removed in the setting of bacteremia and pocket
infection and not replaced prior to discharge due to patient
preference. Need for new Port may be addressed at a later time
if indicated.
-Pain control: Patient remained on a strict narcotics at the
time of discharge, and pain control likely will remain an
ongoing concern in the outpatient setting.
-Soft blood pressures: Intermittently soft blood pressures in
the setting of frequent Dilaudid use may be reassessed on PCP
[**Last Name (NamePattern4) 702**].
-Depression and borderline personality disorder: Patient
declined psychiatric involvement, with the exception of
psychiatric nurse specialists, on this admission, but likely
would benefit from psychiatric follow-up if ever amenable in the
future.
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Acetaminophen (Liquid) 325 mg PO Q6H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Diazepam 10 mg PO Q8H:PRN insomnia, anxiety
5. DiphenhydrAMINE 100 mg PO HS:PRN insomnia
6. Docusate Sodium (Liquid) 50 mg PO BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
8. Gabapentin 500 mg PO HS
9. HYDROmorphone (Dilaudid) 6 mg PO Q3H:PRN pain
10. Ibuprofen Suspension 600 mg PO Q6H:PRN pain
11. Glargine 70 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Lactulose 45 mL PO Q8H:PRN constipation
13. Mirtazapine 30 mg PO HS
14. Omeprazole 40 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Simvastatin 20 mg PO DAILY
17. traZODONE 100 mg PO HS:PRN insomnia
18. Zolpidem Tartrate 10 mg PO HS
19. HydrOXYzine 25 mg PO Q6H:PRN itch
20. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
21. Prochlorperazine 10 mg PO Q6H:PRN nausea
22. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
Discharge Medications:
1. Acetaminophen (Liquid) 325 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Diazepam 10 mg PO Q8H:PRN insomnia, anxiety
RX *diazepam [Valium] 10 mg 10 mg by mouth every 8 hours Disp
#*3 Tablet Refills:*0
4. DiphenhydrAMINE 100 mg PO HS:PRN insomnia
5. Docusate Sodium (Liquid) 50 mg PO BID
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose 1
inhalation . twice a day Disp #*1 Unit Refills:*0
7. Gabapentin 500 mg PO HS
RX *gabapentin 250 mg/5 mL 500 mg by mouth at night Disp #*30
Each Refills:*0
8. HYDROmorphone (Dilaudid) 6 mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 3 tablet(s) by mouth Q3H Disp
#*21 Tablet Refills:*0
9. HydrOXYzine 25 mg PO Q6H:PRN itch
10. Ibuprofen Suspension 600 mg PO Q6H:PRN pain
11. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 1 puff .
every 6 hours Disp #*1 Unit Refills:*0
12. Mirtazapine 30 mg PO HS
RX *mirtazapine 30 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*0
13. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
17. traZODONE 100 mg PO HS:PRN insomnia
RX *trazodone 100 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*0
18. Zolpidem Tartrate 10 mg PO HS
RX *zolpidem 10 mg 1 tablet(s) by mouth at bedtime Disp #*1
Tablet Refills:*0
19. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
RX *albuterol 2 puffs every 4 hours Disp #*1 Unit Refills:*0
20. Lactulose 45 mL PO Q8H:PRN constipation
21. Regular U 500 70 Units Breakfast
Regular U 500 70 Units Lunch
Regular U 500 70 Units Dinner
22. Diabetes supplies
Please provide glucometer. Also, please provide alcohol swabs,
lancets, test strips, and insulin syringes needed for one (1)
month supply. Two (2) refills.
23. Insulin U500
Regular U 500 70 Units at Breakfast
Regular U 500 70 Units at Lunch
Regular U 500 70 Units at Dinner
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
klebsiella septicemia
sepsis
complicated central line/port site blood stream infection
poorly controlled type 1 diabetes with complications
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you. You were admitted for
abdominal pain and found to have diabetic ketoacidosis. You were
treated with pain medications and insulin, and your abdominal
pain and diabetic ketoacidosis have now resolved.
It is very important that you take your medications as
prescribed, especially your insulin.
Followup Instructions:
You have an appointment with you PCP: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 63642**], MD
Telephone: [**Telephone/Fax (1) 7976**]
Time: Thursday, [**10-6**], at 1:00pm
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
You should also follow-up with the [**Last Name (un) **] center. Please call
([**Telephone/Fax (1) 4847**] to make an appointment.
ICD9 Codes: 311, 3051, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3912
} | Medical Text: Admission Date: [**2150-8-18**] Discharge Date: [**2150-8-23**]
Date of Birth: [**2085-11-28**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 64 year old male who
has a history of hypertension, high cholesterol, diabetes,
who was found to have [**Year (4 digits) 8813**] arch dissection and cath showed
multivessel disease.
PAST MEDICAL HISTORY: Significant for hypertension, [**Year (4 digits) 8813**]
arch dissection, high cholesterol. Loss of the right kidney
due to [**Year (4 digits) 8813**] arch dissection.
MEDICATIONS ON ADMISSION: Zestril, aspirin, labetalol,
Norvasc.
PHYSICAL EXAMINATION: Afebrile, vital signs stable. Lungs
were clear to auscultation. Heart was regular rate and
rhythm with a 4/6 systolic ejection murmur. Abdomen was
soft, nondistended, nontender. Bowel sounds were present.
Extremities were warm and well perfused.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2150-8-18**] where CABG times one, LIMA to LAD, was performed.
AVR with pericardial valve was performed. Resection and
replacement of the ascending [**Date Range 8813**] arch were performed.
Patient was transferred to the TSRU postoperatively where he
did well. His blood sugar was high for awhile and patient
was restarted on his pre-op medications with good results.
Patient was slowly weaned from the ventilator. After
beginning aggressive diuresis, patient was able to be
extubated and did well. Patient continued to improve and was
started on p.o. pain medications. His diet was advanced. He
continued to be diuresed in the intensive care unit and he
did well.
Physical therapy was consulted for ambulation and it was
recommended at that time that patient could be discharged
home after medical clearance. He was slowly weaned from his
nitroglycerin drip and patient continued to do well. He was
transferred to the floor postoperatively. His chest tubes
were removed. His wires were removed. His Foley catheter
was also removed. He continued to be diuresed and had
aggressive pulmonary toilet. He was able to be weaned from
oxygen at that time and did well. Patient was discharged
home on postoperative day five after clearance by physical
therapy.
DISCHARGE MEDICATIONS:
1. Aspirin 325 p.o. q.d.
2. Amlodipine 5 mg p.o. b.i.d.
3. Labetalol 400 mg p.o. b.i.d.
4. Percocet one to two tabs p.o. q.four hours p.r.n.
5. Zantac 150 p.o. b.i.d.
6. Colace 100 mg p.o. b.i.d.
7. Lasix 20 mg p.o. b.i.d.
8. KCl 20 mEq p.o. b.i.d.
Th[**Last Name (STitle) 1050**] was discharged home in stable condition. Patient
was 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.
DISCHARGE DIAGNOSES:
1. Hypertension.
2. CAD status post CABG times one.
3. AVR and [**Last Name (Prefixes) 8813**] arch repair.
4. History of [**Last Name (Prefixes) 8813**] dissection with loss of right kidney.
5. High cholesterol.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 23403**]
MEDQUIST36
D: [**2150-8-23**] 10:06
T: [**2150-8-28**] 09:18
JOB#: [**Job Number 42724**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3913
} | Medical Text: Admission Date: [**2175-7-3**] Discharge Date: [**2175-7-4**]
Date of Birth: [**2112-4-1**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
s/p fall, acidosis.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 63 year old woman with PMHx of Hep C & ETOH
Cirrhosis, Gastritis/Duodenitis, HTN & CKD who presents with
fall 2 days ago after tripping on a rug at home. She was able
to ambulate after the fall but as the hip pain persisted she
came to the ED for evaluation.
.
In the ED, initial vs were: T 94.4 P 105 BP 88/53 RR 18 O2 sat
100%ra. Right hip films were negative for fracture. Laboratory
results were most notable for signficant anion-gap acidosis, and
pancytopenia (worsened from baseline low Hct and Plt). She was
given 2L of NS, as well as vanc/zosyn/Mag sulfate/KCl.
.
She denied cough, pain other than hip pain. She had no abd
pain. no headache. no dysuria. no rash. no diarrhea. no neck
stiffness. She denies metformin use. She denies anti-freeze
ingestion. In speaking with her fiance (who lives with her) she
was feeling well yesterday and had visited by daughter. Eating
normally yesterday with family. Temp check at home 98.3F at
home. Feet were swelling.
.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Diabetes Mellitus, type 2 - on insulin
Chronic Kidney Disease, baseline Cr 1.6-2.0
Hepatitis C-Rx with rebetron-discontinued after poor response
h/o acute hepatitis from tylenol overdose
Hypertension
h/o Chronic Pancreatitis
s/p TAH/BSO [**2155-1-26**]
Substance Abuse (Cocaine, EtOH)
h/o SBO with small bowel resection [**7-1**] and again [**11-1**]
Carpal Tunnel Syndrome
Depression
NSTEMI [**10-3**] in the context of cocaine use
Anemia with baseline Hct 26-30
Social History:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 73770**] (fiance) lives with her. she states she last had
a mixed drink with gin 2 days ago. she denies illicit drug use.
[**First Name9 (NamePattern2) **] [**First Name8 (NamePattern2) 1439**] [**Known lastname 46**] is her HCP.
Family History:
Hypertension. No history of premature CAD. Father with lung
cancer who died in his early 60s, mother with sarcoid who died
in her early 50s. No family hx of breast CA.
Physical Exam:
Vitals: T: 92.4 (oral) BP: 120/53 P: 92 R: 17 O2: 96%2L
General: Arousable to voice and follows commands, oriented
(hosp, year, day), no acute distress, tachypneic
HEENT: Sclera anicteric, MMM, oropharynx clear. right surgical
pupil.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachy. regular rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: cool, 2+ pulses, no clubbing, cyanosis or edema
Neuro:
-MS: awake, response to voice answering questions in short but
appropriate answers. no dysarthria. no R/L confusion or neglect
-CN: right surgical pupil. EOMI to full gaze. face symmetric.
tongue/palate midline.
-Motor: moving all 4 extremities symmetrically.
-[**Last Name (un) **]: light touch intact to face/hands/feet.
-Gait: deferred
Pertinent Results:
LABS:
[**2175-7-3**] 06:30AM BLOOD WBC-0.9*# RBC-3.11* Hgb-9.8* Hct-31.3*
MCV-101*# MCH-31.6 MCHC-31.3 RDW-16.2* Plt Ct-65*#
[**2175-7-3**] 07:20AM BLOOD WBC-2.7*# RBC-2.65* Hgb-8.5* Hct-27.3*
MCV-103* MCH-32.0 MCHC-31.1 RDW-17.2* Plt Ct-50*
[**2175-7-3**] 02:29PM BLOOD WBC-1.1*# RBC-2.03* Hgb-6.4* Hct-21.5*
MCV-106* MCH-31.7 MCHC-29.9* RDW-17.8* Plt Ct-18*#
[**2175-7-4**] 12:21AM BLOOD WBC-2.9*# RBC-2.12* Hgb-6.7* Hct-21.6*
MCV-102* MCH-31.5 MCHC-30.9* RDW-16.8* Plt Ct-12*
[**2175-7-4**] 03:37AM BLOOD WBC-2.6* RBC-1.96* Hgb-5.9* Hct-18.7*
MCV-96 MCH-30.1 MCHC-31.5 RDW-17.8* Plt Ct-11*
[**2175-7-3**] 06:30AM BLOOD Neuts-52 Bands-8* Lymphs-22 Monos-0 Eos-0
Baso-0 Atyps-0 Metas-4* Myelos-14*
[**2175-7-3**] 07:20AM BLOOD Neuts-61 Bands-3 Lymphs-20 Monos-2 Eos-1
Baso-0 Atyps-0 Metas-6* Myelos-7*
[**2175-7-3**] 06:30AM BLOOD Plt Ct-65*#
[**2175-7-3**] 07:20AM BLOOD PT-22.9* PTT-52.0* INR(PT)-2.2*
[**2175-7-3**] 02:29PM BLOOD PT-59.6* PTT-150* INR(PT)-7.1*
[**2175-7-4**] 03:37AM BLOOD PT-150* PTT-150* INR(PT)->21.8*
[**2175-7-3**] 06:30AM BLOOD Glucose-264* UreaN-27* Creat-2.8* Na-132*
K-3.4 Cl-94* HCO3-6* AnGap-35*
[**2175-7-3**] 07:20AM BLOOD Glucose-241* UreaN-26* Creat-2.6* Na-137
K-3.3 Cl-96 HCO3-6* AnGap-38*
[**2175-7-4**] 12:21AM BLOOD Glucose-201* UreaN-18 Creat-2.1* Na-139
K-6.5* Cl-94* HCO3-7* AnGap-45*
[**2175-7-4**] 03:37AM BLOOD Glucose-489* UreaN-15 Creat-1.8* Na-132*
K-7.4* Cl-85* HCO3-7* AnGap-47*
[**2175-7-3**] 07:20AM BLOOD ALT-54* AST-117* CK(CPK)-2426*
AlkPhos-125* TotBili-1.6*
[**2175-7-3**] 02:29PM BLOOD LD(LDH)-553* CK(CPK)-[**Numeric Identifier 100369**]*
[**2175-7-4**] 12:21AM BLOOD CK(CPK)-[**Numeric Identifier 3026**]*
[**2175-7-4**] 03:37AM BLOOD ALT-59* AST-353* LD(LDH)-875*
CK(CPK)-7550* AlkPhos-72 TotBili-0.8
[**2175-7-3**] 07:20AM BLOOD cTropnT-0.10*
[**2175-7-3**] 02:29PM BLOOD CK-MB-80* MB Indx-0.7 cTropnT-0.08*
[**2175-7-3**] 07:20AM BLOOD Albumin-2.4* Calcium-6.8* Phos-5.1*#
Mg-0.9*
[**2175-7-4**] 03:37AM BLOOD Calcium-8.3* Phos-8.2*# Mg-1.8
[**2175-7-3**] 07:20AM BLOOD Acetone-NEGATIVE Osmolal-306
[**2175-7-3**] 07:20AM BLOOD ASA-NEG Ethanol-19* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2175-7-3**] 11:01AM BLOOD Type-ART pO2-96 pCO2-30* pH-6.96*
calTCO2-7* Base XS--25 Intubat-NOT INTUBA
[**2175-7-3**] 12:46PM BLOOD Type-ART pO2-105 pCO2-35 pH-6.91*
calTCO2-8* Base XS--26
[**2175-7-3**] 05:18PM BLOOD Type-CENTRAL VE pO2-98 pCO2-25* pH-6.96*
calTCO2-6* Base XS--26
[**2175-7-4**] 12:25AM BLOOD Type-[**Last Name (un) **] Temp-34.4 pO2-38* pCO2-29*
pH-6.97* calTCO2-7* Base XS--26
[**2175-7-4**] 04:25AM BLOOD Type-[**Last Name (un) **] Temp-34.2 pO2-36* pCO2-21*
pH-7.08* calTCO2-7* Base XS--23
[**2175-7-3**] 11:01AM BLOOD Lactate-17.8*
[**2175-7-3**] 03:11PM BLOOD Lactate-19.8* K-4.6
[**2175-7-4**] 04:25AM BLOOD Lactate-20.8*
[**2175-7-3**] 03:11PM BLOOD freeCa-0.88*
[**2175-7-4**] 04:25AM BLOOD freeCa-0.97*
[**2175-7-3**] 05:17PM BLOOD CYANIDE-PND
.
.
MICRO:
BLOOD CX:
[**2175-7-3**] 9:50 am BLOOD CULTURE VENIPUNTURE.
Blood Culture, Routine (Preliminary):
THIS IS A CORRECTED REPORT [**2175-7-4**].
GRAM NEGATIVE ROD(S).
PREVIOUSLY REPORTED ALSO POSITIVE FOR GRAM POSITIVE
COCCI [**2175-7-3**].
Anaerobic Bottle Gram Stain (Final [**2175-7-3**]):
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name 50967**] [**Doctor Last Name **] ON [**2175-7-3**] @ 7:45 P.M..
Aerobic Bottle Gram Stain (Final [**2175-7-3**]):
THIS IS A CORRECTED REPORT [**2175-7-4**].
GRAM NEGATIVE ROD(S).
PREVIOUSLY REPORTED AS [**2175-7-3**].
GRAM POSITIVE COCCI IN CLUSTERS.
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name 50967**] [**Doctor Last Name **] [**2175-7-4**] 3:15PM.
.
.
STUDIES:
[**2175-7-3**] CT ABD/PELVIS:
IMPRESSION:
1. Limited assessment without IV or oral contrast. There is a
suggestion of wall thickening involving the hepatic flexure of
the colon ( c/w colitis), as well as in recto-sigmoid. No free
air or pneumatosis.
2. Diffusely fatty liver.
3. Pancreatic parenchymal calcifications, likely sequela from
chronic
pancreatitis.
4. Bilateral lower lobe consolidation in the visualized lungs,
with tiny
adjacent pleural effusions.
.
[**2175-7-3**] CXR:
IMPRESSION: No acute intrathoracic process.
.
[**2175-7-3**] ECG:
Sinus tachycardia with ventricular premature depolarizations and
diffuse
non-diagnostic repolarization abnormalities. Compared to the
previous tracing of [**2175-6-21**] the heart rate is increased, now
with ventricular ectopic activity
.
Brief Hospital Course:
63 year old woman with medical history notable for HepC/EtOH
cirrhosis, DM2, hypertension and CKD presenting after a fall c/b
hip pain found to have significant anion-gap metabolic acidosis.
.
# Anion-gap metabolic acidosis with notable lactic acidosis: The
etiology of her acidosis remained unclear, though was ultimately
felt more likely due to an overwhelming septic picture,
supported by rapid growth of gram negative and gram positive
bacteremia. Initial delta-delta suggested co-incident non-anion
gap acidosis as well, and initial pCO2 of 30 suggested
inadequate respiratory compensation.
.
As above, the source of her profound lactic acidosis remained
unclear given lack of clear causitive medication; additionally
she initially appeared to have adequate organ perfusion (global
and mesentery) given benign abdominal exam, lack of abdominal
complaints, and relative normotension. Metabolic derangements
could have been related to severe thiamine deficiency, though
uncommon, this was treated. Ethylene glycol ingestion was also
entertained, but felt less likely given negative serum osm gap
unless it is now very late in the course.
.
Toxicology consult was obtained, without clear etiology, though
cyanide poisoning was entertained, and the antidone was
administered given lack of alternate explanations and the
patients rapid clinical decline. She was also empirically
treated with broad spectrum antibiotics (vancomycin, cefepime,
flagyl) without clear source. Surgical consult and CT abdomen
were obtained to further evaluate for an abdominal source, and
preliminary [**Location (un) 1131**] revealed no clear abcess or evidence of
mesenteric ischemia.
.
Over the course of her first 12 hours in hospital, her acidemia
progressed, her arterial PCO2 rose (to 47) and her mental status
declined prompting intubation. She also developed worsening
hypotension, prompting placement of a central venous catheter,
and iniation of levophed and vasopressin. Multiple attempts to
place an arterial line were unsucessful (residents x2, critical
care attending, surgical resident). OGT revealed coffee
grounds, though her HCT (baseline 30) declined slightly (27),
her labs ultimately revealed a DIC picture over the course of 12
hours, (INR >21, platlets 11), GIB was felt unlikely to
contribute to such a profound acidemia, despite her known liver
history. Cardiac enzymes were flat (CK MB 80s, MBI 0.7, though
peak trop 0.10).
.
Given lack of alternate explanations for her acidemia and
clinical decline, the renal service was consulted regarding
initiation of CVVH for removal of possible toxic ingestions and
to optimize management of the acidemia. She was treated
empirially with continuous bicarbonate infusion and CVVH was
initiated via a left femoral temporary HD catheter.
.
Despite the above interventions, her clinical status continued
to decline. Her CK rose to >10,000 (no evidence of rhabdo on
UA), her acidemia progressed, with venous PH=6.81/24/80 at 8PM,
her potassium rose to 7 despite CVVH. Given her grave
condition, a family meeting was held, led by her daughter
[**Name (NI) 1439**]. Decision was made to make the patient DNR/DNI, but to
continue with current measures. Her acidemia improved slightly
however lactate continued to rise. Microbiology data revealed
rapid growth of gram negative rods (2/2 bottles), and gram
positive cocci (1/2 bottles), supporting an overwhelming septic
picture of unclear etiology, but possibly enteric translocation
from GIB.
.
Despite the above efforts, the patient expired at 3AM the
following morning. An autopsy was offered to the family, and
accepted.
.
.
# Pancytopenia: most likely [**2-27**] septic picture as above.
Rapidly rising INR 2->7->21, also likely reflected DIC, though
fibrinogen 60. She was treated empirically with antibiotics as
above.
.
# Fall c/b hip pain: initial hip films were unremarkable for
fracture.
.
# Hep C cirrhosis: LFTs within her baseline range. her altered
mental status was felt more likely related to acidosis as
opposed to hepatic encephalopathy
.
# CKD - initially near her baseline Cr of 2.6. she rapidly
became anuric, likely [**2-27**] hypotension, and was started on CVVH
as above, primarily given concern for toxic ingestion.
.
# Diabetes mellitus type 2 uncontrolled: no clear evidence of
DKA. she was followed with q4 HISS.
.
# FEN: she remained NPO.
# Prophylaxis: pneumoboots
# Access: PIV, and R IJ TLC.
# Code: DNR/DNI after discussion with daughter [**Name (NI) **].
# Communication: Patient, daughter is HCP [**Location (un) 1439**] h
[**Telephone/Fax (1) 100367**], c [**Telephone/Fax (1) 100370**])
.
Medications on Admission:
Medications: (per d/c summary on [**2175-6-23**])
Cholecalciferol 800 unit daily
Calcium Carbonate 500 mg TID
Pantoprazole 40 mg Q12H
Humalog 6 units Subcutaneous qac.
Verapamil 180 mg daily
Albuterol Sulfate 1-2 Puffs Q6H prn
Amylase-Lipase-Protease 20,000-4,500- 25,000 unit TID W/MEALS
Sertraline 100 mg daily
Discharge Medications:
pt expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired.
Discharge Condition:
pt expired.
Discharge Instructions:
pt expired.
Followup Instructions:
pt expired.
ICD9 Codes: 0389, 2762, 5789, 412, 2768, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3914
} | Medical Text: Admission Date: [**2188-9-17**] Discharge Date: [**2188-12-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Ankle Fracture (Left)
Major Surgical or Invasive Procedure:
- Open reduction and internal fixation of right ankle fracture
on [**2188-9-18**]
- G tube placement and removal
- PICC line placement
History of Present Illness:
80 yo M transferred from the ortho service, etoh abuse presents
with a ankle fracture s/p fall in bathroom while intoxicated.
Pt. drinks 1 pint of tequila a day and his last drink was on the
day of admission. He lives in an elderly hosing unit and he
pulled the bathroom emergency cord. Maintenance man found him
lying on floor in toilet water with a half empty bottle of
Tequila. He is s/p an ORIF on [**9-18**]. After the surgery, he was
noted to be hypertensive in the pacu to 190/110. He was also
confused and agitated. The primary team had a high suspicion for
etoh withdrawal given the timing and hx of etoh use. His BP was
controlled with lopressor and IV hydral. He was started on an
ativan CIWA (q2hrs). Psychiatry liason feels the symptoms are
more c/w post-op delirium and recommend haldol and not using
benzos in this elderly man. Medicine consulted for help in
management of withdrawal symptoms and agitation and felt that
presentation was consistent with acute alcohol withdrawal. No
more surgical issues per ortho therefore recommended transfer to
medicine.
Past Medical History:
1. alcohol abuse
2. history of prostate cancer [**2178**], [**Doctor Last Name **] grade [**6-12**], s/p
TURP [**4-/2179**]
3. GERD
4. history of central retinal vein occlusion
5. hypertension
6. history of anemia, thought to be due to alcoholic bone
marrow suppression
7. glaucoma
Social History:
Drinks about 1.5 quarts of Tequila, per previous report. Former
smoker.
Family History:
noncontributory
Physical Exam:
General Appearance: Well nourished
Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 112 (82 - 112) bpm
BP: 156/69(90) {106/59(68) - 156/73(92)} mmHg
RR: 30 (15 - 30) insp/min
SpO2: 90%
Eyes / Conjunctiva: No(t) PERRL
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Breath Sounds: Clear : anteriorly)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: No(t) Attentive, No(t) Follows simple commands,
Responds to: Verbal stimuli, No(t) Oriented (to): , Movement:
Non -purposeful, Tone: Not assessed
Pertinent Results:
[**2188-9-17**] 11:05AM BLOOD:
WBC-7.9 RBC-3.76* HGB-12.0* HCT-34.9* MCV-93 MCH-32.0 MCHC-34.5
RDW-13.9 NEUTS-69.7 LYMPHS-23.8 MONOS-4.1 EOS-2.1 BASOS-0.3 PLT
COUNT-238
PT-13.8* PTT-25.5 INR(PT)-1.2*
GLUCOSE-93 UREA N-11 CREAT-0.8 SODIUM-145 POTASSIUM-4.0
CHLORIDE-108 TOTAL CO2-22 ANION GAP-19
.
[**2188-11-7**] RPR: negative
[**Date range (3) 97446**]: C. diff negative x5
.
RIGHT HIP, KNEE, ANKLE X-RAY [**2188-9-17**]
FINDINGS:
There are degenerative changes present at the hip joints as well
as the lowerlumbar spine. There is no right hip fracture.
There are degenerative changes present at the right knee joint.
There is
vascular calcification noted. There is no acute fracture.
There is a comminuted fracture present through the lateral
malleolus, with
subluxation of the ankle mortice.
.
CT HEAD [**2188-9-17**]
FINDINGS: There is no evidence for edema, mass effect,
hemorrhage, or
infarction. There is no shift of normally midline structures.
There is
preservation of normal [**Doctor Last Name 352**]-white matter differentiation. There
is mild-to-moderate prominence of the ventricles and the sulci
consistent with age-related parenchymal loss. There is a
moderate periventricular hypodensities suggestive of small
vessel microvascular ischemia, unchanged compared to prior
examination. There are calcifications in the basal ganglia and
left dentate nuclei which are age related and unchanged. Soft
tissue density material in the right external auditory canal
most likely representative of cerumen and would recommend
clinical correlation. The visualized sinus airspaces are clear,
and the mastoid air cells are unremarkable. There are no
fractures identified.
IMPRESSION: No acute intracranial pathology.
.
CT CSPINE [**2188-9-17**]
CONCLUSION:
1. Widening of the right odontoid-lateral mass interval of
approximately 6 mm as compared to the left, which is 3 mm may
represent rotatory subluxation. If clinical suspicion is high,
further imaging may be warranted.
2. Multilevel degenerative changes in the cervical spine with
congenital
fusion at multiple levels as described above.
3. Anterolisthesis of the bodies of C5 on C6 and C7 on T1.
.
EEG [**2188-9-26**]
MPRESSION: This is an abnormal portable EEG in the awake and
sleeping
states due to the bursts of generalized slowing and background
suppression and the slow and disorganized background. These
abnormalities suggest a moderate encephalopathy involving both
cortical
and subcortical structures. Medications, metabolic disturbances
and
infection are among the most common causes. The excessive beta
activity
suggests a medication effect. There were no lateralized or
epileptiform
features seen.
.
CT HEAD [**2188-10-10**]
FINDINGS: There is a small right frontal subgaleal hematoma
without
intraluminal air to suggest laceration. There is no underlying
fracture
detected. The visualized paranasal sinuses and mastoid air cells
are clear.
There are bilateral lens replacements in the orbits. The orbital
regions are otherwise unremarkable.
There is no acute intracranial hemorrhage, mass lesion, shift of
normally
midline structures or evidence of major territorial infarct.
Bilateral basal ganglia calcifications noted. Moderate confluent
periventricular
hypoattenuation is consistent with chronic small vessel
ischemia.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Small right frontal subgaleal hematoma without underlying
fracture.
3. Moderate chronic small vessel microvascular ischemia within
the
periventricular white matter.
.
CT CSPINE [**2188-10-10**]
FINDINGS: There is an acute fracture of the dens type 2 in which
the anterior arch of C1 is subluxed posteriorly through the
fracture line. There is extensive surrounding hematoma within
the anterior and posterior vertebral space. The cranial most
aspect of the dens is tipped posteriorly.
Multilevel degenerative changes present within the cervical
spine are again noted with fusion of C2 through C4.
Anterolisthesis of C5 on C6 and C7 on T1 are again noted. There
is stable minimal widening of the right odontoid lateral mass
interval in which rotatory subluxation cannot be excluded.
Vascular calcifications of the internal carotid arteries are
again noted.
Interstitial changes within the lung apices are grossly stable.
IMPRESSION:
1. Acute fracture of the dens (type 2) with posterior
translation of the
anterior arch of C1 into the fracture line. There is significant
post-
fracture hematoma. Posterior subluxation is present of C1 on C2.
This is an unstable fracture and cervical stabilization is
necessary as discussed with Dr. [**First Name (STitle) **] at 10:40 p.m. on the date
of exam. MRI without gadolinium is
recommended as well as neurosurgical consultation.
2. Degenerative changes as previously described.
3. Vascular calcifications.
.
TIB/FIB RIGHT (AP & LAT) [**2188-10-17**]
FINDINGS: In comparison with study of [**10-16**], the cast has been
removed. No
change in the appearance of the metallic fixation device about a
previous
fracture of the distal fibula. The fracture line is still
faintly seen.
Views of the knee and upper leg show no abnormality.
.
XRAY ENTIRE SPINE [**2188-10-30**]:
IMPRESSION:
1. Cervical spine -- known base of dens fracture seen, but not
well visualized. See comment.
2. Thoracic spine -- moderately severe to severe multilevel
degenerative changes. No obvious fracture. See comment.
3. Lumbar spine: Moderately severe to severe multilevel
degenerative changes. No obvious fracture. See comment
Brief Hospital Course:
The [**Hospital 228**] hospital course by problem is as follows:
.
Ankle Fracture:
The patient was admitted after being found down, intoxicated,
with new right ankle fracture. He underwent ORIF on [**2188-9-18**] by
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5322**]. He was initally put in a hard boot/air cast and was
non-weight bearing on that extremity. He was seen again by
ortho in [**Month (only) **] and felt that he could begin walking again. He
is now ambulating with a cam walker until further advised by
ortho. PT was re-initiated and has been tolerating it well. He
is also on lovenox for DVT prophylaxis until ortho feels safe it
can be stopped. He will follow up with orthopedics ideally 2
weeks after discharge.
.
EtOH Withdrawal / Encephalopathy
Following surgery, the patient was found to be agitated and
mildly hypertensive within the window for EtOH withdrawal. Given
his history of known withdrawal, he was started on aggressive
benzodiazepene treatment for withdrawal, and moved into the
intensive care unit for further monitoring. His admission head
CT and a follow-up head CT in the ICU showed no development of
intracranial bleed. He received valium per the CIWA scale for 7
days. He also received oxycodone for pain control, and was
administered oxycodone whenever he developed tachycardia or
hypertension. His HR and BP stabilized after oxycodone
administration, leading to the belief that a large component of
his agitation was secondary to pain. His vitamin b12 was also
found to be low and he was repleted with IM cyanocobalmin. After
7 days, he still remained quite sedated with episodes of
agitation manifested by tachycardia and hypertension. He was
therefore treated with haldol for six days without change in his
mental status. He remained for 10 days post BZD use in a coma
without purposeful movement but with intact reflexes and
respiration. Neurologic exam remained non-focal. EEG showed no
epileptiform activity. A trial of flumazenil on [**10-1**] produced
improvement in ability to follow commands such as opening eyes
or moving toes, but this remained short lived. He remained
sedated and unresponsive on [**10-2**], and eventually becomae
responsive to verbal stimuli, capable of performing purposeful
movements on [**10-3**]. He was therefore transitioned to the the
medical floor. On the floor, his mental status improved
somewhat,and he was intermittently A&Ox2 (person and place) and
able to ask and answer questions appropriately in spanish.
Spanish is his primary language, but he does speak some english.
Unfortunately, he continued to have episodes of agitation.
Toxic/metabolic/infectious work-up of delirium was unrevealing.
The psychiatry team reevaluated the patient and felt that this
may be a new baseline secondary to extensive alcohol history and
nutritional deficiencies. He received increased doses of
thiamine, folic acid. Given his prolonged period of altered
mental status, he was evaluated by the speech and swallow team
and was felt unsafe to take anything po. A G-tube was placed by
interventional radiology on [**10-16**]. Tubefeeds were started on
[**10-18**]. On [**10-23**] he was reevaluated by speech and able to take a
modified diet (pureed and nectar thickened liquids). He was
continued on tube feeds to supplement his diet. on [**11-16**] speech
and swallow allowed him to advance his diet and his G-tube was
removed in IR on [**11-20**]. The patient was eating and drinking
well without evidence of aspiration. On [**10-23**], the patient was
given B12 treatment with dosing/administration appropriate for
pernicious anemia (please see below under anemia). His agitation
improved very slowly. The patient was given Seroquel QHS,
depakote and haldol prn for agitiation. Starting in [**Month (only) 1096**],
his mental status appeared to settle down. He was maintained on
standing low dose Haldol 0.5mg [**Hospital1 **], Quetiapine 50mg at night, as
well as Valproate, and low dose haldol for breakthrough. BZD
were avoided. There was concern for persistent short term
memory loss for which he had neuropsych testing that confirmed
this. By the middle of [**Month (only) 1096**] the patient was completely
lucent, agreeable and alert and oriented x3.
.
Dens fracture: The patient suffered a fall out of a chair at the
nurses station where he was placed to be more carefully
monitored on [**10-10**]. The patient was found to have a dens
fracture (type 2). He was transferred to the ICU and evaluated
by the spine team. He was neurologically intact. They
recommended a hard collar to be worn continuously for 3 months.
Patient repeatedly removed collar and required a 1:1 sitter for
prevention. As patient's mental status improved to baseline he
began to understand the importance of keeping the collar on to
prevent the risk of paralysis. We was able to be weaned off 1:1
sitter without removing his collar. Must wear hard c-collar at
all times until [**2188-1-10**] unless further advised by orhto.
.
Urinary Tract Infection: The patient was found to have a proteus
UTI in his course in the ICU. He was treated with a 10 day
course of ceftriaxone. On [**10-23**] he was again found to have
another UTI. Urine cultures were contaminated initally and then
negative. He was treated with a 7 day course of ceftriaxone.
Currently he has no urologic issues.
.
Concern for PICC Infection: For low grade temperatures, patient
was cultured and had GPC that speciated to coag-neg staph from
his initial PICC line placed in [**Month (only) 359**]. He received vancomycin
for 3 days while awaiting culture data and the PICC line was
pulled. Antibiotics were discontinued when culture returned
with coag neg staph. Subsequent cultures remained negative.
His most recent PICC was placed on [**2188-10-11**] and has had no
evidence of cellulitis or infection. His PICC was D/C'd in early
[**Month (only) 1096**] as the patient no longer required IV ABX or
medications.
.
Anemia: The patient's anemia is likely related to repeated
phlebotomy draws as it had slowly trended down from the mid 30s
on admission as well as to his B12 deficiency and alcohol abuse.
There was no evidence of bleeding. The patient was initially
given IM and then oral B12 repletion doses for treatment of B12
deficiency. However with his continued delirium there was
concern for pernicious anemia. On [**10-23**], he was given a second
course of B12 treatment with B12 1 gm IV x 7 days. He should
continue B12 1gm IV/IM once a month indefinately. His Hct has
remained stable in the high 20s.
.
Asbestosis: CXR shows right pleural plaque consistent with
asbestosis. Will need outpatient pulm follow up.
.
Alcohol abuse: We recommend sobriety. A social work consult was
obtained to assist counseling the patient and give the patient
resources for support. MVI, folate and thiamine were continued
in house.
.
Hypertension: Metoprolol was continued with good effect until
the end of [**Month (only) 1096**] when it was noted that his SBP was mostly in
the 90s and HR in the 50s. Metoprolol was discontinued and his
BP remained stable
.
Code: FULL code for this admission
Medications on Admission:
" eye drops and sleeping pills"
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
7. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
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. Valproic Acid 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
12. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for abdominal pain.
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-5**] Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
17. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
18. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
19. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO
twice a day.
20. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-5**]
Ophthalmic twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Right ankle fracture
Acute alcohol withdrawal
C1-spine fracture (Dens type 2)
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted after a fall while intoxicated. You were
found to have a right ankle fracture. On [**2188-9-18**] you had an
operation to repair your ankle fracture.
Your hospital course was complicated by acute alcohol withdrawal
requiring monitoring and treatment in the intensive care unit.
You suffered a fall and fractured your cervical spine. To
prevent paralysis you must WEAR YOUR COLLAR AT ALL TIMES FOR at
least 3 MONTHS (until [**2188-1-10**]). Orthopedics will help to
determine when it is ok to remove the collar.
We recommend that you do not drink alcohol in the future.
Please follow your medication list closely.
Attend all follow up appointments.
Please contact your doctor or go to the emergency room if you
experience any of the following symptoms: body weakness,
difficulty moving, increased pain, fevers >100.4, chills, chest
pain, shortness of breath, leg pain or other concerning
symptoms.
Followup Instructions:
Orhtopedics Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2189-1-2**] 11:30. The orthopedics office is attempting
to make an earlier appointment that that they will contact you
with the final appiontment time.
.
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 2177**] [**Telephone/Fax (1) 11463**]. [**2188-1-1**] at 2pm
Completed by:[**2188-12-10**]
ICD9 Codes: 2930, 5990, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3915
} | Medical Text: Admission Date: [**2172-9-14**] Discharge Date: [**2172-9-23**]
Date of Birth: [**2131-10-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
s/p Bicycle crash vs auto
Major Surgical or Invasive Procedure:
[**2172-9-17**]
1. Tracheostomy
2. Percutaneous endoscopic gastrostomy.
History of Present Illness:
44 yo male s/p bicycle crash vs. auto in which he was the
helmeted driver of the bicycle. Per EMS, +LOC, but found awake
at scene. Transferred to [**Hospital1 18**] for trauma evaluation.
Past Medical History:
Denies
Social History:
Lives with his girlfriend
Family History:
Noncontributory
Physical Exam:
Upon admission:
BP: 130/68 HR: 65 R 19 O2Sats 100 NR
Gen: WD/WN, lying quiet, rigid cervical collar in use.
HEENT: Large right 4cm forehead/eyelid laceration with frank
bleeding. Pupils: Rt 3.0mm to 2.5mm;Lt 2.5mm to 2.0mm. EOMs: Pt
follows only right to left upper and lateral/medial gazes with
much encouragement, falls asleep quickly.
Neck: Supple. No posterior point tenderness within confines of
the cervical collar.Voice is thick. Pt in supine position.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro: GCS 13. Initially awake and alert, opening eyes to voice.
oriented to self, month and location of hospital. Does
not recall name of hospital. Able to recall being hit by a car.
Falls asleep again requiring vigorous stimuli and shaking of
arm.
Orientation: Oriented to person, place, and date.Does not
perform
tests for finger to nose or for pronation assessment.
Language: Speech Thick with comprehensible words at times.
Cranial Nerves:
I: Not tested
II: Pupils unequal, round and reactive to light, as described
above.
III, IV, VI: Extraocular movement exam limited due to blood in
eyes and pts decreasing loc and disinterest.
V, VII: Facial strength reported to feel "okay" unable to
discern
if feels different.
VIII: Hearing intact to voice.
IX, X: Not tested
[**Doctor First Name 81**]: Not able to test
XII: Attempting to stick tongue out when asked. Full motion not
done.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power 5-/5 throughout. MAE's. Does not
understand to keep palms upward to test pronation. Does hold
arms
off of bed.
Sensation: Intact to light touch
Reflexes: (No fractures) B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: Does not comply for testing.
Pertinent Results:
[**2172-9-14**] 08:56PM TYPE-ART PO2-361* PCO2-44 PH-7.33* TOTAL
CO2-24 BASE XS--2
[**2172-9-14**] 07:04PM GLUCOSE-231* UREA N-15 CREAT-0.9 SODIUM-140
POTASSIUM-3.1* CHLORIDE-104 TOTAL CO2-21* ANION GAP-18
[**2172-9-14**] 07:04PM CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-1.7
[**2172-9-14**] 07:04PM WBC-21.9*# RBC-4.49* HGB-13.7* HCT-37.4*
MCV-83 MCH-30.4 MCHC-36.5* RDW-13.0
[**2172-9-14**] 07:04PM PLT COUNT-336
[**2172-9-14**] 07:04PM PT-13.4 PTT-22.6 INR(PT)-1.1
[**2172-9-14**] 04:14PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2172-9-14**] 04:14PM GLUCOSE-206* LACTATE-3.6* NA+-141 K+-2.9*
CL--103 TCO2-20*
Head CT scan [**2172-9-14**]
IMPRESSION:
1. Small subdural hematoma along the right temporal lobe with
associated
pneumocephalus and temporal bone fracture. Probable small
suddural hematoma
along the inferior frontal lobes adjacent to frontal bone
fracture.
2. Please refer to dedicated facial bone CT for detailed
description of
extensive facial fractures.
C-spine CT scan [**2172-9-14**]
IMPRESSION: No C-spine fractures or malalignment. Please see
maxillofacial CT report for details on facial bone fractures.
CT Chest/Abdomen/Pelvis [**2172-9-14**]
IMPRESSION: No evidence of traumatic injury in the chest,
abdomen, or pelvis,
with probable focus of aspiration in the superior segment of the
left lower lobe.
CT Sinus/Mandible [**2172-9-14**]
IMPRESSION:
Extensive facial trauma with "smash" fractures on the right and
Le [**Location 56204**]
injury on the left. Please note, right temporal and right
frontal skull
fractures noted with underlying small extra-axial hemorrhage and
pneumocephalus.
Repeat head CT scan [**2172-9-15**]
IMPRESSION:
1. Slight increase in the small subdural hematoma along the
right temporal
lobe with stable associated pneumocephalus and no mass efefct.
2. Unchanged probable small subdural hematoma along the inferior
frontal
lobes adjacent to the frontal bone fracture.
2. Please refer to dedicated facial bone CT for detailed
description of
extensive facial fractures.
Brief Hospital Course:
He was admitted to the Trauma service. Neurosurgery and Plastic
surgery were consulted given his injuries. He was taken to the
trauma ICU where he remained sedated and intubated. Serial head
CT scans were followed; repeat scan showed a slight increase in
the hemorrhage along the right temporal lobe. He will follow up
as an outpatient with Dr. [**Last Name (STitle) 548**].
Plastics was consulted for his extensive facial fractures and
are recommending operative repair at a later date. He was also
evaluated by Ophthalmology and was initially started on eye
drops. Prior to discharge his drops were stopped, with the
exception of the artifical tears; in preparation for a more
involved eye exam off of the dilating medication.
A tracheostomy and peg tube was placed. Tube feedings were
initiated for which he was able to tolerate. He was eventually
weaned from the ventilator. His mental status remained stable
and he was transferred to the regular nursing unit. An
evaluation by speech and swallow was done and his diet was
upgraded to thin liquids with ground solids. The tracheostomy
was left in place for his upcoming surgery.
Extensive patient and family teaching was done regarding
tracheostomy care and tube feedings.
He was evaluated by Physical and Occupational therapy and made
significant gains; he was eventually cleared for discharge to
home with his family.
Medications on Admission:
Denies
Discharge Medications:
1. Polyvinyl Alcohol 1.4 % Drops Sig: Two (2) Drop Ophthalmic
four times a day.
Disp:*1 Bottle* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*450 ML(s)* Refills:*0*
3. Colace 50 mg/5 mL Liquid Sig: Ten (10) ML's PO twice a day as
needed for constipation.
Disp:*450 ML's* Refills:*0*
4. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
5. Augmentin 250-62.5 mg/5 mL Suspension for Reconstitution Sig:
Ten (10) ML's PO three times a day for 7 days.
Disp:*qs ML's* Refills:*0*
6. Keppra 100 mg/mL Solution Sig: Five (5) ML's PO twice a day
for 6 weeks.
Disp:*qs ML's* Refills:*0*
7. Ensure Plus Liquid Sig: Two (2) CANS PO three times a
day: Bolus tube feedings.
Disp:*qs ML's* Refills:*1*
8. Oxygen Therapy
Humified compressed air via trach collar
9. Tracheostomy care
Tracheostomy suction catheter, 14Fr
Disp# 10
Refills - 3
10. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): Apply around right orbital region
as directed.
Disp:*1 Tube* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Pedestrian struck by auto
Facial fractures (LeForte III on right/II on left)
Small subdural hemorrhage
Right basilar skull fracture
Right anterior temporal fracture
Pulmonary contusion
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
Return to the Emergency room if you develop any increased
headaches, changes in your vison, fevers, chills, productive
cough with thick sputum that is not white or clear in color,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea and/or any other symptoms that are concerning
to you.
You have been cleared to take in oral pureed foods and
pre-thickened liquids. Because of your injuries and higher than
usual caloric needs you will need to take in enough calories to
help with your healing. We are recommending that you have at
least 2 cans 3x/day of either Boost Plus or Ensure Plus to give
you the adequate nutrition needed.
Followup Instructions:
Please call Plastic surgery regarding your surgery which is
tnetaively scheduled for [**2172-9-28**]. You will need to call
[**Telephone/Fax (1) 5343**] for specific information regarding the time and
preparation.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery. Call
[**Telephone/Fax (1) 6429**] for an appoitntment.
Follow up with Dr. [**Last Name (STitle) 548**], Neurosurgery in 6 weeks for a repeat
head CT scan; inform the office when you are making this
appointment that you will need the CT scheduled. Call
[**Telephone/Fax (1) 2992**] for an appointment.
Completed by:[**2172-9-29**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3916
} | Medical Text: Admission Date: [**2175-11-29**] Discharge Date: [**2175-12-1**]
Date of Birth: [**2132-7-24**] Sex: M
Service: TRA
HISTORY OF PRESENT ILLNESS: This is a 43 year-old healthy
male who fell from scaffolding approximately 15 feet after
losing his footing. He apparently landed on his head and at
this time his GCS was 3 upon arrival by EMS. He was intubated
at the scene and minimal movement of his lower extremities
during the intubation as noted by EMS. He was hypotensive at
the scene and bradycardic with his blood pressure
systolically in the low 80s. His pupils were noted to be
nonreactive on the right and fixed and dilated at 6 mm and on
the left fixed at 3 mm.
PHYSICAL EXAMINATION: Upon admission vital signs: His
temperature was 96.8, heart rate 103, blood pressure 125/64,
respiratory rate 18 and 100% on assist control of FIO2 of
100%, 600 x 18 with a PEEP of 5. Patient was noted to be
intubated, unresponsive to any commands with pupils unequal
and nonreactive. The left was 6 mm and the right was 3 mm and
he did have a positive cough reflex. There was noted to be a
significant concern for [**Doctor Last Name 352**] matter emanating from his
tympanic canals and significant blood in the oropharynx and
nasopharynx on examination with severe deformity but no open
skull fractures obvious over his examination of the scalp.
His neck was in a hard collar and there was no obvious
deformity or tracheal shift. He had clear and equal breath
sounds bilaterally without any obvious external injury of the
chest. His heart was in regular rate and rhythm without any
murmurs, rubs or gallops. His abdomen was slightly obese and
nondistended with normoactive bowel sounds and he was
nontender throughout. There were no obvious external injuries
to his abdomen. His pelvis was stable. All of his extremities
were without obvious deformity or injury or abrasion and
there was noted to be a slightly increased tone throughout
with a negative Babinski sign. His spine examination was
unremarkable throughout with no obvious step off or
deformity. His rectal examination revealed decreased tone and
was guaiac negative with no masses or lesions noted. He did
not possess a bulbocavernosus reflex.
PAST MEDICAL HISTORY: Unremarkable.
MEDICATIONS: None.
ALLERGIES: None known.
SOCIAL HISTORY: The patient is separated from his wife and
works in construction and in carpentry. We were not able to
determine whether he was a smoker or a drinker.
HOSPITAL COURSE: At this time the patient was brought into
the trauma bay and was noted to be in critical condition with
a very concerning neurologic examination for severe acute
brain injury. He was reintubated with a #8 without
significant difficulty after significant blood was noted in
the oropharynx. This was suctioned out without significant
difficulty. He was now hemodynamically stable after 2 liters
of normal saline for resuscitation. With his heart rate in
low 100s, his blood pressure systolically in the 120s, the
only obvious injury we had at this time that would be
contributing to his neurologic status and his episode of
hypotension and hemodynamic instability was considered to be
likely from the central nervous system and from this acute
brain injury. Neurosurgery was immediately called to the
trauma bay and evaluate the patient with Dr. [**Last Name (STitle) **] staffing
the consults, the patient was then rushed to the CT scanner
where a CT scan of the head revealed a large subdural
hematoma, subarachnoid hemorrhage and interventricular
hemorrhage and significant cerebral edema, most marked on the
left side with mild compression of the left cerebral peduncle
suggestive of impending herniation. This was discussed with
Dr. [**Last Name (STitle) **] immediately by the house officers involved. He
also had multiple fractures that were noted on this CT scan
of the left sphenoid and temporal fractures extending to the
occipital condyle. This was also worrisome for possible
injury to the vasculature of the vertebral artery on the left
side and there was also concern on further review of the CT
scan for damage to the internal carotid artery on the left
side.
His laboratory values were unremarkable. His white count was
14,000. His hematocrit was 36.2. His coagulation parameters
were within normal limits with an INR of 1.1. His tox screen
was negative for urine and blood. At this point the plan was
to admit this patient to the trauma Intensive Care Unit with
this significant acute brain injury. Neurosurgery declined
intervention at this time due to the grave prognosis and the
unlikely ability to gain any improvements with intervention.
Discussions were had between the teams in regard to placement
of drains or decompression craniotomy and this was not
pursued. The patient's family was contact[**Name (NI) **] including his
wife who he had been separated from who was on her way in as
well as his entire family that lived in [**State 760**] including
his mother and father who are on their way at this time.
The patient was admitted to the trauma SICU and never showed
any improvement in neurologic status and was at this point
evaluated by the [**Location (un) 511**] Organ Bank as a possible
transplant candidate. Later in the afternoon of [**2175-11-30**] the patient was declared brain dead and later expired.
This was all discussed with the family at length.
DISCHARGE DIAGNOSIS: Acute brain injury, status post fall.
Patient expired.
DISPOSITION: Patient expired.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 33889**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2175-12-21**] 12:27:23
T: [**2175-12-21**] 13:41:22
Job#: [**Job Number 71064**]
ICD9 Codes: 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3917
} | Medical Text: Admission Date: [**2179-5-27**] Discharge Date: [**2179-8-12**]
Date of Birth: [**2116-8-2**] Sex: F
Service: SURGERY
CHIEF COMPLAINT: Enterocutaneous fistula, subphrenic
abscess, in need of nutritional support and wound care
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 62-year-old
female with a two year history of bilateral lower extremity
claudication secondary to bilateral aorto-iliac and
superficial femoral artery disease. On [**2179-5-27**], she
underwent an aortobifemoral bypass graft which was
complicated by a splenic laceration requiring a splenectomy.
She had an estimated blood loss of 5200 at that time.
Postoperatively, she had a large hemorrhagic stool.
Colonoscopy soon revealed severe ischemic proctitis. This
was all occurring at an outside hospital. Subsequent
exploratory laparotomy was significant for infarcted left
colon down to the proximal rectum. Of note, the patient is
status post sigmoid colectomy for diverticulitis in the past.
The patient underwent a left colectomy at that time, with
peritoneal reflection with a transverse colostomy. Her
abdominal wound was left open at that time.
On postoperative day 12 at the outside hospital, the patient
spiked a fever, developed a bandemia and began draining
succus from the superior aspect of her wound. CT of the
abdomen and blood cultures were negative per report. She was
started on Zosyn and made nothing by mouth and was then
transferred to [**Hospital1 69**] for
further management of her enterocutaneous fistula.
PAST MEDICAL HISTORY:
1. Diverticulitis status post sigmoid colectomy
2. Hypercholesterolemia
3. Aorto-iliac occlusion disease status post aortobifemoral
bypass on [**2179-5-10**]
4. Status post splenectomy [**2179-5-10**]
5. Status post left colectomy and transverse colostomy for
ischemia, [**2179-5-11**]
MEDICATIONS ON ADMISSION:
1. Zosyn 3.375 grams intravenously every six hours
2. Pantoprazole 40 mg intravenously every 24 hours
3. Aspirin 325 mg as needed
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vitals: Temperature 98.4, heart rate
96, blood pressure 132/70, respiratory rate 24, oxygen
saturation 96% on 2 liters. In general, she is
non-toxic-appearing. Her lungs are clear to auscultation
bilaterally. Her heart is regular rate and rhythm. Her
abdomen is soft, with minimal tenderness at wound skin edges.
She is obese, nondistended, atympanic. She has normal active
bowel sounds, no gas or stool in ostomy bag. She has a large
midline abdominal incision from the subxiphoid area to the
infraumbilical area. It is open, with granulation tissue and
fibrinous and necrotic exudate throughout. There is succus
draining from the superior aspect. Extremities: She has
bilateral groin incisions with staples. She has skin
reaction and mild cellulitis and scant serous exudate over
her incisions. She has bilateral positive femoral pulses,
bilateral dorsalis pedis palpable pulses, and 2+ edema in her
lower extremities. The patient also has left foot drop.
HOSPITAL COURSE: On [**2179-5-27**], the patient was admitted
to the floor to Dr.[**Name (NI) 6275**] service. She was made nothing
by mouth, and initially started on Zosyn for antibiotics.
Intravenous access was obtained, and morphine was started for
pain. The patient was started on wet-to-dry dressing changes
on her wound.
Over the next few days, the patient was started on total
parenteral nutrition, as a PICC line was placed. Also a sump
drain was placed into her wound, and dressing changes were
started with Dakin solution for debridement.
On hospital day four, the patient had acute onset of
tachycardia and tachypnea, and was transferred to the Unit.
At this time, the patient received her first CT, which showed
no evidence of pulmonary emboli. It did show a left-sided
pleural effusion. When this pleural effusion was drained
percutaneously in Radiology, it was found to be a left
subphrenic abscess. A CT-guided percutaneous placement of
drainage catheter within the left subphrenic abscess was
performed.
Over the next few days, the patient was provided with
nutritional support through her total parenteral nutrition.
The patient was followed by Physical Therapy, and her pain
was managed adequately. She was also continued on Zosyn at
this time.
The final report from the abscess drainage showed sparse
growth of E. coli. This was sensitive to multiple
antibiotics, including Zosyn, so Zosyn was continued. The
patient experienced multiple episodes of respiratory distress
on the floor. Each time she was ruled out for any cardiac
event. Lasix was started for possible fluid overload from
all of her total parenteral nutrition. The patient was also
started on Fluconazole around this time for yeast in her
urinary tract.
The patient also showed signs of depression, and was started
on Zoloft. The patient was encouraged to ambulate, and was
started on clears, which the patient tolerated somewhat,
often with nausea and no appetite. The Vascular Surgery team
was consulted because of increasing gas in the
retroperitoneum and to evaluate the graft in place. However,
CT obtained showed no air on the graft, and some fluid which
was determined to be just perioperative hematoma or lymph
fluid, and the patient was to be followed clinically for any
signs of infection in her graft.
Around hospital day 16, pseudomonas aeruginosa grew out of
her abscess, so the patient was started on Cipro on top of
her Zosyn. After the sensitivities were obtained, the
patient was started in imipenem. Around hospital day 20, the
patient developed herpetic lip/mouth lesions and was started
on acyclovir. The pigtail drainage catheter continued to
drain throughout this time, and the patient received
metabolic support. The patient also received some bedside
debridement, and continued to have her dressing changed with
Dakin solution and a sump drain placed.
Around hospital day 28, the pigtail catheter drainage had
decreased in amount, and a son[**Name (NI) **] was performed to the
point where the pigtail catheter could be taken out. At this
point, the patient was only on imipenem, and was working with
her nutritional status and her low oral intake with total
parenteral nutrition supplementation. Upper gastrointestinal
studies were also performed to make sure there was no
physical reason for her low oral intake. These all turned
out to be negative.
Over the next weeks, the patient had minor changes in her
nutritional support, with Nutrition input. To encourage her
oral intake, she had multiple changes in her total parenteral
nutrition, however, the patient was nauseated and vomiting
much of the time. However, during this time, her wound
slowly contracted and stayed clean, with her twice a day to
three times a day dressing changes.
A Gastroenterology consult was obtained to help with her low
oral intake. An esophagogastroduodenoscopy was performed by
Gastroenterology, which showed erythema and erosion in the
stomach body, compatible with gastritis, but otherwise normal
esophagogastroduodenoscopy to the second part of the
duodenum. Recommendations were to continue with proton pump
inhibitor and, if symptoms persist, to continue to consider
gastric emptying study to evaluate for gastroparesis.
Finally, by hospital day 71, the patient was taking in
adequate amounts of oral intake to discontinue her total
parenteral nutrition. By hospital day 76, we were
comfortable that she was taking in enough oral nutrition to
no longer need supplementation. Her wound no longer needed
debridement, and was only being changed with a Xeroform with
some damp normal saline gauze on top of it.
CONDITION AT DISCHARGE: Patient stable.
DISCHARGE STATUS: To home with VNA. VNA to change dressings
twice a day and to assess nutritional status.
DISCHARGE DIAGNOSIS: Enterocutaneous fistula, subphrenic
abscess, nutritional support, wound care
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg by mouth twice a day
2. Pantoprazole 40 mg by mouth once daily
3. Sertraline HCl 50 mg by mouth once daily
4. Ambien 10 mg by mouth daily at bedtime
FOLLOW UP PLANS:
1. The patient is to follow up at Dr.[**Name (NI) 6275**] office on
[**8-23**] at 12:15 P.M.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Name8 (MD) 43099**]
MEDQUIST36
D: [**2179-8-11**] 23:24
T: [**2179-8-12**] 01:17
JOB#: [**Job Number 39864**]
ICD9 Codes: 5119, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3918
} | Medical Text: Admission Date: [**2175-1-23**] Discharge Date: [**2175-2-7**]
Date of Birth: [**2100-9-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
74 yo male s/p fall from tractor and crush injury from tree
branch. - Loc. +HD stable
Injuries:
Mult rib fx: R [**Doctor Last Name **] and P
T4 vert body inf corner fx
Comminuted spinous process fx T2-8
R liver lobe contusion
L pubic ramus fx
R iliac fx
B pulmonary contusion
laceration under right eyebrow
Major Surgical or Invasive Procedure:
IR angio: 2 pelvic vessels, 2 gel foamed vessels
IVC Filter
PEG/perc tracheostomy
Past Medical History:
none known
Social History:
unknown
Family History:
nc
Physical Exam:
Afebrile, Vitals WNL
RRR
CTAB
soft NT/ND
no edema, extrem warm
follows commands, moves all extremities
Pertinent Results:
Micro/Imaging:
[**2175-2-6**] No LUE DVT
[**2175-2-3**] CXR no relevant change from prior
[**2175-2-3**] BLE Leni no DVT
[**2175-1-30**] RUQ Ultz cbd 4.5mm, no e/o cholecystitis
[**2175-1-30**] echo
[**2175-1-29**] BAL Klebsiella, pan sensitive
[**2175-1-29**] Blood cx Pend
[**2175-1-29**] Urine cx Neg
[**2175-1-29**] CXR NGT tip in stomach
[**2175-1-28**] CXR fluid overload, inc. cardiac size
[**2175-1-28**] R ankle/foot no obvious fx, linear density at achilles
insertion, ? sm avulsion fx
[**2175-1-27**] CXR LLL collapse improved. Persist RLL, mod b/l pleural
eff
[**2175-1-26**] CXR unchanged fr yesterday
[**2175-1-26**] Bronch lvg Klebsiella, haemophilus (not influenza)
[**2175-1-25**] Blood cx PRELIM: neg
[**2175-1-25**] CXR ETT ok. Pulm edema better. b/l atalect and pl
effusion unchanged
[**2175-1-25**] TTE RV dil w pressure overload. 2+ tri regurg. PA HTN.
LV and EF wnl.
[**2175-1-25**] CTA PRELIM: no pulm embolism, cannot rule out
subsegmental PE
[**2175-1-25**] Urine cx PENDING
[**2175-1-25**] angio see OMR
[**2175-1-25**] sputum PRELIM: gram=oropharyngeal. cx=Sparse gram neg
rods
[**2175-1-23**] CXR pulmonary opacities suggestive of contusion
[**2175-1-23**] Pelvis R lateral rib fx,L pubic rami fx
[**2175-1-23**] CT head OSH:Prelim No ICH or fracture.
[**2175-1-23**] CT chest OSH:Mult rib fx: t4 vert bod fx, T2-T8 sp fx
[**2175-1-23**] CT c spine OSH:Prelim No fracture or malalignment
[**2175-1-23**] CTAabd/pel Prelim: Area of arteria bleeding/extrav,
hematoma larger than OSH
[**2175-1-23**] CTAabd/pel Medial rt liver lobe contusion, left pubic
ramus fx
[**2175-1-23**] CTAabd/pel Post right hepatic lac/contusion, fx right
iliac bone non disp.
[**2175-1-23**] MRI Tspine Mild compression deformity of L1
[**2175-1-23**] MRI Tspine ? trabecular contusion T10-11 and inf T4
with no retropulsion
[**2175-1-23**] MRI Tspine ext edema throughout, esp interspinous lig
[**2175-2-7**] 02:23AM BLOOD WBC-4.6 RBC-2.70* Hgb-8.6* Hct-26.7*
MCV-99* MCH-31.8 MCHC-32.2 RDW-16.1* Plt Ct-201
[**2175-2-6**] 01:36AM BLOOD WBC-4.6 RBC-2.87* Hgb-8.9* Hct-28.2*
MCV-98 MCH-31.0 MCHC-31.5 RDW-15.9* Plt Ct-196
[**2175-2-5**] 01:55AM BLOOD WBC-5.2 RBC-2.92* Hgb-8.8* Hct-28.4*
MCV-97 MCH-30.2 MCHC-31.0 RDW-15.7* Plt Ct-178
[**2175-2-4**] 01:04AM BLOOD WBC-6.5 RBC-3.06* Hgb-9.3* Hct-29.0*
MCV-95 MCH-30.3 MCHC-32.1 RDW-15.5 Plt Ct-124*
[**2175-2-3**] 02:05AM BLOOD WBC-6.3 RBC-3.03* Hgb-9.3* Hct-28.9*
MCV-95 MCH-30.8 MCHC-32.4 RDW-15.4 Plt Ct-128*
[**2175-2-2**] 01:07AM BLOOD WBC-5.9 RBC-3.21* Hgb-10.2* Hct-31.3*
MCV-98 MCH-31.7 MCHC-32.5 RDW-15.3 Plt Ct-109*
[**2175-2-1**] 02:18AM BLOOD WBC-4.2# RBC-3.12* Hgb-9.5* Hct-29.7*
MCV-95 MCH-30.4 MCHC-31.9 RDW-15.0 Plt Ct-104*
[**2175-1-31**] 01:46AM BLOOD WBC-8.8 RBC-3.49* Hgb-10.7* Hct-32.1*
MCV-92 MCH-30.6 MCHC-33.2 RDW-15.2 Plt Ct-153
[**2175-2-5**] 01:55AM BLOOD PT-14.0* PTT-28.1 INR(PT)-1.2*
[**2175-1-31**] 01:46AM BLOOD PT-13.7* PTT-27.6 INR(PT)-1.2*
[**2175-1-30**] 12:45AM BLOOD PT-13.9* PTT-26.9 INR(PT)-1.2*
[**2175-2-7**] 02:23AM BLOOD Glucose-112* UreaN-28* Creat-1.1 Na-150*
K-4.0 Cl-123* HCO3-22 AnGap-9
[**2175-2-6**] 01:36AM BLOOD Glucose-122* UreaN-25* Creat-1.1 Na-144
K-3.6 Cl-117* HCO3-21* AnGap-10
[**2175-2-5**] 03:56PM BLOOD Glucose-120* UreaN-24* Creat-1.0 Na-147*
K-3.8 Cl-117* HCO3-23 AnGap-11
[**2175-2-5**] 01:55AM BLOOD Glucose-119* UreaN-23* Creat-1.0 Na-143
K-3.8 Cl-113* HCO3-24 AnGap-10
[**2175-2-4**] 05:03PM BLOOD Glucose-113* UreaN-22* Creat-0.9 Na-142
K-3.9 Cl-110* HCO3-25 AnGap-11
[**2175-2-4**] 01:04AM BLOOD Glucose-103 UreaN-21* Creat-0.8 Na-144
K-3.9 Cl-107 HCO3-33* AnGap-8
[**2175-2-3**] 01:23PM BLOOD Glucose-136* UreaN-23* Creat-0.8 Na-142
K-3.4 Cl-103 HCO3-32 AnGap-10
[**2175-2-3**] 02:05AM BLOOD Glucose-138* UreaN-23* Creat-0.8 Na-142
K-3.8 Cl-105 HCO3-31 AnGap-10
[**2175-2-7**] 02:23AM BLOOD ALT-89* AST-100* AlkPhos-250*
TotBili-2.7*
[**2175-2-6**] 01:36AM BLOOD ALT-99* AST-122* CK(CPK)-30* TotBili-3.4*
[**2175-2-5**] 03:56PM BLOOD CK(CPK)-34*
[**2175-2-5**] 01:55AM BLOOD ALT-104* AST-137* AlkPhos-204*
TotBili-4.8*
[**2175-2-4**] 05:03PM BLOOD ALT-109* AST-142* CK(CPK)-60 TotBili-5.0*
[**2175-2-3**] 01:23PM BLOOD CK(CPK)-81
[**2175-2-3**] 02:05AM BLOOD ALT-90* AST-122* AlkPhos-133* Amylase-54
TotBili-5.4*
[**2175-2-2**] 01:07AM BLOOD ALT-90* AST-113* CK(CPK)-69 AlkPhos-99
Amylase-58 TotBili-5.1*
[**2175-1-30**] 12:45AM BLOOD ALT-90* AST-88* LD(LDH)-348* AlkPhos-63
TotBili-6.8* DirBili-5.2* IndBili-1.6
[**2175-2-3**] 02:05AM BLOOD Lipase-52
[**2175-1-25**] 09:18AM BLOOD CK-MB-13* MB Indx-1.0 cTropnT-<0.01
[**2175-2-7**] 02:23AM BLOOD Calcium-7.7* Phos-2.8 Mg-2.4
[**2175-2-6**] 01:36AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.4
[**2175-2-5**] 03:56PM BLOOD Phos-3.3 Mg-2.4
[**2175-1-23**] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2175-2-7**] 06:22AM BLOOD Type-ART Temp-37.2 Rates-/36 PEEP-5
FiO2-40 pO2-103 pCO2-28* pH-7.45 calTCO2-20* Base XS--2
Intubat-INTUBATED Vent-SPONTANEOU
[**2175-2-6**] 07:31PM BLOOD Type-ART Temp-38.1 Rates-/31 Tidal V-360
PEEP-10 FiO2-40 pO2-85 pCO2-35 pH-7.42 calTCO2-23 Base XS-0
Vent-SPONTANEOU
[**2175-2-6**] 04:51AM BLOOD Type-ART pO2-109* pCO2-37 pH-7.37
calTCO2-22 Base XS--3
[**2175-2-6**] 02:16AM BLOOD Type-ART pO2-123* pCO2-32* pH-7.40
calTCO2-21 Base XS--3
[**2175-2-5**] 05:09PM BLOOD Type-ART Temp-37.2 Rates-/25 Tidal V-1000
PEEP-8 FiO2-40 pO2-115* pCO2-36 pH-7.45 calTCO2-26 Base XS-1
Vent-SPONTANEOU
[**2175-2-5**] 11:35AM BLOOD Type-ART Temp-36.7 Rates-/22 Tidal V-1000
PEEP-8 FiO2-40 pO2-113* pCO2-36 pH-7.43 calTCO2-25 Base XS-0
Intubat-INTUBATED Vent-SPONTANEOU
[**2175-2-4**] 06:07PM BLOOD Type-ART Temp-37.2 Rates-/25 PEEP-10
FiO2-40 pO2-111* pCO2-40 pH-7.45 calTCO2-29 Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
[**2175-2-4**] 01:10PM BLOOD Type-ART Temp-37.2 Tidal V-1000 PEEP-15
FiO2-50 pO2-119* pCO2-38 pH-7.49* calTCO2-30 Base XS-6
Intubat-INTUBATED
[**2175-2-4**] 06:28AM BLOOD Type-ART Temp-38.8 Rates-/20 PEEP-10
FiO2-50 pO2-137* pCO2-43 pH-7.47* calTCO2-32* Base XS-7
Intubat-INTUBATED
[**2175-2-4**] 12:35AM BLOOD Type-ART Temp-37.9 Rates-/30 PEEP-10
FiO2-50 pO2-124* pCO2-39 pH-7.53* calTCO2-34* Base XS-9
Intubat-INTUBATED Vent-SPONTANEOU
[**2175-2-7**] 06:22AM BLOOD Glucose-106* Na-146 K-3.2*
[**2175-2-6**] 07:31PM BLOOD K-3.7
[**2175-2-5**] 11:35AM BLOOD K-3.5
[**2175-2-5**] 02:04AM BLOOD Glucose-108*
[**2175-2-4**] 01:10PM BLOOD K-3.8
[**2175-2-4**] 06:28AM BLOOD Glucose-121* Lactate-1.1 K-3.6
[**2175-2-7**] 06:22AM BLOOD freeCa-1.15
[**2175-2-6**] 02:16AM BLOOD freeCa-1.12
[**2175-2-5**] 02:04AM BLOOD freeCa-1.14
Brief Hospital Course:
74 yo male s/p fall from tractor and crush injury from tree
branch. - Loc. +HD stable with injuries: Mult rib fx: R [**Doctor Last Name **] and
P, T4 vert body inf corner fx, comminuted spinous process fx
T2-8, R liver lobe contusion, L pubic ramus fx,
R iliac fx, B pulmonary contusion, laceration under right
eyebrow. 4 PRBCs given, 2 FFP given. On [**1-25**] overnight he was
reintubated for presumed fluid overload - tachycardic,
hypotensive, desated, decreased oxygenation. He went to IR and
had an embolization for a bleed secondary to his pelvic
fractures. He went into AF after this, was corrected and broken
with dilt gtt, and was transitioned to PO diltiazem and remained
mostly in NSR with occasional AF - which broke after IV
amiodarone and PO amio was then added. He did have a 1st degree
AV block when in sinus rhythm. He had an increasing WBC and his
BAL grew out klebsiella - he was treated for 10 days with broad
spectrum abx for this. On [**2-1**] he was trached (perc) and
PEG'd, TF were Nutrin 2.0 to a goal of 40. He became
hypernatremic and on the discharge day was switched to a less
concentrated formula to help correct his hypernatremia. Ortho
recommended a TLSO (which he was fit for) while out of bed. he
remained in sinus on the amio and no AC was started. We tried
to wean him to trach mask, however he became tachypneic on [**2-6**]
and was put back on CPAP and PS at PS of 10 and PEEP of 5. His
HCTs have been stable. His WBC improved and his VAP is presumed
to be successfully treated. He is in good condition on [**2-7**]
for discharge to an acute outpt facility with a need for close
watching his sodium, need to wean his vent, and a need to
monitor for further episodes of AF. He will also need PT and OT
and his TLSO out of bed.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Year (2) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
4. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: sliding scale
Injection ASDIR (AS DIRECTED).
5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
8. Gabapentin 400 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3
times a day).
9. Oxycodone 5 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q3H (every 3
hours) as needed for pain control.
10. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times
a day).
13. Diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day).
14. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for anxiety.
15. Ondansetron 4 mg IV Q8H:PRN nausea
16. Metoprolol Tartrate 5 mg IV Q4H:PRN hr>90, SBP>150
hold hr<60, SBP<100
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Injuries:
Mult rib fx: R [**Doctor Last Name **] and P
T4 vert body inf corner fx
Comminuted spinous process fx T2-8
R liver lobe contusion
L pubic ramus fx
R iliac fx
B pulmonary contusion
laceration under right eyebrow
Ventilator acquired pneumonia
atrial fibrillation
Hypernatremia
respiratory failure
Discharge Condition:
Good
Discharge Instructions:
please call or return if you have fevers >101, chest pain,
shortness of breath, uncontrollable atrial fibrillation,
worsening hypernatremia, worsening respiratory status, or
anything that causes you concern
Followup Instructions:
Follow up in trauma clinic in 2 weeks
([**Telephone/Fax (1) 2537**]
ICD9 Codes: 5185, 2760, 2851, 2762, 4168, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3919
} | Medical Text: Admission Date: [**2107-6-10**] Discharge Date: [**2107-6-14**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
1. bilateral distal radius closed reduction, percutaneous
pinning.
History of Present Illness:
86 y/o female s/p mechanical fall down 1 flight of stairs. No
LOC. Bilateral wrist deformities. Down for 3 hours before being
found.
Past Medical History:
GERD
Depression
Sciatica
TAH
Appy
?Gout
Social History:
widowed, lives at home alone
Physical Exam:
132/69 HR 92 RR 22 95% RA
NAD, AOx3
NCAT, PERRL
C-collar in place, midline tenderness to palp
RRR
CTAB
Bilateral wrist deformities
non-focal neuro exam
Pertinent Results:
B wrist x-ray: bilateral distal comminuted radial fracture with
complete dorsal displacement
CT spine: Old compression fractures of the thoracic spine with
spinal stenosis at the T12 level. No clear evidence of an acute
fracture.
CT cervical spine: 1) Comminuted burst fracture of C2, with
posterior displacement of the posterior elements of C2, and
without evidence of canal compromise. Epidural hematoma at the
C2 level.
Brief Hospital Course:
86 y/o female s/p fall down stairs. She was evaluted in the
emergency department and noted to have a C2 burst fracture,
bilateral wrist fractures, and a t-spine compression fracture.
The patient was admitted to the hospital and evaluted by the
trauma and orthopedic surgery teams. Her bilateral wrist
fractures were partially reduced in the ED and the patient was
subsequently taken to the OR for further closed reduction and
percutaneous pinning. She was also evaluted by Dr. [**First Name (STitle) 1022**] of
ortho-spine and his recommendation was that the patient continue
wearing a cervical collar x 3 months and that there was nothing
to do regarding the old t-spine compression fractures. The
patient was discharged from the hosptial in good condition. She
will follow up with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 1022**] of orthopedics.
Medications on Admission:
gabapentin
protonix
prozac
cochicine
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Please cont taking your regular home meds as directed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 10283**] Center - [**Location (un) **]
Discharge Diagnosis:
1. C2 burst fracture s/p placement of c-collar
2. Bilateral distal radius posteriorly angulated fracture s/p
bilateral distal radius closed reduction, percutaneous pinning.
3. Thoracic compression fractures, likely old
Discharge Condition:
Good
Discharge Instructions:
Please resume taking your home medications. Take percocet as
needed for pain. Keep your cervical collar on at all times for 3
months.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**1-9**] weeks regarding your wrist
fractures. Please follow up with Dr. [**First Name (STitle) 1022**] in 3 months regarding
your cervical vertebra fractures. Call for appoitments.
ICD9 Codes: 2749, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3920
} | Medical Text: Admission Date: [**2201-4-8**] Discharge Date: [**2201-4-8**]
Date of Birth: [**2121-5-19**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Transferred from OSH intubated for neurosurgical consultation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname **] [**Known lastname 9035**] is a 79 yo LHM who was transferred from [**Hospital6 38673**] after he fell out of bed this morning and was
unable to stand up with significant weakness noted on the left
side. His wife states that last night he was in his usual state
of health and was out singing with a group that he performs with
regularly. He had no complaints of headache or neck pain and no
neurologic symptoms. His wife noted that he had recentyl been
hospitalized 3 weeks prior to this incident at [**Hospital3 **] for a
bacteremia and was started on IV antibiotics with a PICC line on
discharge. He was hospitalized for 5 days and she reports that a
TTE was done with no evidence of endocarditis. He had been
afebrile at home and she reports was in seemingly good health
and
able to perform with his musical group.
On the morning of [**2201-4-8**] he awoke and mumble that he could not
get up. His wife said that he then slipped down the edge of the
bed and was lying on the ground and said "help I can't get up".
His son was called for help and thought that there was an
assymetry to his hace with the left being weak and he was not
moving his left arm well. He was taken to [**Hospital3 **] and CT was
performed. He was transferred for neurosurgical consultation.
ROS unobtainable given critical illness
Past Medical History:
Hypertension
BPH
Depression/ Anxiety
Prior melanoma resections x 3
Social History:
worked as an educator. retired. active in musical groups and
singing. prior smoker - quit 25 years ago. No etoh
Family History:
non-contributory
Physical Exam:
ON ADMISSION
Vitals: 98 BP 132/68 P 72 R 18 SpO2 100% on ventilator
General: intubated, off of sedation, no spontaneous movement
HEENT: NC/AT, ET tube in place
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: coarse breath sounds
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status:
intubated off sedation, but no response to sternal rub
-Cranial Nerves:
R pupil is 4 mm and nonreactive L pupils is 3 and post-surgical,
weak corneals, + Doll's eyes, + gag
-Motor: increased tone in LE b/l
no spontaneous movement or response to painful stim
-Sensory:
no response to painful stim
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 3 0
R 2 2 2 3 0
Plantar response was extensor bilaterally.
-Coordination: unable to test
-Gait: unable to test
Pertinent Results:
[**2201-4-8**] 09:45AM BLOOD WBC-12.1* RBC-3.70* Hgb-11.5* Hct-35.8*
MCV-97 MCH-31.2 MCHC-32.2 RDW-13.2 Plt Ct-171
[**2201-4-8**] 09:45AM BLOOD Neuts-86.7* Lymphs-9.6* Monos-3.3 Eos-0.3
Baso-0.1
[**2201-4-8**] 09:45AM BLOOD PT-11.5 PTT-25.7 INR(PT)-1.1
[**2201-4-8**] 09:45AM BLOOD Glucose-212* UreaN-23* Creat-1.1 Na-135
K-3.3 Cl-102 HCO3-21* AnGap-15
[**2201-4-8**] 09:45AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
[**2201-4-8**] 09:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2201-4-8**] 10:01AM BLOOD Type-ART Tidal V-450 PEEP-5 FiO2-40
pO2-164* pCO2-46* pH-7.38 calTCO2-28 Base XS-1 -ASSIST/CON
Intubat-INTUBATED
[**2201-4-8**] 09:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300 Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2201-4-8**] 09:45AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2201-4-8**] 09:45AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
NCHCT [**2201-4-8**]: Large right basal ganglia hemorrhage resulting
in shift of the midline structures and a subfalcine and downward
herniation. The degree of bleed appears slightly worse from
prior study.
CXR [**2201-4-8**]: Appropriate ET tube position. Orogastric tube
could be advanced 8 cm for better positioning.
Brief Hospital Course:
Mr. [**Known lastname 9035**] arrived to [**Hospital1 18**] intubated for airway protection.
He was examined by our ED neurology resident and found to have a
blown pupil on the right with little spontaneous movements or
withdrawal to painful stimuli in his extremities. A repeat CT
scan of his head obtained in the ED confirmed the devastating
size of his CNS intraparenchymal hemorrhage. He was admitted to
the neuro ICU. On further family discussions, the family
confirmed that he would not want to remain intubated and depend
on mechanical life support. They agreed for comfort measures.
Subsequently, Mr. [**Known lastname 9035**] was terminally extubated and placed
on a morphine drip. He peacefully passed away at 2045hrs on [**4-8**], [**2200**] with his family at bedside. All of their questions were
answered. The medical examiner's office was informed about the
patient's death, and declined to perform an autopsy.
Medications on Admission:
Amlodipine 20 mg daily
Paxil 15 mg daily
Amitriptyline 20 mg daily
Aciphex
Avodart
Flomax
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal brain hemorrhage [**12-25**] hypertension
Discharge Condition:
Expired.
Discharge Instructions:
Patient expired at 845PM on [**2201-4-8**].
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2201-4-8**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3921
} | Medical Text: Admission Date: [**2110-4-17**] Discharge Date: [**2110-5-1**]
Date of Birth: [**2057-4-5**] Sex: F
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 3444**] is a 53-year-old woman
with multiple medical problems including multiple past
hospitalizations for chronic obstructive pulmonary disease,
pulmonary hypertension and question of obstructive sleep
apnea and obesity - hypoventilation syndrome who presented to
the Emergency Department from a sleep study with 9 out of 10
pleuritic chest pain, hypoxia to 85% on 15 liters
supplemental oxygen via nasal cannula. Per her family, the
patient has had a few days of coughing, malaise productive of
yellow sputum prior to admission. The patient was in the
process of an evaluation for obstructive sleep apnea with a
sleep study on the night prior to admission. Per report, she
had an impressive sleep study with chronic hypoxia. On the
morning of admission, she complained of chest pain that was
much worse than her chronic chest pain syndrome and was
graded 9 out of 10. She was hypoxic to 80% on 6 liters of
oxygen through nasal cannula. This increased to 90% on a
100% nonrebreather. She was also tachycardic to the 120s and
had a blood pressure of 160/90. She was taken to the
Emergency Department where she had a chest x-ray performed
which was consistent with congestive heart failure and she
was treated initially with a nitroglycerin drip, intravenous
heparin and 2 mg of intravenous morphine sulfate to make her
chest pain free and for the possibility of unstable angina.
With the nitroglycerin, her blood pressure decreased to
60/40, thereby the nitroglycerin was turned off and she was
bolused with intravenous fluid with a drop in her blood
pressure to 80/60.
CT angiogram was performed to rule out a pulmonary embolism.
The CT angiogram demonstrated bilateral pneumonia. At this
point, her mental status began to decline and the patient was
intubated and dopamine was started for blood pressure
support. At the time of institution of vasopressor therapy,
her blood pressure was 42/38. She was at that point
transported to the Medical Intensive Care Unit. Per report
of her son, she had recently been discharged from pulmonary
rehabilitation three days prior to admission where she had
been following a recent hospitalization to [**Hospital1 **] [**First Name (Titles) 767**] [**3-17**] to [**3-23**] for chest pain.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease. She is on home
oxygen therapy with 2 liters of oxygen via nasal cannula.
She is dependent on chronic inhaled steroids. Pulmonary
function test in [**2109-6-14**] demonstrated an FVC of 1.98
liters, FEV1 of 1.50 liters and an FEV1/FVC ratio of 101% of
predicted. The results were interpreted as consistent with a
mild restrictive ventilatory defect with a diffusing capacity
suggestive of an interstitial process. She also had a
significant increase in lung volumes following bronchodilator
treatment which is suggestive of a concurrent obstructive
process.
2. Type II diabetes mellitus
3. Fibromyalgia
4. Depression
5. Osteoarthritis
6. Question rheumatoid arthritis
7. Chronic chest pain syndrome
8. Paget's disease
9. Obstructive sleep apnea
10. Stress test in [**2109**] revealed ability to achieve 80% of
maximum predicted heart rate. The ejection fraction was
calculated at 66% and there were no regional wall motion
abnormalities.
HOME MEDICATIONS:
1. Serevent 2 puffs [**Hospital1 **]
2. Insulin sliding scale
3. Neurontin 400 mg tid
4. Synthroid 112 mcg q day
5. Protonix 40 mg q day
6. Celexa 30 mg q day
7. Amitriptyline 1 to 2 mg q day
8. Flovent 2 puffs [**Hospital1 **]
9. Albuterol
10. Tums
11. Colace
12. Calcitriol 0.25 mcg q day
ALLERGIES: SHE IS ALLERGIC TO FLEXERIL, KEFLEX AND ULTRAM.
SHE IS ALSO ALLERGIC TO CODEINE.
SOCIAL HISTORY: She lives alone in [**Hospital1 3494**]. She is
currently unemployed. She quit tobacco use in [**2094**] and prior
to that smoked a half pack a day for 15 years. She reports
no ethanol use. She is a Jehovah's witness.
FAMILY HISTORY: Not available at the time of admission.
PHYSICAL EXAMINATION:
VITAL SIGNS: Heart rate 97, blood pressure 89/51 as measured
by an arterial line, respiratory rate 14, oxygen saturation
95%.
GENERAL: The patient was an obese African-American female
who was intubated and sedated.
HEAD, EARS, EYES, NOSE AND THROAT: Her pupils were widely
dilated and the sclerae were anicteric. No jugular venous
distention or lymphadenopathy was present in the neck.
CHEST: Coarse air movement bilaterally with good air entry.
No wheezes or crackles were appreciated.
HEART: Regular rate and rhythm with normal first heart sound
and a split second heart sound. No murmurs were appreciated.
ABDOMEN: Soft, nontender and nondistended.
EXTREMITIES: There was trace bilateral lower extremity edema
with cool extremities.
DATA: White count 9.7 with 71% neutrophils, 1% bands, 22%
lymphocytes, hematocrit 40.6, platelets 203, sodium 140,
potassium 5.4, chloride 104, bicarbonate 27, BUN 9,
creatinine 1.0, glucose 161, CK 68, troponin less than 0.3.
PT 16.3, INR 1.9, PTT 36.8. Arterial lactate 2.5.
Urinalysis done on a catheterized specimen revealed a large
amount of blood with 21 to 50 red blood cells and 3 to 5
white blood cells. A preintubation arterial blood gases on a
100% nonrebreather revealed a pH of 7.33, PCo2 of 55 and PO2
of 64. Post intubation arterial blood gases on 100% oxygen
revealed a pH of 7.33, PCo2 of 42 and a PO2 of 77.
IMAGING: CT examination of the chest revealed extensive
bilateral air space opacities predominantly at the bases.
HOSPITAL COURSE: She was admitted to the Medical Intensive
Care Unit for management of her bilateral pneumonia
complicated by hypoxic respiratory failure and hypotension
suggestive of septic physiology.
1. PULMONARY: She was intubated on arrival to the Medical
Intensive Care Unit. During the course of her Medical
Intensive Care Unit stay, she was treated with inhaled
bronchodilators and inhaled corticosteroids. The vent
settings were weaned down gradually as her pulmonary status
allowed. She was extubated on the 13th, 10 days after
initial intubation. She was extubated successfully without
any post extubation difficulty. On the day after extubation,
she was transferred to the general medicine floor. Her
supplemental oxygen requirements at that time were 4 liters
of oxygen via nasal cannula (she is on baseline 2 liters of
oxygen via nasal cannula at home). After reaching medical
floor, she had a pulmonary consult. They recommended
continuing her in treatment and performing a sleep study
after several weeks of pulmonary rehabilitation to further
evaluate the extent of her obstructive sleep apnea and
obesity - hypoventilation syndrome. On the floor, she
received BIPAP. Her BIPAP settings were IPAP of 16 and EPAP
of 10 with 3 liters of oxygen. She reported that these BIPAP
settings enabled her to sleep well.
2. CARDIOVASCULAR: Given her initial hypotension, on
arrival to the Medical Intensive Care Unit she was started on
a dopamine drip. She also received free boluses of
intravenous fluid for blood pressure support. Dopamine drip
was weaned off after four days. At that point, she was
approximately 7 liters net for the course of her hospital
stay. She underwent prn diuresis to relieve some of the
total body fluid overload. This has also helped relieve some
of her pulmonary edema with an improvement in her respiratory
status. At the time of arrival to the medical floor, she was
approximately 1.5 liters net in for the course of her
hospital day. She underwent additional prn diuresis on the
floor. She had good response to intravenous Lasix. After
being weaned off the dopamine drip maintaining her blood
pressure within a normal range was no longer a problem.
3. INFECTIOUS DISEASE: Given her bilateral lower lobe
pneumonia and her recent stay at a rehabilitation facility,
she was started on broad spectrum antibiotic coverage. She
was initially started on levofloxacin for treatment of
community acquired pneumonia. However, this antibiotic
therapy was changed to include vancomycin and metronidazole
to provide broader coverage. She received a total of 14 days
of levofloxacin, 14 days of vancomycin and 12 days of
metronidazole prior to discharge. Blood and urine cultures
drawn at the time of admission demonstrated no growth. A
sputum culture at the time of admission demonstrated moderate
growth of yeast and sparse growth of oropharyngeal flora. A
urine test for the Legionella antigen was negative. Follow
up blood cultures also demonstrated no growth. A sputum
culture performed after one week of intubation showed sparse
growth of 2 strands of Klebsiella pneumoniae. The strands
were sensitive to levofloxacin.
4. ENDOCRINE: She has a history of type II diabetes
mellitus which was insulin requiring at home. She was given
stress dose steroids on initial admission to the Medical
Intensive Care Unit. Her glycemic control was covered with a
regular insulin sliding scale. She did not have any trouble
with hypoglycemia or hyperglycemia during the course of her
hospital stay.
5. HEMATOLOGY: On presentation to the Medical Intensive
Care Unit, she was noted to have a mildly elevated PTT and a
mildly elevated INR in the setting of receiving heparin for
unstable angina in the Emergency Department. The heparin was
discontinued on arrival to the Medical Intensive Care Unit
and she was given vitamin K therapy for treatment of her
coagulopathy. Her PTT and INR declined to normal limits with
vitamin K treatment.
6. FLUIDS, ELECTROLYTES AND NUTRITION: She was maintained
on tube feeds during the course of her Medical Intensive Care
Unit stay. She was transitioned to a diabetic diet after
extubation. Her electrolytes were followed closely and
repeated aggressively with her aggressive diuretic therapy.
DISCHARGE CONDITION: Stable
DISCHARGE DIAGNOSES:
1. Bilateral pneumonia complicated by hypoxic respiratory
failure and septic shock
2. Chronic obstructive pulmonary disease
3. Restrictive lung disease
4. Obesity - hypoventilation syndrome
5. Obstructive sleep apnea
6. Type II diabetes mellitus
7. Fibromyalgia
8. Depression
9. Osteoarthritis
10. Question of rheumatoid arthritis
11. Chronic chest pain syndrome, non cardiac in nature
12. Paget's disease
13. Gastroesophageal reflux disease
14. Hypothyroidism
DISCHARGE MEDICATIONS:
1. Albuterol 2 puffs q4h
2. Flovent 2 puffs [**Hospital1 **]
3. Colace 100 mg [**Hospital1 **]
4. Celexa 30 mg q day
5. Levothyroxine 112 mcg q day
6. Neurontin 400 mg q hs
7. Protonix 40 mg q day
8. Tums 500 mg [**Hospital1 **]
9. Multivitamin 1 tablet q day
10. Amitriptyline 100 mg q hs
11. Regular insulin sliding scale
12. Dulcolax 10 mg po/pr [**Hospital1 **] prn
13. Prednisone taper 10 mg on [**5-1**] (check to see if
prednisone was administered at hospital prior to discharge),
then 5 mg on [**5-2**] and [**5-3**], then discontinue.
14. Percocet 1 to 2 tablets q6h prn
15. Ativan 1 mg q hs prn
16. Ambien 10 mg po q hs prn
17. Calcitriol 0.25 mcg q day
DISCHARGE STATUS: She will be discharged to pulmonary
rehabilitation. Her fingersticks should be checked 4x a day
and she should be covered with a regular insulin sliding
scale for management of any hyperglycemia. She should be on
nighttime BIPAP for her obstructive sleep apnea. The BIPAP
settings should be IPAP of 16, EPAP 16 on 3 liters of oxygen.
FOLLOW UP: She will follow up with her primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
NOTE: During the course of her hospital stay, her son, [**Name (NI) 449**]
[**Name (NI) 14164**], was made her healthcare proxy. These forms were
sent to the medical records department and entered into the
OMR.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. [**MD Number(1) 5381**]
Dictated By:[**Last Name (NamePattern1) 7787**]
MEDQUIST36
D: [**2110-5-1**] 07:36
T: [**2110-5-1**] 07:41
JOB#: [**Job Number 99987**]
ICD9 Codes: 486, 4280, 496, 4111, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3922
} | Medical Text: Unit No: [**Numeric Identifier 67902**]
Admission Date: [**2108-6-1**]
Discharge Date: [**2108-6-22**]
Date of Birth: [**2108-6-1**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: This is a 33 [**4-13**] week
gestational age twin admitted with respiratory distress.
Maternal history: This is a 28-year-old G9, P5 with history
notable for smoking 1 pack per day, depression, no
medications. Prenatal screens were as follows: A positive
blood type, antibody negative, hep B surface antigen
negative, RPR nonreactive, rubella immune, GBS unknown.
Antenatal history: [**Last Name (un) **] [**2108-7-16**] by ultrasound with
uncertain LMP, spontaneous dichorionic/diamniotic twin
gestation with normal fetal survey in both twins at 19 weeks.
Pregnancy was complicated by preterm contractions leading to
admission [**2108-5-13**] through [**2108-5-19**] for treatment with
mag, tocolysis, and betamethasone at that time. Spontaneous
recurrence of preterm labor occurred leading to C section for
breech/transverse lie under spinal anesthesia. There was no
intrapartum antibiotics or other clinical evidence of
chorioamnionitis. Rupture of membranes occurred at delivery,
yielding clear amniotic fluid. Nuchal cord was noted at
delivery. Neonatal course: Infant emerged with good tone and
consistent respiratory effort, well-maintained heart rate.
She was orally and nasally bulb suctioned, dried, brief
facial C-PAP administered with subsequent onset of
spontaneous respirations. Apgar scores were 6 at 1 minute, 8
at 5 minutes.
PHYSICAL EXAMINATION: Birth weight 1,820 grams, head
circumference 30 cm, length 44 cm, heart rate 170-180,
respiratory rate 70-80, temperature 98.7, blood pressure
60/34 with a mean of 43, saturation 90 percent in room air
which improved to 94 percent in 30 percent FI02 on CPAP of 6.
Anterior fontanelle soft and flat, nondysmorphic. Palate
intact. Neck/mouth normal. Mild nasal flaring. Chest with
mild intercostal retractions. Good breath sounds bilaterally.
No adventitious sounds. CVS: Well perfused. Regular rate and
rhythm. Femoral pulse is normal. No murmur appreciated.
Abdomen was soft, nondistended, no organomegaly. No masses.
Breath sounds active. Anus patent. Three vessel umbilical
cord. Normal female genitalia externally. Baby active,
responsive to stimulation. Tone appropriate for gestational
age. Moving all extremities equally. Suck, gag, and grasp
intact. Normal spine, limbs, hips, and clavicles.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: She was
on CPAP for less than 24 hours and has been in room air every
since. She has had occasional episodes of apnea but she has
been spell-free for more than 5 days.
CARDIOVASCULAR: She has been stable throughout admission. She
was noted to have an intermittent murmur during the end of the
hospitalization. She did not have a cardiac evaluation.
FLUIDS, ELECTROLYTES, NUTRITION: She was started on feeds on
day of life 2 and has been gradually advanced on calories as
well as volume. She is currently on Similac 24 calories and
feeding well all p.o. To date the weight on [**2108-6-22**] is
2,270 grams.
GI: She was on phototherapy which was discontinued on day of
life #7 with a rebound bilirubin of 5.3/0.2.
HEMATOLOGY: She is on iron and her hematocrit at birth was
46.6.
INFECTIOUS DISEASE: She was on ampicillin/gentamicin for 48
hour rule out. Initial blood culture was negative.
NEUROLOGY: No head ultrasounds were done.
Sensory/Audiology: Hearing screening was performed and she passed
in both ears.
Ophthalmology: No eye exam was performed.
The baby is feeding well, gaining weight.
PEDIATRICAIN: Dr. [**Last Name (STitle) 38832**], phone number [**Telephone/Fax (1) 7976**], fax
([**Telephone/Fax (1) 67903**].
CARE/RECOMMENDATIONS:
She will be discharged on Similac 24 calories.
Medications on discharge: Iron.
Car seat testing: Passed.
State newborn screening: Were sent on [**5-25**], [**6-7**], and [**2108-6-15**].
The most recent is still pending. She received a hepatitis B
vaccine on [**2108-6-19**].
FOLLOW UP APPOINTMENTS:
She will need to have a hip ultrasound at 4-6 weeks of age
because of her hips in breech position
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1) Born at less than 32
weeks; 2) Born between 32 and 35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school age siblings; or 3) with chronic lung disease.
Influenzae 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 influenzae is recommended for household
contacts and out of home caregivers. Follow-up appointment
includes an appointment with the pediatrician on [**Last Name (LF) 766**], [**2108-6-25**].
DISCHARGE DIAGNOSIS:
1. Prematurity.
2. Respiratory distress.
3. Hyperbilirubinemia.
4. Breech Hips
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern4) 56030**]
MEDQUIST36
D: [**2108-6-21**] 15:41:42
T: [**2108-6-21**] 16:39:09
Job#: [**Job Number 67904**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3923
} | Medical Text: Admission Date: [**2195-2-10**] Discharge Date: [**2195-2-14**]
Date of Birth: [**2132-6-30**] Sex: F
Service: General Cardiology
CHIEF COMPLAINT: Chest pain in the setting of EKG changes.
HISTORY OF PRESENT ILLNESS: She is a 62-year-old female with
a past medical history significant for mitral valve prolapse,
borderline elevated cholesterol, and early menopause.
Negative for hypertension or diabetes with a positive family
history in that her father expired from a MI at the age of
63, who was in her usual state of health until five days
prior to admission when she noticed epigastric pressure
radiating into her neck after exercising and lasting
approximately five minutes.
On day of admission, again, patient after exercising noted
some same epigastric pressure, but much more severe and
radiating into neck and bilaterally into the shoulders. Not
associated with any nausea or vomiting, but associated with
some diaphoresis. Patient presented to [**Hospital3 **] Emergency
Room, where an EKG revealed ST elevations in V3 and V4.
Patient was given aspirin, Plavix, started on a nitroglycerin
gtt., Heparin gtt., and patient became chest pain free with
resolution of ST elevations. Patient was secondarily started
on Integrilin gtt. and transferred to the [**Hospital1 **] Hospital for a catheterization.
REVIEW OF SYSTEMS: The patient was free of any headache,
vision changes. No URI symptoms. No cough, no shortness of
breath, no abdominal pain, no nausea, vomiting, diarrhea, or
constipation, no edema, no dysuria, no numbness, tingling, or
weakness. No hematuria. No hematochezia, hematemesis,
hemoptysis.
PAST MEDICAL HISTORY:
1. Mitral valve prolapse.
2. Borderline hypercholesterolemia.
3. Early menopause.
ALLERGIES:
1. Sulfa.
2. Penicillin.
MEDICATIONS:
1. E-Vista unknown dose.
2. Multivitamins daily.
3. Aspirin 81 mg one p.o. q.d.
FAMILY HISTORY: Significant for a father who expired at the
age of 63 from myocardial infarction.
SOCIAL HISTORY: The patient resides with her husband and
son. She does not smoke tobacco. She consumes two glasses
of wine per week. Otherwise, no other drugs. The patient
does exercise regularly.
PHYSICAL EXAMINATION: Patient's temperature was 96.4. Her
blood pressure is 140/90. Pulse was 84. Satting at 98% on
room air. Generally, she is a well-appearing female in no
acute distress completing full sentences without development
of shortness of breath. HEENT is normocephalic, atraumatic.
Extraocular movements are intact. Oropharynx is clear with
no lesions or exudates noted. Neck is supple with no JVD, no
lymphadenopathy. Heart is regular rate and rhythm with no
murmurs, normal S1, S2, no clicks or gallops. Lungs are
clear to auscultation bilaterally with no wheezes, crackles,
or rales. Abdomen is mildly obese, soft with good bowel
sounds, nontender, and nondistended with no masses palpated,
or hepatosplenomegaly. Groin bilaterally are free of any
bruits. Her extremities are free of any clubbing, cyanosis,
or edema. Dorsalis pedis 2+ bilaterally. Neurologic
examination: Cranial nerves II through XII are intact.
Strength is [**5-27**] and symmetric. Reflexes are 2+ throughout.
Toes are downgoing.
DATA FROM [**Hospital6 **]: White count 10.3, hematocrit
38.0, platelet count is 225.
EKG from [**Hospital3 **] revealed normal sinus rhythm at 60,
normal axis. She was noted to be leftward from old EKG.
Normal intervals. New ST elevations of 2 mm in V3 through
V4, T-wave inversions in lead III.
HOSPITAL COURSE BY SYSTEMS:
1. For ST elevation MI, patient was continued on her
nitroglycerin gtt., aspirin, Plavix, Heparin, and Integrilin.
The patient was taken to the Catheterization Laboratory
emergently, where a cardiac catheterization was performed.
The results of the catheterization were as follows: Patient
had one vessel coronary artery disease in the LAD that
revealed tubular 90% mid vessel lesion, but otherwise
angiographically was normal. Patient had mild systolic
ventricular dysfunction, mild diastolic ventricular
dysfunction, her LVEDP was 18. Her right sided filling
pressures were normal at 10 ml Hg. Patient was stented in
the mid LAD and the procedure was performed without
complications.
Post catheterization the patient was weaned off her
nitroglycerin gtt., but was maintained on Heparin.
Approximately four hours post catheterization, patient
continued to have vagal responses with hypotension into the
90/50 range, and nausea and emesis. Later she complained of
back pain.
Patient underwent an emergent noncontrast CT of her abdomen
and pelvis, which revealed a large extraperitoneal hemorrhage
displacing the urinary bladder to the left tracking along the
right psoas muscle. Patient was emergently brought up to the
floor and was transfused 2 units of blood in the setting of a
hematocrit drop from 36.1 to 31.7. During infusion of blood,
patient was noted to hypotense to 70/40, and developed some
dizziness. She was put in the reverse Trendelenburg. A
femoral line was placed. Patient was given aggressive
hydration with fluid and was transferred to the CCU. In the
CCU, the patient received another unit of blood. Her
hematocrit stabilized at approximately 34-35. Patient had no
further evidence of bleeding. She had no further episodes of
hypotension. Patient also underwent an ultrasound of her
femoral arteries which revealed no evidence of
pseudoaneurysm.
The patient was maintained in the CCU for 24 hours, where
q.4h. hematocrits were drawn and remained stable in the 34-35
range. She was then transferred to the floor for medical
management.
2. CAD: For coronary artery disease secondary prevention,
the patient was maintained on aspirin 325 mg q.d. She was
also started on a statin, Lipitor 40 mg one p.o. q.d. She
was initially maintained on captopril, and on date of
discharge changed to lisinopril 5 mg one p.o. q.d. and she
was maintained on metoprolol 50 mg one p.o. b.i.d.
Patient had good blood pressure control in the range of
130s/70-80s with pulse mostly in the 70s-80s. Repeat EKGs
were performed on the floor, which revealed no acute ST-T
wave changes or resolution of elevations that were seen on
EKG during her ST elevation MI. The patient had no further
episodes of chest pain, shortness of breath, or epigastric
pain during her hospitalization.
3. Heme: Patient's hematocrit throughout her hospitalization
post transfusion of 3 units remained stable in the 34-35
hematocrit range. Her hematocrit on discharge was 34.4.
4. Thrombocytopenia: During her hospitalization, the
patient's platelet count nadired to 144, and it was felt that
this thrombocytopenia was likely secondary to consumption in
the setting of retroperitoneal bleed. A HIT antibody was
sent and was pending at the time of discharge. This will
need to be followed up by the patient's primary care
physician. [**Name Initial (NameIs) **] platelet count did stabilize at 152 and
there were no further episodes of thrombocytopenia noted.
Patient had no evidence of bleeding.
5. GI: Patient was maintained on a bowel regimen as well as
Zofran for nausea. By the time of discharge, patient had no
nausea x24 hours,
6. Code: Patient was a full code.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 one p.o. q.d.
2. Plavix 75 mg one p.o. q.d.
3. Atorvastatin 40 mg one p.o. q.d.
4. Metoprolol 25 mg one p.o. b.i.d.
5. Lisinopril 5 mg one p.o. q.d.
FOLLOW-UP PLANS: Patient is to followup with her primary
care physician within one week of discharge. She has advised
me that she has a cardiologist located in the same building
as her primary care physician, [**Name10 (NameIs) **] she would like to followup
with this cardiologist. She is advised that she should
follow up with a cardiologist within two weeks of discharge.
Patient is to continue her current medication regimen and her
metoprolol and/or lisinopril may need to be titrated up for
continued hypertension outpatient.
DISCHARGE CONDITION: Stable. She is stable on room air.
She is able to ambulate with Physical Therapy without
difficulty. She is tolerating a regular diet without
development of any nausea or emesis. She has had no further
evidence of abdominal pain, epigastric pain, chest pain, or
shortness of breath. Her hematocrit and platelet count has
stabilized.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**MD Number(1) 5226**]
Dictated By:[**Last Name (NamePattern1) 5843**]
MEDQUIST36
D: [**2195-2-13**] 09:50
T: [**2195-2-13**] 12:01
JOB#: [**Job Number 16023**]
ICD9 Codes: 4240, 2875, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3924
} | Medical Text: Admission Date: [**2110-12-12**] Discharge Date: [**2110-12-20**]
Date of Birth: [**2094-8-6**] Sex: F
Service: MED ICU/[**Doctor Last Name 1181**] MED
PATIENT'S ANTICIPATED DATE OF TRANSFER IS [**2110-12-20**].
HISTORY OF PRESENT ILLNESS: This is a 16 year old female
with a history of cystic fibrosis status post bilateral lung
transplants in [**2108-9-11**], who was admitted on [**2110-12-12**], following a rigid bronchoscopy with dilation and
Mitomycin application to reduce swelling and scar tissue in
the left main stem bronchus. Shortly after application of
Mitomycin, the patient developed a stridor and was treated
with Albuterol and racemic epinephrine treatment before
transfer to the Post Anesthesia Care Unit for observation.
While in the Post Anesthesia Care Unit, the patient acutely
desaturated with a pulse oximetry of 60%, was given a
nebulizer treatment, non-rebreather mask and failed to
improve with hypoxia in a range of pAO2 of 44. The patient
was on CPAP with a pressure support of 8 and PEEP of about 10
and FIO2 of 100, and her oxygen saturations improved to the
90s. The patient was transferred to the Medical Intensive
Care Unit for observation.
Initially, this was thought to be an allergic reaction to
Mitomycin and was treated with intravenous steroids, Benadryl
and Pepcid. For the next 36 hours in the Medical Intensive
Care Unit, the patient could not be weaned off oxygen and
would acutely desaturation if the FIO2 dropped below 90%.
With the concern of her possible PE causing shunt, the
patient was intubated on the third day of hospital stay for a
CT scan. The patient acutely desaturated with oxygen of 60s
while on the vent prior to having the CT scan. Multiple
blood gases drawn showed pO2 in the 31 to 35 range. The
decision was made for an emergent bronchoscopy at the bedside
where a mucous plug was discovered in the left main stem
bronchus. Once removed, the patient's oxygen saturations
rapidly improved.
The patient was extubated the following day with oxygen
saturations in the 95 to 96% on room air. She was observed
overnight and transferred to the Medical Floor. The patient
was scheduled for a stent on Friday, [**2110-12-19**].
PAST MEDICAL HISTORY:
1. Cystic fibrosis status post bilateral lung transplant in
[**2108-9-11**].
2. Asthma.
3. Gastroesophageal reflux disease.
4. Pancreatic insufficiency.
5. Seizures thought secondary to cyclosporin.
ALLERGIES: Multiple, multiple allergies including Imipenem,
Zosyn, Piperacillin, penicillin, Estrianam, Vancomycin,
.............and tobramycin.
SOCIAL HISTORY: The patient lives in [**Hospital3 **]. Sister also
with cystic fibrosis.
MEDICATIONS ON ADMISSION TO THE HOSPITAL:
1. Prograf 7 mg p.o. twice a day.
2. Cellcept [**Pager number **] mg p.o. twice a day.
3. Prednisone 5 mg p.o. q. day.
4. Zantac 150 mg p.o. twice a day.
5. Bactrim Double strength Monday, Wednesday and Friday.
6. Neurontin 300 mg p.o. twice a day.
7. Procardia 30 mg p.o. q. day.
8. Ultrase 7 to 8 with meals, 3 to 4 with snacks.
9. Insulin NPH 32 units q. a.m.
10. Humalog 2 units q. a.m.
PHYSICAL EXAMINATION: Temperature 101.6 F.; blood pressure
between 100 and 140 over 50 to 90; pulse between 70 and 145;
the patient's respirations between 20 and 30. She was 96% on
room air. In general, pleasant young female in no acute
distress. HEENT: Moist mucous membranes. No oropharynx
lesions. Heart: Regular rate and rhythm, S1, S2, no
murmurs, rubs or gallops. Lungs clear to auscultation
bilaterally, no wheezes, rhonchi or crackles. Abdomen soft,
nontender, nondistended. Bowel sounds are positive.
Extremities are warm, two plus dorsalis pedis pulses. No
edema. Neurological: Answers questions appropriately.
LABORATORY: On [**2110-12-19**], white blood cell count of
5.4, hematocrit of 26.7, platelets of 150, neutrophils of
64.7, lymphocytes 30.4, monocytes 3.4, eosinophils 1.0,
basophils 0.5. Chemistry sodium 139, potassium 4.2, chloride
99, bicarbonate 27, BUN 18, creatinine 0.6, glucose 113,
calcium 8.9, phosphorus 3.6, magnesium 1.4.
The patient had a CT scan of the chest which ruled out
pulmonary embolism and showed diffuse air space and disease
in the right lung and left lower lobe consistent with
infection. It showed parenchymal opacification around the
left lower lobe consistent with bleeding. There were
multiple enlarged lymph nodes in the mediastinum and hilum,
consistent with post-infectious lymphadenopathy or with
secondary post-transplantation lymphoma. A small right
pleural effusion.
ASSESSMENT: This is a 16 year old white female with a
history of cystic fibrosis status post bilateral lung
transplant now status post stent placement in the left
mainstem bronchus with a right middle lobe and left lower
lobe pneumonia, awaiting transfer back to the [**Hospital3 18242**].
HOSPITAL COURSE:
1. PULMONARY: The patient is now status post stent
placement with oxygen saturations in the mid-90s on two
liters. Currently, the patient is continued on her
immunosuppressants including mycophenolate mofetil and
tacrolimus and she is on a Prednisone taper. She should be
receiving 30 mg for the next two days, and 20 mg for the two
days after that, 10 mg for the two days after that and then
back down to 5 mg every day as her baseline dose. It should
be noted that prior to the stent placement, the patient's
oxygen saturations continued to decline. It was unclear
whether or not the patient was not appropriately hypoxic
vasoconstricting versus if she had a pulmonary embolism. A
CT angiogram showed no evidence of a pulmonary embolism.
The patient was instructed to lay on her right side to help
with the ventilation perfusion match. Post-stent placement
the patient now is saturating well.
2. INFECTIOUS DISEASE: The patient continued to spike
temperatures up to 101.6 F., after transfer from the Medical
Intensive Care Unit to the floor. Pan cultures show the
patient has a likely source of pulmonary given the findings
on chest x-ray and follow-up CT scan. At the time of
dictation, sputum Gram stain and culture were pending. The
patient was started on Clindamycin for questionable
aspiration. At the time of this dictation, the patient was
to be started on tobramycin, Ciprofloxacin and Vancomycin as
well although these are pending to be started upon her
transfer to [**Hospital1 **].
3. GASTROINTESTINAL: The patient with a history of
pancreatic insufficiency. The patient takes her own Ultrase,
pancreatic enzymes prior to meals and snacks.
4. ENDOCRINE: The patient with insulin dependent diabetes
mellitus. Blood sugars have been completely out of control
given that the patient's p.o. intake has also been very
erratic. The patient usually takes 32 units of NPH in the
morning with 2 units of Humalog. These will need to be
adjusted according to the patient's p.o. intake. She is also
covered with a Humalog insulin sliding scale. We are just
covering with q.a.d. fingersticks and adjusting as necessary.
5. OPHTHALMOLOGY: The patient was seen by Ophthalmology
regarding blurry vision. No pathology was seen on
examination. It was determined that she likely has a
refractory error and they recommended follow-up as an
outpatient.
6. CARDIOVASCULAR: The patient had an echocardiogram while
she was at the [**Hospital1 69**].
Findings were consistent with right ventricular strain.
Question whether this is acute versus chronic. A CT scan
showed no evidence of pulmonary embolism. The patient also
with status post new lung status post transplant, so it would
be less likely that it is a permanent pulmonary process as
usually right ventricular strain would improve with improved
lungs. We would recommend a follow-up echocardiogram once
her acute issues have been treated.
7. FLUIDS, ELECTROLYTES AND NUTRITION: The patient has been
very hypophosphatemic and hypomagnesemic treated with p.o.
Neutra-Phos and magnesium oxide. Once the patient gets a
PICC line placed, we would recommend intravenous replacement.
8. NEUROLOGICAL: The patient has history of seizures,
questionable secondary to cyclosporin. Would continue
patient on Gabapentin.
DISCHARGE DIAGNOSES:
1. Cystic fibrosis status post bilateral lung transplant in
[**2108-9-11**].
2. Asthma.
3. Gastroesophageal reflux disease.
4. Pancreatic insufficiency.
5. Seizures thought secondary to cyclosporin.
CONDITION ON DISCHARGE: Fair.
DISPOSITION: The patient will be discharged to [**Hospital3 18242**].
DISCHARGE MEDICATIONS: As per her Page One and to be
determined by her physicians at [**Hospital3 1810**]. Her
baseline medications include:
1. Mycophenolate mofetil 500 mg p.o. twice a day.
2. Ranitidine 150 mg p.o. twice a day.
3. Bactrim double strength one tablet p.o. q. Monday,
Wednesday and Friday.
4. Gabapentin 300 mg p.o. three times a day.
5. Tacrolimus 6 mg p.o. twice a day; note this level was
changed from her usual 7 mg dose given that her trough levels
were above standard.
6. Prednisone taper.
7. Procardia 30 mg p.o. q. day.
8. NPH 32 units q. a.m.
9. Humalog 2 units q. a.m.
10. Humalog insulin sliding scale.
11. Ultrase 7 to 8 with meals, 3 to 4 with snacks.
Antibiotic regimen again to be discussed with the [**Hospital1 **]
attendings.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 6369**]
MEDQUIST36
D: [**2110-12-19**] 18:52
T: [**2110-12-19**] 20:26
JOB#: [**Job Number **]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3925
} | Medical Text: Admission Date: [**2130-5-27**] Discharge Date: [**2130-5-30**]
Date of Birth: [**2096-10-8**] Sex: F
Service: MED
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 33 yo F, 2 months post-partum from NSVD, who presented
to an OSH ([**Hospital **] Hosp [**Telephone/Fax (1) **]) yesterday complaining of
dizziness, nausea, vomiting, tingling fingers and confusion. She
was brought to the OSH by her husband. As per the husband she
had told him that she felt "strange, and had never felt like
this before".
At the ED there she had no c/o HA, recent fever, trauma. Her
only recent complaint was feeling constantly dehydrated despite
drinking large amounts of water ([**5-2**]+L per day), tiredness,
"feeling overwhelmed" and occasional constipation.
Pregnancy was complicated by multiple visits to OB/L&D for
"false labor" and dehydration.
After arrival at the ED and placement in an exam room, she was
found on the floor unresponsive, having vomited and "twitching".
During her stay in the ED she was occasionally alert & awake,
but agitated and combative.
Pertinent findings on physical exam were: afebrile, with supple
neck, no signs of trauma, agitation as above, nonfocal neuro
exam, downgoing babinskis.
Initial sodium was 120, K=3.4, bicarb 20, BUN=9, Cr=0.8, Hct=35,
WBC 10.6, FS=103.
Initial Head CT was read as suboptimal exam [**12-26**] motion artifact,
suggestion of diffuse decrease in ventricular size & cortical
sulci, [**Month (only) **] grey-white differentiation, no focal parenchymal
findings, ? cerebral edema.
In the ED she received 3mg Ativan IV, Compazine 10mg IV, 1L NS.
She was transferred to the ICU where she was started on
hypertonic saline (total of 284mL of 3% saline). She was
evaluated by renal and neurology.
Neuro interventions included LP w/ normal opening pressure
(170mm), neg CSF(prot 29, glucose 70, wbc 1).
Other relevant findings/interventions were blood cx (NGTD), Mg
repletion (3g total), dexamethasone 10mg. (see below for full
summary of labs etc).
Prior to transfer she had a MRI brain that was read as (resident
read) 1. diffuse sulcal inc. flair signal ? artifact vs diffuse
SAH vs meningitis. 2. inc cortical signal - but no ev for acute
infarct/global ischemia 3. no shift - films did not accompany
the patient.
Past Medical History:
1. psychiatric admission age 13 2. Interstitial cystitis, 3.
pelvic pain, 4. endometriosis, 5. H/O UTIs
PSxHx: Left bunionectomy
Social History:
married, lives with husband & son, employed as psych RN
Family History:
father w/ epilepsy, maternal GM w/ schizophrenia
Physical Exam:
PE: VS:
Gen: awake, does not respond to commands, agitated - saying
"please help me"
HEENT: PERRLA, pupils 4->3 w/ light, EOMI grossly intact, neck
supple, FROM
LUNGS: CTA B, no wheezes, ronchi, rales
CARD: RRR, 2/6 SEM best @ base, no radiation
ABD: soft, ND, NT, NABS
EXT: warm, no c/c/e
NEURO: alert, not responsive to commands, CN 2-12 grossly
intact, MAEW, B LE reflexes [**1-25**]+, no clonus. did not assess
gait.
Pertinent Results:
[**2130-5-27**] 06:24PM GLUCOSE-109* UREA N-6 CREAT-0.6 SODIUM-131*
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-25 ANION GAP-13
[**2130-5-27**] 06:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2130-5-27**] 06:24PM WBC-12.8* RBC-3.89* HGB-12.3 HCT-34.1* MCV-88
MCH-31.7 MCHC-36.2* RDW-12.5
Brief Hospital Course:
1. Altered mental status - The initial differential included new
onset seizure disorder, hyponatremia (alone, or by possibly
lowering seizure threshold), central demyelinating process
secondary to rapid correction of hyponatremia, toxic metabolic
syndromes, or other exogenous toxic ingestion, brain structural
lesions (poss. causing seizures), endocrine disorders. The
normal LP at OSH helps eliminate meningitis. Her CT at the
outside hospital had shown question of cerebral edema, the MRI
showed diffuse increase in sucal flair signal. She was
transfered from [**Hospital1 **] ICU to the MICU at [**Hospital1 18**]. Her tox
screen was negative except for positive opiods. She regained
mental status and was transferred to the floor. On the floor
and MRV was obtained to rule out venous thrombosis causing
increased ICP leading to her nausea, vomiting, and altered
mental status. The MRV was normal. Neurology was involved in
her evaluation and felt she was safe to discharge home with
instructions on restricting free water intake.
2. Hyponatremia - Her hyponatremia seemed to be somewhat chronic
in nature, although this may represent acute exacerbation. She
states that she had been told to drink a lot of fluid because
she was breast feeding. Prior to coming into the hospital she
was drinking 6-7 liters of water a day. She was placed on a
free water restriction while in the hospital and her Na was
checked every 6, then every 12 hours. Once her free water was
restricted her Na remained normal for the duration of her
hospital admission. She met with a nutritionist while in the
hospital to get advice on maintaining apropriate PO intake and
avoiding another occurance of this in the future.
3. Psych - She was evaluated by psychology while she was in the
hospital. She is to follow up with her psychologist and
counselor as an outpatient.
4. Prophylaxis - She was maintained on normal diet for the
course of her hospital stay. She was initially treated with
Heparin SC but these were stopped once she was ambulating on her
own.
5. Breast feeding - She was initially interested in continuing
to breast feed. We obtained a pump for her but told her to
discard all milk until the Ativan had washed from her system.
She later decided that she was not interested in breast feeding
as she was nervous it had contributed to her initial
hyponatremia.
6. Nausea - She was having trouble with nausea during her
hospital admission. She was treated with Zofran and Compazine
while in the hospital. We tested a urine HCG which was
negative.
Medications on Admission:
vitamins, no herbals, no other OTCs
Discharge Medications:
1. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*40 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hyponatremia
Discharge Condition:
good
Discharge Instructions:
Return to emergency room if you feel any symptoms similar to
those that preceeded your current admission (severe
lightheadedness, nausea, finger tingling)
Limit free water intake to 1500 ml per day.
Followup Instructions:
Please call PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 22799**] at [**Telephone/Fax (1) 57852**] in 1 week
Follow up with Dr. [**First Name (STitle) **] (psychiatrist) and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 35041**]
(therapist) next week.
ICD9 Codes: 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3926
} | Medical Text: Admission Date: [**2135-3-31**] Discharge Date: [**2135-4-15**]
Date of Birth: [**2051-4-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
83yo M with ATRIAL FIBRILLATION on coumadin and recent ischemic
stroke s/p PEG h/w GIB. Pt was in his USOH at rehab until this
AM when he noted having a bowel movement of stool with bright
red blood. No rectal pain, no previous episodes of this, no
abdominal pain. Denies SOB, CP, nausea/vomiting, dizziness,
lightheadedness. Patient has history of guaiac positive stools
felt to be related to radiation proctitis and had colonoscopy in
[**9-/2134**] which showed continued proctitis as well as sigmoid
diverticulosis.
Of note, patient was recently discharged on [**3-23**] when he
presented with an acute R-sided MCA infarct. INR was therapeutic
so no tPA was administered. Course complicated by a hospital
acquired pneumonia that was treated with a 8 day course of vanc
and zosyn. He also had one blood culture that came back growing
[**Female First Name (un) **] (TORULOPSIS) GLABRATA. TTE and HIV negative, so source
was unclear. Started on micafungin 100 mg IV q24 hr for a
fourteen day course to end on [**2135-4-2**]. PEG was placed on [**3-20**] for
due to repeated speech/swallow failure. Prior to d/c to
[**Hospital1 1319**], some blood was noted in the PEG residuals.
In the ED, initial VS were: 100.2 98 124/70 18 98%. Labs notable
for INR elevated to 5.2, Hct 32.6. PEG lavage showed bright red
blood. Patient received 2u FFP, 10mg IV vitamin K, PPI bolus.
Guaiac showed bright red blood in stool.
On arrival to the MICU, patient had medium amount of bright red
blood without clots or stool. Patient denied abdominal pain,
chest pain, or shortness of breath.
.
MICU COURSE: On arrival to the MICU, patient had [**3-18**] BM's with
medium amount of bright red blood without clots or stool.
Patient denied abdominal pain, chest pain, or shortness of
breath. Crit dropped 6 points. PEG lavage in ED lavage was
positive for blood. Was HD stable and did not require pressors
but antihypertensives were held. Rec'd 2units of pRBCs, 2units
FFP. Early AM on [**4-1**] re-bled, 2 large melanotic stools, at CT
abd/pelv without any identifiable source. Bleeding stopped
spontaneously. Crit nadir 26, currently 28.8. Thought to be from
radiation proctitis, diverticulosis, or bleed related to PEG
tube. Called out to floor for further management and evaluation.
Of note he finished his 14 day course of micafungin (last day =
[**4-2**]).
Past Medical History:
R-sided MCA infarct [**2134**] with residual left sided weakness and
mild dysarthria
Atrial Fibrillation - on coumadin
Ischemic Stroke [**2132**] - left insula and left frontal (some gait
instability no other deficits)
Type II DM - HbA1c 6.4
Prostate Cancer s/p radiation and hormonal therapy in [**2128**]
?OSA
Low back pain
Social History:
- patient is a preacher at a Pentecostal Church
- married
- he has 2 children who are 52 and 53 yo.
He denies tobbaco, alcohol and illicit drug use.
Family History:
- His father died of cancer (unknown) in his 80's
- His mother died of unkown cause in her 80's
- Brother with DM
Physical Exam:
Vitals: afebrile, HR 80s-70 irreg, BP 120-130/60s 97%RA
General: oriented and largely appropriate but can be tangential,
NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. PEG site C/D/I
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
General: Cooperative, NAD. Extremities with no edema, pulses
palpated.
Neurologic: Mental Status: Awake, alert. conversant. dysarthria.
Mild difficulties with word finding.
CN:II-Vi intact. VII: left sided facial droop
Left side upper extremity motor [**5-19**]. Left lower -[**6-18**].
Right side upper/lower [**6-18**].
Sensory: decreased sensation to light touch on left side. Gait:
deferred
Pertinent Results:
[**2135-4-13**] 03:25AM BLOOD WBC-7.8 RBC-3.59* Hgb-10.6* Hct-31.0*
MCV-86 MCH-29.6 MCHC-34.3 RDW-15.0 Plt Ct-276
[**2135-4-12**] 06:15AM BLOOD WBC-6.5 RBC-3.54* Hgb-10.5* Hct-31.2*
MCV-88 MCH-29.6 MCHC-33.5 RDW-14.5 Plt Ct-296
[**2135-4-11**] 05:42AM BLOOD WBC-8.3 RBC-3.71* Hgb-10.9* Hct-31.8*
MCV-86 MCH-29.4 MCHC-34.3 RDW-15.0 Plt Ct-262
[**2135-4-10**] 05:33AM BLOOD WBC-6.8 RBC-3.47* Hgb-10.5* Hct-30.6*
MCV-88 MCH-30.2 MCHC-34.2 RDW-15.0 Plt Ct-273
[**2135-4-9**] 06:39AM BLOOD WBC-8.6 RBC-3.16* Hgb-9.5* Hct-27.2*
MCV-86 MCH-30.0 MCHC-34.8 RDW-15.3 Plt Ct-266
[**2135-4-8**] 06:47AM BLOOD WBC-8.5 RBC-3.57* Hgb-10.8* Hct-31.6*
MCV-88 MCH-30.2 MCHC-34.2 RDW-14.7 Plt Ct-317
[**2135-4-7**] 06:00AM BLOOD WBC-7.3 RBC-3.40* Hgb-10.2* Hct-29.4*
MCV-86 MCH-30.0 MCHC-34.7 RDW-15.3 Plt Ct-269
[**2135-4-6**] 05:03AM BLOOD WBC-7.1 RBC-3.34* Hgb-10.1* Hct-28.9*
MCV-87 MCH-30.4 MCHC-35.1* RDW-15.4 Plt Ct-257
[**2135-4-4**] 06:09AM BLOOD WBC-5.6 RBC-3.41* Hgb-10.3* Hct-29.5*
MCV-86 MCH-30.1 MCHC-34.9 RDW-14.7 Plt Ct-245
[**2135-4-3**] 02:30AM BLOOD WBC-6.7# RBC-3.46* Hgb-10.5* Hct-29.9*
MCV-86 MCH-30.2 MCHC-35.0 RDW-14.6 Plt Ct-240
[**2135-4-2**] 01:21AM BLOOD WBC-3.8* RBC-3.37* Hgb-10.1* Hct-29.0*
MCV-86 MCH-30.1 MCHC-34.9 RDW-15.0 Plt Ct-235
[**2135-4-1**] 03:07AM BLOOD WBC-4.9 RBC-2.97* Hgb-8.6* Hct-26.7*
MCV-90 MCH-28.8 MCHC-32.2 RDW-15.0 Plt Ct-275
[**2135-3-31**] 08:35PM BLOOD WBC-5.6 RBC-3.66* Hgb-10.8* Hct-32.6*
MCV-89 MCH-29.5 MCHC-33.1 RDW-14.3 Plt Ct-362
*****
[**2135-4-14**] 08:40AM BLOOD PT-19.1* PTT-79.0* INR(PT)-1.8*
[**2135-4-13**] 03:25AM BLOOD PT-17.1* PTT-64.0* INR(PT)-1.6*
[**2135-4-12**] 09:05PM BLOOD PT-16.5* PTT-66.2* INR(PT)-1.6*
[**2135-4-12**] 06:15AM BLOOD PT-15.4* PTT-40.2* INR(PT)-1.4*
[**2135-4-12**] 03:15AM BLOOD PT-14.8* PTT-69.7* INR(PT)-1.4*
[**2135-4-11**] 05:42AM BLOOD PT-15.3* PTT-70.0* INR(PT)-1.4*
[**2135-4-10**] 10:31PM BLOOD PT-16.4* PTT-150* INR(PT)-1.5*
[**2135-4-10**] 05:33AM BLOOD Plt Ct-273
[**2135-4-8**] 05:02PM BLOOD PT-25.7* INR(PT)-2.5*
[**2135-4-8**] 06:47AM BLOOD PT-21.1* PTT-38.9* INR(PT)-2.0*
[**2135-4-7**] 03:07PM BLOOD PT-21.0* PTT-38.2* INR(PT)-2.0*
[**2135-4-7**] 06:00AM BLOOD PT-21.9* PTT-39.8* INR(PT)-2.1*
[**2135-4-6**] 05:03AM BLOOD PT-24.6* INR(PT)-2.4*
[**2135-4-5**] 05:14AM BLOOD PT-28.2* PTT-41.7* INR(PT)-2.7*
[**2135-4-4**] 06:09AM BLOOD PT-31.1* PTT-66.1* INR(PT)-3.0*
[**2135-4-3**] 05:57AM BLOOD PT-25.8* INR(PT)-2.5*
[**2135-4-2**] 01:21AM BLOOD PT-16.9* PTT-32.7 INR(PT)-1.6*
[**2135-4-1**] 05:25PM BLOOD PT-15.8* INR(PT)-1.5*
[**2135-4-1**] 03:07AM BLOOD PT-20.9* PTT-43.0* INR(PT)-2.0*
[**2135-3-31**] 08:55PM BLOOD PT-52.3* PTT-83.7* INR(PT)-5.2*
*******
[**2135-4-13**] 03:25AM BLOOD Glucose-73 UreaN-8 Creat-0.8 Na-139 K-3.8
Cl-104 HCO3-26 AnGap-13
[**2135-4-12**] 06:15AM BLOOD Glucose-67* UreaN-9 Creat-0.9 Na-141
K-3.8 Cl-107 HCO3-25 AnGap-13
[**2135-4-11**] 05:42AM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-141
K-4.0 Cl-105 HCO3-27 AnGap-13
[**2135-4-10**] 05:33AM BLOOD Glucose-143* UreaN-14 Creat-0.9 Na-138
K-3.9 Cl-103 HCO3-28 AnGap-11
[**2135-4-12**] 06:15AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.9
====
CTA Abdomen Pelvis
Final Report
INDICATION: Bright red blood per rectum with a history of
diverticular
disease, evaluate source of bleed.
TECHNIQUE: Mesenteric CTA with and without contrast. Coronal and
sagittal
reformations were provided and reviewed.
DLP: 2049.18 mGy-cm.
ABDOMEN: The visualized portions of the lungs again show
bilateral
ground-glass opacities with a more consolidative-appearing
process appearing
on the right, predominantly in a peribronchovascular
distribution. This has
improved from prior. There are trace bilateral pleural effusions
which are
also improved. The heart size is enlarged. There is no
pericardial effusion
or pneumothorax.
The liver enhances homogeneously without focal lesions. The
gallbladder
contains multiple gallstones without evidence of cholecystitis.
There is no
biliary ductal dilatation. A new wedge-shaped hypodensity is
seen at the base
of the spleen (3B:247). The pancreas and right adrenal gland are
normal.
Again noted is diffuse thickening of the left adrenal gland
without
nodularity. The kidneys enhance symmetrically and excrete
contrast without
hydronephrosis. Bilateral hypodensities likely represent cysts
but are too
small to characterize fully. A 2.9-mm non-obstructing stone is
seen within
the left kidney (2:36). There is no free air or free fluid. No
retroperitoneal or mesenteric lymphadenopathy is seen.
Moderate atherosclerosis and soft plaque is seen throughout the
abdominal
aorta and at the bifurcation of the iliac vessels. The portal
vein, splenic
vein, and superior mesenteric vein are patent.
A percutaneous G-tube is present. The stomach is unremarkable.
There are no
foci of contrast extravasation seen on the arterial or delayed
phases to
suggest the location of the bleed.
PELVIS: Air seen in the bladder with Foley catheter in place.
The prostate
and rectum are normal. Minor diverticulosis is seen in the
sigmoid colon
without diverticulitis. There is no inguinal or pelvic
lymphadenopathy.
There is no free pelvic fluid.
BONES: There are no suspicious osseous lesions. Moderate
degenerative
changes are noted about the lower lumbar spine marked by disc
space narrowing
and vacuum phenomenon at L3-S1. Incidental note is made of a
pectus
excavatum.
IMPRESSION:
1. No source of bleeding identified.
2. Wedge-shaped splenic hypodensity representing a splenic
infarct.
3. Widespread pulmonary consolidations, right greater than left,
consistent
with multifocal pneumonia, improved from prior.
4. Cholelithiasis without cholecystitis and sigmoid
diverticulosis without
diverticulitis.
5. Cardiomegaly.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24374**]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: FRI [**2135-4-1**] 4:46 PM
========
Colonoscopy [**2135-4-12**]
Contents: The patient's G-tube was found to be passing through
the descending colon. The tissue surrounding the tube was
friable and demonstrated contact bleeding.
Mucosa: Neovascularization in the rectum with no bleeding was
noted. These findings are consistent with mild radiation
proctitis.
Excavated Lesions A few diverticula were seen in the left colon.
Diverticulosis appeared to be of mild severity.
Impressions:
Diverticulosis of the left colon
Proctitis in the colon
Foreign body in the colon
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
Patient is an 83 year old male with chronic atrial fibrillation
on coumadin s/p CVA to right middle cerebral artery, s/p G-tube
placement for feeding who presented to [**Hospital1 18**] with bright red
blood per rectum.
Patient was initially admitted to the medical ICU due to several
episodes of bright red blood per rectum. He had a subsequent
drop in hematocrit of 6 points. He remained hemodynamically
stable during this period. Of note, his INR upon presentation
was 5.2. He under went a CTA abdomen which did not show an
obvious source of bleeding. Given that his hematocrit was stable
and he had stopped bleeding per rectum spontaneously, a tagged
RBC scan was deffered. In the ICU he required 2units of reds
cells and 2 units of FFP.
From a prior hospitalization, there was one positive blood
culutre which showed fungal growth which was possibly a
contamination. He was treated with micafungin and there was no
further evidence of fungemia.
He coumadin was held in the MICU and he was on a heparin drip to
prvent CVA from his atrial fibrillation. Note patient has had
prior R-MCA secondary to atrial fibrillation.
Once his pressures were stable and he had definitively stopped
bleeding, he was then transferred to the medical floor for
further care and workup of his GI bleeding.
Following discharge from the medical ICU, The patient was seen
and consulted on by gastroenterology. Gastroenterology
recommended doing a colonoscopy to localize his bleeding.
However given his elevated INR, his Coumadin was held. In the
interim he was placed on a heparin drip. We placed this patient
on a heparin drip for the length of his stay at [**Hospital1 18**] (except
when it was discontinued for procedures for a few hours and
subsequently restarted).
*It is important that he is anticoagulated because he has
chronic atrial fibrillation and he is status post stroke to the
right middle cerebral artery.*
It took several days for his INR to drop to an acceptable range
to where the procedure could be performed safely without any
increased risk of bleeding. During this time, he was on a
heparin drip which was adjusted to a PTT from 60-100.
On [**2135-4-12**], the patient went for colonoscopy. The
patient?????? Gtube was found to be passing through the descending
colon. The tissue surrounding the tube was friable and
demonstrated contact bleeding. Also, the colonoscopy showed a
diverticulosis of the left colon, proctitis and then otherwise
normal colonoscopy to the cecum. Gastroenterology recommended
that his INR remain between [**3-18**] to prevent re-bleeding and also
extreme care when managing the tube such that it does not
migrate out of the stomach.
General surgery was consulted, they felt that exploratory
laparotomy at this juncture given that the patient was
tolerating feeds through the percutaneous tube would be very
high risk. After consulting with gastroenterology, general
surgery felt that his G tube was safe to be used for feeding.
Gastroenterology recommended that the patient follow-up in 3
[**Known lastname **] for endoscopic removal of the percutaneous gtube.
In the interim, they recommended that the patient be fed
through the PEG, his coumadin to be restarted, and to follow up
in 3 [**Known lastname **]. The patient was subsequently restarted on his tube
feeds, glucerna 85 ML's per hour and his Coumadin was restarted
at 1 mg. No changes were made to the patient's medications
during his inpatient stay.
Transitional issues: Chronic atrial fibrillation-INR of [**3-18**] for
atrial fibrillation.
Medications on Admission:
colace 100mg [**Hospital1 **]
lantus 12u [**Hospital1 **]
metoprolol 25mg PO BID
micafungin 100 IV QD (until [**4-2**])
nystatin 5ml QID
simvastatin 10mg QHS
lisinopril 20mg QD
lovenox 120mg SC q24h (until [**4-2**])
coumadin 2mg daily
Allergies: None
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation. Capsule(s)
2. insulin glulisine Subcutaneous
3. insulin regular human 100 unit/mL Solution Sig: sliding scale
Injection qachs: Sliding scale provided.
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day: hold for hr less than 55 or bp less than 100.
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. heparin (porcine) 1,000 unit/mL Solution Sig: see attached
sheet Injection adjust per PTT: Weight based protocol until
INR [**3-18**].
9. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
10. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
11. Heparin gtt at 750unit/hr
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Acute lower gastrointestinal bleed attributed to
percutaneous endoscopic gastrostomy tube traversing through the
descending large bowel, with acute blood loss anemia.
2. Atrial fibrillation requiring chronic anti-coagulation
3. chronic radiation proctitis status post radiotherapy for
prostate adenocarcinoma
4. Type II diabetes mellitus
5. Hypertension
6. Hyperlipidemia
7. Status post ischemic stroke to the right middle cerebral
artery
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Transitional Issues:
*GTUBE SAFE FOR USE.
*Gtube placement. Currently in stomach however it may become
dislodged if moved. Must be very careful when handling tube. If
patient developes an acute abdomen please have a very high
suspicion that g-tube is emptying into his peritoneum. In this
event, stat transfer to [**Hospital1 18**] for surgical evaluation.
Discharge Instructions:
Dear Reverend [**Known lastname **],
You were hospitalized for a lower G.I. bleed. This bleeding was
a combination of the way your feeding tube is positioned in your
large bowel and your very high level of blood thinner when you
presented to the emergency department with bleeding. Going
forward, we will continue to use your feeding tube and restart
you on your Coumadin. It is imperative that your INR is a very
closely monitored so that it does not get too high. Also, please
have your hematocrit or blood level checked twice a week.
*You may continue to use the the feeding tube. However, if you
notice any belly pain please let your physicians know, and this
may be a surgical emergency requiring transfer back to [**Hospital1 **].
In approximately one month, you will need to have your feeding
tube evaluated by GI for possible removal or revision. Your
doctors at rehab [**Name5 (PTitle) **] make a follow up appointment with your
primary care doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] MD, upon discharge.
In the meantime, please resume your normal rehabilitation
activities. Please resume your normal medications with the
following changes:
1. We have started you on heparin while waiting for your INR to
reach therapeutic levels, this should be continued for 2 days
after your INR is therapeutic
2. We are discharging you on 1mg of coumadin per day (you were
previously taking 2 mgs). Your INR (coumadin) blood levels will
be titrated and managed by the doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **].
It was a pleasure taking care of you.
Sincerely,
[**Hospital1 18**] Internal Medicine.
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2135-5-4**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: FRIDAY [**2135-6-10**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) 132**] C.
Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL
GROUP
Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 133**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2135-4-27**] at 3:00 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 2762, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3927
} | Medical Text: Admission Date: [**2144-7-16**] Discharge Date: [**2144-9-18**]
Date of Birth: [**2085-7-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
tachypnea, increased oxygen requirement
Major Surgical or Invasive Procedure:
Intubation
Extubation
Right sided thoracentesis
History of Present Illness:
59 year old female with mental retardation, anemia, ileus and
volvulus s/p resection and recent hospitalization with
pericardial effusion and new mediastinal mass with diffuse
lymphadenopathy presents with recurrent tachypnea and increased
oxygen requirement. Patient was discharged from [**Hospital1 18**]
approximately one week ago back to her group home. During her
last hospitalization she was found to have a pericardial
effusion with evidence of tamponade and this was drained. She
then developed a-fib with RVR that was suppressed with verapamil
and metoprolol. She was also noted to have a large mediastinal
mass and diffuse lymphadenopathy. Pericardial fluid and lymph
node FNA both did not show clear evidence of malignancy. She was
discharged to her group home acute care facility and recommended
to have entire excision of her egg-sized left axillary lymph
node for further diagnosis.
She now represents with tachypnea and increased oxygen
requirement. At her home she was noted to be more tachypnic with
slightly increased O2 requirement. She has needed intermittent
oxygen and occasionally refuses it. The patient has history of
tachypnea during her last hospitalization that resolved with
sitting up (may have been mechanical from her large
abdomen/ileus) and with nebulizer treatments. At
[**Hospital3 1196**] ED she received solumedrol 125mg once,
sasix 20mg IV once, zosyn 1 dose. CTA chest showed no evidence
of PE, small bilateral pleural effusion, moderate pericardial
effusion and large mediastinal mass encasing and narrowing the
SVC, extensive lymphadenopathy. No comment was made on a
consolidation. She was in normal sinus rhythm and had a negative
first set of cardiac enzymes. She was transferred to [**Hospital1 18**] for
further evaluation.
History is difficult to obtain from the patient. She often says
yes to all questions. When asked if she has pain, she does point
to her distended abdomen and to her chest.
Past Medical History:
- h/o mediastinal mass and diffuse lymphadenopathy; s/p FNA,
diagnosis unclear
- h/o pericardial effusion s/p drainage; path/cytology
inconclusive
- h/o paroxysmal a-fib w/ RVR s/p pericardiocentesis; no
anticoagulation 2/2 blood pericardial effusion
- Mental retardation of unknown etiology.
- h/o ileus requiring occasional rectal tube
- Status post volvulus and colonic resection.
- DJD.
- Bilateral knock knees (talus valgus, pes planus).
- Neurodermatitis.
- Psoriasis.
- History of obesity.
- Status post left oophorectomy.
- microcytic anemia 28.5
- GERD
Social History:
Patient lives at [**Location 18355**] Center for mentally disabled. Her HCP
is her brother [**Name (NI) **].
Family History:
Father died of prostate cancer, CABG, MIs; he also had colon CA.
maternal aunt with ovarian and breast cancer. MI and CAD
throughout family on both sides. Mother is still living.
Physical Exam:
VS: T 98.4 SBP 120/68 pulsus 6 HR70s RR30s 94% on 4L
GEN'L: pale, obese, talkative and fairly comfortable
HEENT: nc/at, MMM slightly dry, edentulous with poor dentition
NECK: no JVP appreciated
LN: no clear submandibular/anterior cervical or supraclavicular
LN noted; pt did not allow palpation of axillary LN (ticklish)
CVS: NR/RR, clear heart sounds, +s1/s2, no clear murmurs
PUL: soft expiratory wheezes, no clear [**First Name9 (NamePattern2) **]
[**Last Name (un) **]: +BS (normal), distended, soft, old abdominal surgical
scar, +tympany, no tenderness to deep palpation, no clear
masses, organs not palpated
EXT: marked edema to thighs, deformed feet, pulses not
appreciated LE, 2+ radial, lower extremities cool, no edema of
upper
GU: deferred; foley in place
NEURO: alert, oriented to name. Moves all four extremities. Has
difficulty complying with exam. Able to pull herself up to sit
on her own.
Pertinent Results:
OSH labs:
u/a trace blood, otherwise negative
trop <0.01
CK 7
total protein 6.1
T. bili 0.6, ast 24, alt 35, alk phos 281
BNP 153
ABG: 7.35/59/74/32 on 5L
IN-HOUSE LABORATORY RESULTS:
K:4.1
Lactate:1.2
HEMOLYZED SLIGHTLY
141 103 15
-------------< 155
4.3 29 0.4
Ca: 9.3 Mg: 1.8 P: 4.5
MCV 82
12.6 > 8.3 < 472
----------------
28.1
N:97.4 L:1.9 M:0.5 E:0.1 Bas:0.1
Labs at admission and discharge
[**2144-9-17**] 09:20AM BLOOD WBC-7.5 RBC-2.36*# Hgb-7.3*# Hct-22.3*#
MCV-94 MCH-30.9 MCHC-32.7 RDW-20.8* Plt Ct-524*#
[**2144-9-17**] 12:00AM BLOOD WBC-5.0# RBC-4.14*# Hgb-12.7# Hct-40.1#
MCV-97 MCH-30.7 MCHC-31.7 RDW-20.5* Plt Ct-273
[**2144-9-16**] 09:00AM BLOOD WBC-10.9 RBC-2.62* Hgb-8.2* Hct-25.6*
MCV-98 MCH-31.3 MCHC-32.1 RDW-21.0* Plt Ct-450*
[**2144-7-17**] 05:15AM BLOOD WBC-13.4* RBC-3.21* Hgb-7.6* Hct-26.7*
MCV-83 MCH-23.6* MCHC-28.4* RDW-16.3* Plt Ct-465*
[**2144-7-16**] 10:02AM BLOOD WBC-12.6* RBC-3.44* Hgb-8.3* Hct-28.1*
MCV-82 MCH-24.1* MCHC-29.5* RDW-16.3* Plt Ct-472*
[**2144-9-17**] 09:20AM BLOOD Neuts-94.5* Bands-0 Lymphs-2.6* Monos-2.2
Eos-0.6 Baso-0.2
[**2144-7-16**] 10:02AM BLOOD Neuts-97.4* Lymphs-1.9* Monos-0.5*
Eos-0.1 Baso-0.1
[**2144-9-17**] 09:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Target-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2144-9-16**] 09:00AM BLOOD Plt Ct-450*
[**2144-9-17**] 09:20AM BLOOD Plt Smr-NORMAL Plt Ct-524*#
[**2144-7-16**] 10:02AM BLOOD Plt Ct-472*
[**2144-7-17**] 05:15AM BLOOD PT-15.9* PTT-25.8 INR(PT)-1.4*
[**2144-9-17**] 12:00AM BLOOD PT-13.7* PTT-39.3* INR(PT)-1.1
[**2144-9-17**] 12:00AM BLOOD Fibrino-694*
[**2144-7-21**] 04:43AM BLOOD D-Dimer-752*
[**2144-9-16**] 01:49AM BLOOD Gran Ct-8330*
[**2144-9-15**] 12:00AM BLOOD Gran Ct-8325*
[**2144-7-28**] 12:00AM BLOOD Gran Ct-[**Numeric Identifier **]*
[**2144-7-20**] 05:30AM BLOOD ESR-107*
[**2144-9-16**] 04:15AM BLOOD Ret Aut-6.4*
[**2144-8-20**] 05:55AM BLOOD Ret Aut-0.6*
[**2144-9-17**] 12:00AM BLOOD Glucose-113* UreaN-14 Creat-0.3* Na-134
K-3.5 Cl-102 HCO3-27 AnGap-9
[**2144-9-16**] 01:49AM BLOOD Glucose-102 UreaN-12 Creat-0.3* Na-136
K-3.3 Cl-105 HCO3-25 AnGap-9
[**2144-7-17**] 05:15AM BLOOD Glucose-169* UreaN-21* Creat-0.4 Na-140
K-4.4 Cl-102 HCO3-32 AnGap-10
[**2144-7-16**] 10:02AM BLOOD Glucose-155* UreaN-15 Creat-0.4 Na-141
K-4.3 Cl-103 HCO3-29 AnGap-13
[**2144-9-14**] 12:00AM BLOOD estGFR-Using this
[**2144-9-17**] 12:00AM BLOOD ALT-24 AST-15 LD(LDH)-177 AlkPhos-130*
TotBili-0.3
[**2144-9-16**] 01:49AM BLOOD ALT-23 AST-15 LD(LDH)-170 AlkPhos-101
TotBili-0.4
[**2144-9-16**] 12:00AM BLOOD ALT-18 AST-10 LD(LDH)-136 AlkPhos-76
TotBili-0.2
[**2144-7-22**] 05:34AM BLOOD ALT-11 AST-10 LD(LDH)-264* CK(CPK)-6*
AlkPhos-138* TotBili-0.4
[**2144-7-20**] 05:30AM BLOOD LD(LDH)-264*
[**2144-9-6**] 12:01AM BLOOD proBNP-110
[**2144-7-22**] 05:34AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-1219*
[**2144-7-21**] 04:43AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-3161*
[**2144-9-17**] 12:00AM BLOOD Albumin-2.3* Calcium-7.9* Phos-2.6*
Mg-2.0
[**2144-7-16**] 10:02AM BLOOD Calcium-9.3 Phos-4.5 Mg-1.8
[**2144-9-16**] 01:49AM BLOOD calTIBC-157* VitB12-1256* Folate-8.6
Hapto-248* Ferritn-632* TRF-121*
[**2144-9-4**] 12:00AM BLOOD Triglyc-115
[**2144-8-23**] 12:00AM BLOOD TSH-7.5*
[**2144-8-23**] 04:26AM BLOOD Free T4-1.5
[**2144-8-5**] 05:12AM BLOOD Digoxin-1.0
[**2144-8-25**] 04:08AM BLOOD Type-ART pO2-90 pCO2-46* pH-7.35
calTCO2-26 Base XS-0 Intubat-NOT INTUBA
[**2144-7-18**] 06:39PM BLOOD Type-[**Last Name (un) **] pO2-60* pCO2-50* pH-7.43
calTCO2-34* Base XS-7 Comment-GREEN TOP
[**2144-8-25**] 04:08AM BLOOD freeCa-1.27
[**2144-8-24**] 07:36PM BLOOD freeCa-1.01*
[**2144-9-17**] 06:35AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2144-9-17**] 06:35AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2144-9-17**] 06:35AM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-OCC Epi-<1
[**2144-8-18**] 11:40AM URINE CastHy-1*
[**2144-9-12**] 05:11PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018
[**2144-9-12**] 05:11PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2144-9-12**] 05:11PM URINE RBC-3* WBC-178* Bacteri-MANY Yeast-NONE
Epi-0
[**2144-9-12**] 05:11PM URINE Mucous-FEW
[**2144-7-24**] 05:09PM PLEURAL WBC-600* RBC-5500* Polys-0 Lymphs-93*
Monos-1* Other-6*
[**2144-7-24**] 05:09PM PLEURAL TotProt-1.6 LD(LDH)-135
Todays Discharge labs-
K of 2.9
Na of 135
Cl of 102
Bicarb of 28
BUN of 11
Cr of 0.3
Glucose of 130
Hct 21.6- before receiving 2 units of blood
plts 445
wbc 19.2
Micro Studies-
[**2144-9-15**] 8:30 am URINE Source: Catheter.
**FINAL REPORT [**2144-9-16**]**
URINE CULTURE (Final [**2144-9-16**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
-------------
[**2144-9-13**] 1:46 pm URINE Source: Catheter.
**FINAL REPORT [**2144-9-15**]**
URINE CULTURE (Final [**2144-9-15**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final [**2144-9-13**]):
TEST CANCELLED, PATIENT CREDITED.
SPECIMEN UNACCEPTABLE FOR ANAEROBES.
IMPROPER SPECIMEN COLLECTION.
----------------
[**2144-9-9**] 6:13 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2144-9-11**]**
FECAL CULTURE (Final [**2144-9-11**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2144-9-11**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2144-9-10**]):
NO OVA AND PARASITES SEEN.
.
FEW MACROPHAGES.
.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
[**2144-9-8**] 6:00 pm Immunology (CMV)
**FINAL REPORT [**2144-9-10**]**
CMV Viral Load (Final [**2144-9-10**]):
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC
PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
[**2144-9-8**] 12:20 pm URINE Source: Catheter.
**FINAL REPORT [**2144-9-13**]**
URINE CULTURE (Final [**2144-9-13**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
CEFAZOLIN CEFUROXIME sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2144-9-6**] 4:50 am URINE Source: Catheter.
**FINAL REPORT [**2144-9-8**]**
URINE CULTURE (Final [**2144-9-8**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**2144-9-1**] 12:35 am STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2144-9-2**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2144-9-2**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N. ON [**2144-9-2**] AT 0700.
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).
[**2144-8-9**] 12:40 pm URINE Source: Catheter.
**FINAL REPORT [**2144-8-10**]**
URINE CULTURE (Final [**2144-8-10**]):
GRAM POSITIVE BACTERIA. ~[**2136**]/ML.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
[**2144-8-8**] 7:19 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2144-8-9**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2144-8-9**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11596**] ON [**2144-8-9**] AT 3PM.
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).
[**2144-8-5**] 4:15 pm
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
**FINAL REPORT [**2144-8-11**]**
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
(Final
[**2144-8-6**]):
Positive for Herpes Simplex Virus Type 1 by direct antigen
staining..
REPORTED BY PHONE TO DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Numeric Identifier 78643**] [**2144-8-6**]
10:55AM.
Await culture results.
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2144-8-11**]):
HERPES SIMPLEX VIRUS TYPE 1.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
[**2144-8-3**] 7:57 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2144-8-4**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2144-8-4**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2144-7-31**] 9:15 am BLOOD CULTURE Source: Line-picc.
**FINAL REPORT [**2144-8-6**]**
Blood Culture, Routine (Final [**2144-8-6**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
ENTEROBACTER CLOACAE. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
KLEBSIELLA OXYTOCA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROBACTER CLOACAE
| | KLEBSIELLA
PNEUMONIAE
| | |
KLEBSIELLA OXYTO
| | | |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R <=2 S 4 S
CEFAZOLIN------------- =>64 R <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S <=1 S
CEFUROXIME------------ 16 I <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S <=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S <=0.25 S
PIPERACILLIN---------- 32 I <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S <=1 S
Anaerobic Bottle Gram Stain (Final [**2144-8-1**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1:25A [**2144-8-1**].
GRAM NEGATIVE RODS.
Aerobic Bottle Gram Stain (Final [**2144-8-1**]): GRAM NEGATIVE
RODS.
[**2144-7-31**] 10:32 am URINE Source: CVS.
**FINAL REPORT [**2144-8-2**]**
URINE CULTURE (Final [**2144-8-2**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2144-7-24**] 5:09 pm PLEURAL FLUID #3.
**FINAL REPORT [**2144-8-1**]**
GRAM STAIN (Final [**2144-7-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count..
FLUID CULTURE (Final [**2144-7-27**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2144-8-1**]): NO GROWTH.
[**2144-7-17**] 5:08 pm TISSUE LEFT SUPRACLAVICULAR NODE.
GRAM STAIN (Final [**2144-7-17**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2144-7-20**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2144-7-23**]): NO GROWTH.
ACID FAST SMEAR (Final [**2144-7-18**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final [**2144-7-31**]): NO FUNGUS ISOLATED.
EKG: NSR, normal axis, normal intervals, occasional PAC,
ST/T-wave changes, no Q waves
EKG #2: a-fib, rate 110, normal intervals, no ischemic changes
.
CTA CHEST at OSH:
1. no e/o pulmonary emboli
2. small bilateral pleural effusions. moderate pericardial
effusion.
3. large right superior mediastinal mass encasing adn narrowing
the SVC with insinuation around prevascular space structures and
hilar vasculature. multiple enlarged prevascular and epicardial
lymph nodes are present. Grossly enlarged subpectoral lymph
nodes measure up to 3.5cm in short axis diameter. There is
extensive supraclavicular lymphadenopathy. The appearance favors
lymphooma, although other tumor such as small cell lung cancer
should also be considered. The SVC diameter is narrowed from
20mm to 7mm.
.
CXR: large mediastinum, large heart, increased bilateral pleural
effusions
.
Abdominal XR:Small and large bowel dilatation with likely stool
ball demonstrated.
Axillary lymph node FNA [**7-4**]:
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin B-cell
lymphoma are not seen in specimen. Review of cytospin slide
(1096V-[**7-1**]) shows predominantly blood with admixed lymphocytes
and numerous degenerated cells precluding definitive morphologic
assessment. Correlation with clinical findings and morphology
is recommended. Flow cytometry immunophenotyping may not detect
all lymphomas due to topography, sampling or artifacts of sample
preparation.
[**2144-7-21**] ECHO:
The left atrium is moderately dilated. The estimated right
atrial pressure is 10-15mmHg. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. There are three aortic
valve leaflets. Significant aortic regurgitation is present, but
cannot be quantified. The pulmonary artery systolic pressure
could not be determined. There is a moderate sized pericardial
effusion. The effusion appears circumferential. The echo dense
portion of the effusion, consistent with blood, inflammation or
other cellular elements, is over both the right (1.3cm) and left
(0.8cm) ventricles. The echo lucent portion of the pericardial
effusion is most prominent around the right atrium and is small
in size elsewhere. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen.
Compared with the prior study (images reviewed) of [**2144-7-17**], the
pericardial effusion might be slightly more organized.
[**7-21**] BILATERAL LOWER EXTREMITY ULTRASOUND:
IMPRESSION: No evidence of DVT.
[**7-21**] LEFT UPPER EXTREMITY ULTRASOUND:
IMPRESSION: No left upper extremity DVT identified
[**7-27**] Pleural fluid cytology:
NEGATIVE FOR MALIGNANT CELLS. Many small lymphocytes and
scattered reactive mesothelial cells.
[**8-2**] CT Abdomen and Pelvis
IMPRESSION:
1. No acute abnormality identified.
2. Moderate predominantly gaseous distention of the stomach.
Also, mild
distention of the transverse colon is seen. Overall, the degree
of dilatation involving the colon is significantly decreased
since the prior exam.
3. Moderate bilateral pleural effusions and small pericardial
effusion.
4. Patient's known mediastinal lymphadenopathy is seen on the
superior most
images of this CT scan. These are seen to better detail on the
aforementioned prior exam.
[**8-3**] ECHO:
CONCLUSIONS:
LV systolic function appears depressed. with depressed free wall
contractility. There is a small pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2144-7-21**],
the pericardial effusion appears smaller. The LV systolic
funciton appears worse (but the patient is significantly more
tachycardic - SVT?)
[**2144-8-5**] Direct Antigen Test for HSV Types 1 & 2 (lip):
Positive for Herpes Simplex Virus Type 1 by direct antigen
staining.
Torso CT [**2144-9-8**]
CT CHEST: Multiple enlarged supraclavicular and bilateral
axillary lymph
nodes are again seen. Largest left axillary node (2, 13)
currently measures 2.7 x 1.7 cm, decreased from 4.7 x 3.2 cm.
Largest right axillary lymph node (2, 11) currently measures 2.7
x 1.7 cm, slightly increased from previous, when it measured 2.1
x 1.5 cm.
Infiltrative soft tissue mass in the anterior mediastinum
extending from the supraclavicular region to the right atrium
has decreased in size, though it continues to encase and
slightly narrow the superior vena cava. Mass now measures
roughly 4.4 x 3.1 cm, decreased in size from previous exam when
it measured 6.8 x 4.1 cm.
Small pericardial effusion is slightly decreased. Small right
pleural
effusion and adjacent compressive atelectasis is unchanged.
Loculated small left pleural effusion is unchanged, with minimal
adjacent compressive atelectasis.
Small right hilar lymph node is unchanged. Evaluation of the
lung parenchyma is slightly limited by expiratory phase of scan
acquisition, with no focal nodules or consolidations identified.
CT ABDOMEN: Liver is unchanged in appearance, with multiple
subcentimeter
hypodensities which remain too small to definitively
characterize. Multiple gallstones within the gallbladder lumen
are unchanged. There is no gallbladder wall thickening or
pericholecystic fluid. Pancreas and adrenal glands and kidneys
remain unremarkable. Focal hypodensity in the superior aspect of
the spleen (2, 47) is slightly decreased in prominence. No new
splenic lesions are seen. Stomach and intra-abdominal loops of
bowel are normal. There is no free air, free fluid, or abnormal
intra-abdominal lymphadenopathy.
CT PELVIS: Degree of colonic distension has slightly improved.
However,
there is now marked bowel wall edema, and surrounding
inflammatory stranding in the region of the rectum and sigmoid
colon. This extends roughly to the region of apparent surgical
anastomosis in the left lower quadrant. Pelvic loops of large
and small bowel are otherwise unremarkable. There is a small
amount of free pelvic fluid, unchanged. Uterus is unchanged,
with small focal hyperattenuating focus anteriorly, which is
unchanged, and may represent a small exophytic fibroid. Diffuse
anasarca is unchanged.
There is no osseous lesion suspicious for malignancy.
IMPRESSION:
1. Slight interval improvement in patient's known anterior
mediastinal mass, and bilateral supraclavicular and axillary
lymphadenopathy.
2. Worsening of severe bowel wall thickening and inflammatory
stranding in
the rectum and sigmoid colon, most consistent with colitis,
presumably related to the patient's known C. difficile
infection.
3. Small bilateral pleural effusions and small pericardial
effusion, slightly improved.
4. Cholelithiasis, without evidence of cholecystitis.
5. Slight improvement in small hypodensity in the superior
aspect of the
spleen.
6. Unchanged appearance of tiny subcentimeter hepatic
hypodensities, too
small to definitively characterize.
CXR [**2144-9-8**]
HISTORY: Lymphoma, on chemotherapy, now with fever.
FINDINGS: In comparison with study of [**9-5**], an external device
greatly
obscures detail, as does some marked obliquity of the patient.
Areas of
increased opacification persists in the right lower zone,
consistent with some combination of pleural effusion and volume
loss. A repeat study is
recommended without overlying artifact for patient obliquity.
The study and the report were reviewed by the staff radiologist.
Echo [**2144-9-7**]
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. ?Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is a small
(<1cm) pericardial effusion most prominent around the right
atrium and right ventricle without evidence for hemodynamic
compromise/tamponade physiology.
Compared with the prior pre-drainage study (images reviewed) of
[**2144-8-24**], the pericardial effusion is smaller and tamponade
physiology is no longer suggeted. Biventricular systolic
function and the severity of aortic regurgitation are similar.
Echo [**2144-9-15**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is mild global left ventricular
hypokinesis (LVEF = 45 %). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets appear
structurally normal with good leaflet excursion. Mild (1+)
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is a small (<1cm) anterior
pericardial effusion without evidence for tamponade physiology.
Compared with the prior study (images reviewed) of [**2144-9-7**],
there is mild global hypokinesis and a small anterior
pericardial effusion.
[**2144-9-15**] CXR
REASON FOR EXAM: Lymphoma, new O2 requirement.
Comparison is made to prior study [**2144-9-13**].
Mild pulmonary edema is stable as it does small to moderate
right pleural
effusion tracking towards the fissure. Cardiomediastinal
silhouette is
enlarged due to position of the patient and technique. Small
left pleural
effusion is unchanged. Left PICC tip is in unchanged position in
the
proximate SVC.
[**2144-9-15**] KUB
INDICATION: Patient is 59-year-old female with history of
non-Hodgkin's
lymphoma status post chemotherapy with recurrent problems of
ileus and C. diff
colitis, now presenting with increased abdominal distention and
no bowel
movement for the past 32 hours. Evaluate for obstruction.
EXAMINATION: Upright and supine portable abdominal radiographs
obtained.
COMPARISONS: Comparison to CT from [**2144-9-8**], and abdominal film
from [**2144-9-1**].
FINDINGS: There is marked gaseous distention of the bowel loops,
similar to previous study from [**2144-9-1**]. These loops are likely
colonic loops; however, this study is technically limited. There
is no intraperitoneal free air noted. There is no bowel wall
thickening noted. There is noted to be vascular calcifications
in the abdominal aorta. There is a pleural effusion noted at the
right base. There is a left subclavian central venous catheter
in place. The osseous structures are unchanged from previous
examinations.
IMPRESSION: Gaseous distention of bowel, likely colonic, that is
unchanged from previous examination from [**2144-9-1**].
[**2144-9-15**] EKG
Baseline artifact
Probable sinus tachycardia
Modest low amplitude T waves suggested
Q-Tc interval appears prolonged but is difficult to measure
Findings are nonspecific and baseline artifact makes assessment
difficult
Since previous tracing of [**2144-9-3**], tachycardia now present and
low amplitude T
wave changes suggested
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 158 100 356/440 61 51 40
[**2144-9-17**]
Preliminary Report
Uncomplicated PICC line replacement.
Brief Hospital Course:
59yoF with nodular sclerosing Hodgkin's lymphoma and multiple
medical problems including mental retardation, PAF with RVR, and
chronic ileus. She suffered from recurrent cardiac tamponade
with hemodynamic compromise recurrently during her long
hospitalization, ultimately requiring placement of a pericardial
window into the L pleural space. Because of her ongoing problems
with ileus she was placed on TPN. She also suffered from
infectious complications of C.Diff and a UTI with VRE which are
still being treated.
.
HODGKIN'S LYMPHOMA: patient has nodular sclerosing Hodgkin's
lymphoma with a mediastinal mass with extensive disease causing
compression of her L main stem bronchus, bilateral pulmonary
arteries and of her SVC (no evidence of SVC syndrome). Nodular
Sclerosing Hodgkin's, at least stage 2b. She underwent urgent
treatment with EACOP (no bleomycin due to low pulmonary reserve
and no vincristine due to GI toxicity in a patient w/ paralytic
ileus). Doxarubacin and Cytoxan on Day #1 ([**7-21**]) and Etoposide
on Day 1,2,3. 14 days of Dexamethasone 20mg daily. No evidence
of tumor lysis. R supraclavicular node decreasing in size (was
3cm, now difficult to palpate) with treatment. Also given
procarbazine ([**7-28**] and [**7-29**]) which was discontinued one day
early due to significant neutropenia and ileus with concern for
bowel obstruction. Patient became neutropenic on [**7-30**] and was
restarted on G-CSF for remaining two days of therapy.
Neutropenia resolved on [**8-3**]. Spiked temperature over 101 on
[**7-31**] and was started on Cefepime and Vancomycin (day 1=[**7-31**]).
Flagyl was started on [**7-31**] as pt was found to have GNR in [**2-14**]
blood cultures. Due to decreasing concern for gram positive
infection, Vancomycin was D/C'ed with last dose being on [**8-2**].
Patient was afebrile from [**8-1**] until transfer out of the ICU on
[**8-7**].At time of transfer out of the ICU, patient's blood culture
results were all pending (and showing NGTD) aside from GNR
growth on [**7-31**]. Stool was c. Diff toxin negative on [**8-3**]. Upper
lip ulcer was screened for HSV on [**8-5**] and proved positive by
DFA. With day 1 being [**8-6**], patient was initiated on Acyclovir
400 mg PO BID with plan for 10 total days followed by
suppressive regimen.
.
GND was started as a consolidation regimen on the BMT unit on
[**2144-8-17**]. The first two doses were tolerated well. However, on the
night of [**2144-8-23**] the pt developed hypotension and was found to
be in Afib with RVR again. She had pulses 160s and SBP to 80s,
and was transferred to the [**Hospital Unit Name 153**]. She was restarted on Amiodarone
IV and spontaneously converted to NSR. Her BP stabilized while
in sinus. Her pulsus was recorded as 4 but she did have
pulmonary congestion and distended neck veins. An echo was
obtained which showed RV and RA collapse w tamponade physiology.
On [**8-24**], cardiac surgery was urgently consulted following
the echo that revealed significant pericardial effusion and
right ventricular collapse. Given those findings, she was
brought to the operating room where Dr. [**Last Name (STitle) 2230**] performed urgent
pericardial window. She tolerated the procedure well and there
were no complications. Approximately 150 cc of clear fluid was
removed and sent for cytology. For further surgical details,
please see separate dictated operative note. Following the
operation she was brought to the CVICU for monitoring. Within 24
hours, she was extubated without incident. She was maintained on
Amiodarone and beta blockade for intermittent atrial
fibrillation. TPN was continued for her chronic ileus. Her CVICU
course was otherwise uneventful and she transferred to the SDU
on postoperative day one. She continued to experience atrial
fibrillation. Her mediastinal chest tube was eventually removed
on [**8-31**]. She eventually transferred back to the BMT service on
[**9-2**].
.
Her return to the BMT service was uneventful. She was maintained
on TPN and her cardiac medications. Her GI status continued to
be a concern, as well as her skin breakdown. A rectal tube was
placed on [**2144-9-5**] to help keep her sacral area dry and clean and
assist wound healing. She remained hemodynamically stable and
interacting at baseline. However, she is now confined to her bed
and has not walked this admission.
.
She had a CT scan on [**9-8**] of her torso that showed only mild
improvement in her lymphoma after chemo therapy. Therefore, she
underwent 3 days of ICE chemotherapy, and at discharge is on day
5 after ICE began. During her ICE treatment she became febrile
on Day 3, but they was afebrile till discharge. She also had a
decrease in the number of bowel movements, which increased in
number again once her treatment was complete. She will likely
need more cycles of treatment with this therapy about every 21
to 28 days.
.
TACHYPNEA AND HYPOXIA: Found on chest CT to have tumor causing
compression not only of her SVC but also of her pulmonary
arteries bilaterally which would cause the same V/Q mismatch as
a PE would by decreasing her perfusion. In addition she was
fluid overloaded and had bilateral pleural effusions and had
tumor compression of her L main stem bronchus. Treatment was
directed towards the underlying cause, she received chemotherapy
for her Hodgkin's lymphoma as above and underwent a R sided
thoracentesis 1.1 liters removed. She was intubated x 3 days
due to increased PaCO2 of 80 and somnolence- this increase in
PCO2 was possibly due to patient tiring versus L main stem
bronchus compression; however her mental status significantly
improved. After initiation of chemotherapy and thoracentesis
she was able to be extubated, her mental status was much
improved, her O2 requirement was down from 95% face mask to 6L
NC and her tachypnea resolved. As of [**8-7**] she was breathing
comfortably, free of tachypnea on 3L nasal cannula. She was
weaned from O2 and remained stable without O2 thereafter until
her treatment with ICE. She required 2L nasal canula for 2 days,
and then no longer required oxygen therapy.
.
TACHYCARDIA: Paroxysmal atrial fibrillation with RVR with rate
as high as 190s to low 200s; however, she was normotensive with
these rates. Treated initially with a dilt and esmolol drip;
subsequently she was loaded with IV amiodarone and dilt drip was
discontinued, her atrial fibrillation reverted to sinus rhythm
and the IV amiodarone was stopped. She was transitioned to po
Lopressor 12.5mg tid, which was uptitrated to 25mg TID due to
persistent and intermittent RVR. This can be uptitrated as
tolerated. She still has occasional very short self limited
episodes of paroxysmal atrial fibrillation. CTA negative for PE
but a fib with RVR more frequent and more difficult to control
prior to chemotherapy and may have been due to pulmonary artery
compression causing physiology similar to PE. She then
developed afib during her first neutropenic fever on [**7-31**] to
rates in the low 200s, reduced only to the 150s with 3 doses of
10mg IV diltiazem. As this resulted in hypotension, the patient
was transferred back to the ICU for rate control. She was
mentating at her baseline and with minimal oxygen requirement
throughout her RVR while on the medicine floor. On transfer to
the ICU the pt received 1L NS in setting of on-going diarrhea.
She converted to NSR spontaneous with IVF resuscitation. She was
started on an amiodarone gtt with the hope of maintaining NSR
however she developed bradycardia with the IV infusion and it
was stopped. She received 90mg total. After stopping the
amiodarone on [**7-31**] the pt reverted back to afib with HR
110s-120s but broke again with IVF. At this time she was found
to be bacteremic and her abx were broadened. Off of amiodarone
IV, patient's rate rose to 190 on [**8-4**]. IV amiodarone loading
was continued in separate sessions over the next several days.
Metoprolol 25mg QID was initiated on [**8-5**]. On night of [**8-5**]
patient converted to NSRat rate less than 90. Amiodarone IV
infusion was stopped on evening of [**8-6**] and patient was started
on amiodarone 400 mg PO BID. Patient remained in NSR with rate
less than 80 from [**8-6**] through [**8-7**].
.
She remained in sinus and stable until 7/13-14/08 as noted
elsewhere in this summary. In brief, at that time she became
hypotensive and tachycardia and was found to have Afib with RVR
as well as cardiac tamponade. Her rate and rhythm were
controlled with amiodarone and metoprolol and her tamponade was
treated with a pericardial window. She was eventually
transferred back to the BMT unit stable and in fair condition on
[**2144-9-2**]. She was initially monitored on telemetry, however, the
patient removed the leads, therefore, tele monitoring was not
feasible. She no longer had any more afib until discharge. Her
last EKG before discharge showed mild tachycardia but sinus
rhythm.
.
ILEUS AND ABDOMINAL DISTENTION: Patient has a history of
recurrent ileus. Upon admission to the ICU on [**7-31**], the patient
displayed a soft and non-tender abdomen. The enlarged bowel
segment was originally thought to be colon and typhlitis became
of concern; however, review of CT scan on [**8-2**] revealed that
distention was more related to gastric distention than colonic
distention. Rectal tube was inserted per surgery recs then
removed on [**8-5**] as patient began passing flatus and stooling
spontaneously. Distention of abdomen was followed by serial
exams. Abdominal distention was markedly improved, but still
present at time of patient transfer from ICU on [**8-7**].
.
Her ileus continued to be a problem after transfer to the BMT
unit. She was initially eating well, but developed abdominal
distension with diarrhea. She was switched to NPO and started on
TPN with tap water enemas per GI recommendations on [**2144-8-18**]. The
distension slowly resolved and she has continued TPN until
several days before discharge, at which time she is able to eat
small soft meals.
.
As of her discharge she still having diarrhea, that is sometimes
guaiac positive and sometimes a jelly like quality which GI
contribute to pseudomembrane from C. Diff. However, since
starting PO vancomycin (she is on Day 14 at discharge), her
diarrhea has become less frequent. She remains on TPN, but is
slowly tolerating more POs. GI did not recommend a endoscopy at
this time, but may pursue it in the future when her infection
has been treated. Her ileus has been previously relieved with
repositioning the patient and then rectal tube placement for a
short time.
.
R UPPER LIMB THOMBUS - patient assessed on floor and noted to
have swelling around the PICC; DVT found by US. US on [**8-31**]
showed superficial thrombus. Because the thrombus is superficial
no treatment was needed. However, given her many risk factors
for DVT she was maintained on PPx dose of heparin SC.
.
C. DIFF: Pt was noted to have diarrhea with leukocytosis on
[**2144-8-8**]. She was found to be C diff toxin positive and started
on metronidazole on [**2144-8-9**]. Her leukocytosis resolved within
days of treatment but her diarrhea continued. As of her transfer
back to the BMT unit on [**2144-9-2**] she was still C diff toxin
positive. She was switched to oral vancomycin on [**2144-9-5**] with ID
approval. She remains on PO vanco, which ID recommends a 14 day
course once her diarrhea is controlled and then a gradual
[**Doctor Last Name 2949**]. Her stools are still intermittently a bloody jelly
consistency (likely shedding of pseudomembrane), however, the
volume and number of stools have improved on this treatment,
until after her ICE treatment finished, at which time the number
of loose stools increased again. She may benefit from
probiotics.
.
SKIN BREAKDOWN: Pt has suffered from worsening skin breakdown
throughout her admission complicated by persistent diarrhea.
Wound care has followed closely. To assist in healing of her
sacral ulcer a rectal tube was placed on [**2144-9-5**]. Her vaginal
irritation improved with placement of a Foley catheter on
[**2144-8-17**]. She also suffered from very significant HSV of her
mouth, lips, and vagina. As of [**2144-8-20**] she was dramatically
improved and has since been maintained on suppressive acyclovir
with good effect. It is worth noting that the Pt obsessively
picks at her skin and need frequent reinforcement not to do so.
Finally, pneumoboots have repeatedly had to effect of causing
skin breakdown her calves. For that reason she was switched to
SC heparin. Her calf ulcers and rashes have not recurred now
that she is not on pneumoboots. As of discharge her skin
condition is improving. She still has a perineal ulcer for which
she needs wound care, but her sore on her hip has improved.
.
UTI: On [**2144-9-6**] she began having a leukocytosis (WBC to 18) and
was febrile. Her urine culture was positive for >100,000
enterococcus. She was initially started on amoxicillin for 1
day, then when sensitives returned was stated on linezolid for
VRE infection. Per ID, she is to have a 14 day course, which
will end on [**2144-9-22**]. She then had another urine culture showing
a UTI with E. coli and she was started on ceftriaxone. She is on
day 6 of this treatment. She will need treatment until [**2144-9-19**].
At which time, if the patient is clinically stable a repeat
urine culture should be checked. Of note, a UA was being
followed while on ICE therapy to monitor for hematuria, which
was negative.
DM: Patient is a type II diabetic and on SSI. While on TPN she
received insulin in her TPN. After her TPN was stopped she had
one episode of hypoglycemia with BG of 47, which was increased
to 147 after a [**2-12**] amp of dextrose. Her sliding scale has now
been changed to be less aggressive and she has no longer had
hypoglycemia.
She will be discharged to U [**Hospital **] Rehab Oncology unit for
continued care. In the past two days she has been having a
decrease in her Hct, was 22.3 yesterday and had 1 unit of RBCs,
was 21.6 today and received 2 units of rbcs. She had guaiac neg
stools today and yesterday. Was also given lasix 20mg extra with
her blood. Also had a potassium of 2.9 in AM, was given
repletion before transfer. Her retic count is pending and
haptoglobin was 320. She may need further transfusions. She was
started on G-CSF last night.
Medications on Admission:
calcium oyster 500mg [**Hospital1 **]
multivitamin
Celebrex 100mg [**Hospital1 **]
Iron 325mg [**Hospital1 **]
omeprazole 20mg daily
miralax 17g daily
toprol XL 125mg daily
verapamil 180mg q8H
Albuterol MDI neb PRN
Fleet enemal PRN
Maalox PRN
saline nasal spray PRN
chlorhexidine mouth wash
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for temperature >38.0: max dose 4g per day.
2. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 3 days: Continue for three days for UTI.
3. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 1 days: Give for
one more day for UTI with Ecoli.
4. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
[**Hospital1 **] (2 times a day): hold if SBP<100.
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. Filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H
(every 24 hours): Continue until absolute neurophil count is
>1000.
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
8. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): See flow sheet for scale.
9. Metoclopramide 5 mg/mL Solution Sig: Five (5) mg Injection
Q6H (every 6 hours) as needed for nausea/vomiting.
10. Simethicone 80 mg Tablet, Chewable Sig: 0.5 to 1 Tablet,
Chewable PO TID (3 times a day): for gas.
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold if SBP <100 or hr<60.
13. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): can also use vancomycin liquid same dose.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
16. Acyclovir Sodium 500 mg Recon Soln Sig: 400mg Recon Solns
Intravenous Q8H (every 8 hours).
17. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for Nausea.
19. IVF
Please give 75ml/hr [**2-12**] normal saline IVF
20. Outpatient Lab Work
Please check CBC and Chem 10 on [**2144-9-19**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
-Non-Sclerosing Hodgkins Disease
-Pericardial Effusion/Pleural Effusion - s/p Pericardial Window
-Mental Retardation
-Chronic Ileus
-C. difficile colitis
-Urinary tract infection with vancomycin resistant entercoccous
and E. coli
-Sacral Decubitus Ulcer
-Atrial fibrillation with rapid ventricular response
-Type II diabetes, insulin dependent
Discharge Condition:
Hemodynamically stable, afebrile, unable to ambulate
Discharge Instructions:
You were admitted to [**Hospital1 69**] to
treat your Hodgkin's Disease. You were given mulitple cycles of
chemotherapy for your cancer. You most recently had ICE
cheomotherapy and are on day 5 of treatment. Prior to that you
had 3 cycles of GND and one cycle of modified EACoPP. You had
complications from your cancer including having fluid in your
lungs and around your heart. You had to have the fluid revomed
from around your heart with a pericardial window. The fluid from
your lungs was removed with a thoracentisis. Also for your heart
you had an irregular rhythm for which you were started on
amiodarone.
You also had problems with your colon and at times required a
rectal tube. You also have an infection with C. Diff colitis,
which is was first treated with Flagyl and now you have to take
Vancomycin to treat the infection.
You have have bladder infections, for which you are on
antibiotics. You are taking Linezolid and Ceftriaxone.
You have skin sores that are being taken care of with wound care
that will continue after discharge.
You are weak from your long hospital stay and will require more
intensive physical therapy at rehab.
Followup Instructions:
Heme/onc follow up
Dr. [**First Name (STitle) **] Wed. [**2144-9-23**] at 11:30AM [**Telephone/Fax (1) 3237**], [**Hospital Ward Name 23**] Building
Completed by:[**2144-9-19**]
ICD9 Codes: 7907, 5990, 4589, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3928
} | Medical Text: Admission Date: [**2147-6-5**] Discharge Date: [**2147-6-11**]
Date of Birth: [**2097-5-15**] Sex: M
Service: GU
INDICATIONS: This is a 50-year-old male who was noted to
have gross painless hematuria and his workup demonstrated a
13-17 cm right renal mass extending into the right renal vein
and extending beyond the right renal vein and into the
infrahepatic inferior vena cava. His metastatic workup
revealed pulmonary and mediastinal metastases. In addition,
he was found to have bilateral pulmonary emboli. Because of
these findings, he was started on anticoagulation for a week
and was scheduled for an urgent radical nephrectomy and IVC
thrombectomy.
PHYSICAL EXAMINATION: Patient's pulse was 84; his blood
pressure was 163/77; his respirations was 16; and his O2
saturation of 95% on room air. His chest was clear to
auscultation bilaterally. His heart was regular rate and
rhythm. His abdomen was soft and nontender. There was a
palpable mass in the right upper quadrant with minimal
discomfort on deep palpation on the right upper quadrant. No
appreciable right-sided varicocele or intratesticular masses.
No hernias were noted.
PERTINENT X-RAYS, EKGS, AND OTHER TESTS: CT of the chest,
abdomen, and pelvis revealed a large right renal mass with
invasion of the right renal vein extension through carotid
fascia, extensive collateralization and deformation of the
right psoas muscle, persistent pulmonary emboli on the left
pulmonary artery, and sigmoid diverticulosis without
diverticulitis.
PROCEDURES PERFORMED: A right radical nephrectomy with IVC
thrombectomy.
[**Hospital 1749**] HOSPITAL COURSE: Patient was admitted to the urology
surgical service after which time he was taken to the
operating room. Dr. [**Last Name (STitle) 4229**] and Dr. [**Last Name (STitle) **] performed a right
radical nephrectomy with IVC thrombectomy. Although patient
did tolerate the procedure well, he had an estimated blood
loss of 7 liters. Patient, though, received 9 units of packed
red blood cells during the course of the operation. After the
operation was over, patient was taken directly to the
surgical intensive care unit where he remained intubated and
under close observation.
On the morning of postop day 1, patient received 2 more units
of packed red blood cells for postoperative anemia. His chest
tube was discontinued, and he was extubated both of which he
tolerated well.
On postop day #2, patient was transfused 2 more units of
packed red blood cells for, once again, a hematocrit of under
25. At this time, it was 23.6. Overall, however, he was doing
reasonably well, and he was monitored in the intensive care
unit for the remainder of that day.
On the morning of postop day #3, however, patient's O2
requirement had increased and he was saturating only 92% on a
4 liters of nasal cannula. At this time, we were concerned
that his known pulmonary embolus had worsened. We repeated a
CTA of the chest which revealed no worsening of the known
pulmonary embolus. He was also started on Lovenox at a dose
for treatment of known PE, but he remained stable with a
hematocrit of 25.1. The CTA did reveal, however, new
bilateral atelectasis in the bases and small bilateral
pleural effusions. For this reason, patient was started on an
aggressive diuresis using Lasix IV and on postop day #4, his
O2 was able to be weaned. We continued his diuresis, advanced
his p.o. intake to clears, and transferred him to the floor.
On postop day #5, patient's diet was advanced as tolerated.
He was continued to be ambulated. His Foley was discontinued,
and he was able to void. He was transitioned solely to p.o.
pain medication. Having accomplished all of these milestones,
on the evening of postop day #5, patient was discharged to
home with plans to followup with Dr. [**Last Name (STitle) 4229**] in the office.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Right renal mass, bilateral pulmonary
emboli, and metastatic right renal cancer, postoperative
anemia status post multiple transfusions.
DISCHARGE MEDICATIONS: Coumadin 2 mg p.o. daily,
hydromorphone 2 mg take [**1-3**] p.o. every [**2-4**] p.r.n., oxycodone
20 mg sustained release take 1 p.o. q.12.
FOLLOW-UP PLANS: Patient was instructed to followup with Dr.
[**Last Name (STitle) 4229**] in the office as well as with the pulmonary clinic.
[**Name6 (MD) **] [**Last Name (NamePattern4) 8918**], [**MD Number(1) 19072**]
Dictated By:[**Last Name (NamePattern1) 5032**]
MEDQUIST36
D: [**2147-6-13**] 21:12:23
T: [**2147-6-14**] 04:22:16
Job#: [**Job Number 19073**]
cc:[**Last Name (NamePattern4) 19074**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3929
} | Medical Text: Admission Date: [**2136-1-18**] Discharge Date: [**2136-2-8**]
Date of Birth: [**2136-1-18**] Sex: M
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 46325**] is a former 33
weeks and 5/7 days gestation male admitted to the Newborn
Intensive Care Unit for prematurity.
Mother with a past medical history notable for two deep venous
colitis treated with prednisone and Asacol.
PRENATAL SCREENS: O positive, antibody negative, hepatitis B
surface antigen negative, rapid plasma reagin nonreactive,
Rubella immune, group B strep unknown.
PREGNANCY HISTORY: Intrauterine insemination pregnancy with
gestational age of 33 weeks and 5/7 days pregnancy
complicated by placenta previa resolving at 28 weeks
gestation and by premature rupture of membranes 40 hours
prior to delivery; yielding clear amniotic fluid.
Intrapartum antibiotic prophylaxis started 36 hours prior to
delivery. No maternal fever or fetal tachycardia. Proceeded
to spontaneous vaginal vertex delivery under epidural
anesthesia.
NEONATAL COURSE: The infant cried on transfer to warm and
nasally bulb suction, dried, tactile stimulation provided. Free
flowing oxygen was administered in the first four minutes for
questionable central cyanosis; subsequently pink and in no
distress in room air. Apgar scores were 7 at one minute 8 at
five minutes. Transferred uneventfully to the Newborn
Intensive Care Unit.
PHYSICAL EXAMINATION ON PRESENTATION: Examination was
consistent with 33 weeks gestational age. Birth weight was
1825 g (50th percentile), head circumference was 29.5 cm
(25th percentile), length was 42 cm (25th percentile). Heart
rate was 145, respiratory rate was 58, temperature was 98.2,
blood pressure was 60/28, with a mean of 39. SaO2 was 100%
on room air. Head, eyes, ears, nose, and throat examination
revealed anterior fontanel, soft and flat, nondysmorphic,
palate intact. Neck and mouth was normal. No nasal flaring.
Chest revealed mild retractions, now resolving. Good
bilateral breath sounds. No crackles. Cardiovascular
examination revealed well perfused. A regular rate and
rhythm. Femoral pulses were normal. Normal first heart
sound and second heart sound. No murmurs. The abdomen was
soft and nondistended. No organomegaly. No masses. Active
bowel sounds. A 3-vessel cord. Anus was patent.
Genitourinary revealed prepuce slight retracted and edematous
with a question of mild chordae; this will be confirmed as
edema resolves. Testes were descended bilaterally. Central
nervous system revealed active, alert, and responsive to
stimuli. Tone revealed age appropriate. Moved all limbs
symmetrically with some contractures noted of arms and legs.
Gag, grasp, and Moro were normal. Skin was normal.
Musculoskeletal examination revealed normal spine, limbs,
hips, and clavicles.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: The baby remained in room air
without any respiratory distress. Respiratory baseline rate
was 30s to 40s. No apnea, bradycardia, or desaturations were
noted.
2. CARDIOVASCULAR SYSTEM: The patient initially had a soft
murmur. Baseline heart rate was 130s to 150s. Baseline
blood pressures were 70s/30s with means in the 50s. The baby
did not require any blood pressure support and has been
cardiovascularly stable. Murmur has resolved and was not
detected on the discharge exam.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The baby was
initially started on peripheral intravenous fluids of D-10-W
at 80 cc per kilogram. The baby had an initial dextrostick of
37 and required two dextrose boluses to achieve glucose values of
greater than 50. Subsequent values have been greater than
65 with no further issues.
Enteral feedings were introduced on day of life one. The
baby progressed to full enteral feedings 150 cc/kg per day of
breast milk 26. Currently he has been ad lib feeding at
the breast and being supplemented with expressed breast milk
supplemented with Enfamil powder to achieve 26 calories per
ounce. We recommend supplementing with 3 bottles of BM26/day
until weight gain improves and he approaches his birth percentile
in weight of 50%.
Discharge weight was 2105gms, discharge length
was 47 cm, and discharge head circumference was 33 cm.
The baby is receiving supplemental iron, Fer-In-[**Male First Name (un) **] 0.2 cc
p.o. q.d. (which is 2 mg/kg per day). The baby goes to
breast as well as takes three bottles per day with
supplemental calories. Current growth has been following the
10th percentile; warranting additional calories. Initial
electrolytes at 24 hours revealed sodium was 133, potassium
was 4.3, chloride was 97, bicarbonate was 23.
4. GASTROINTESTINAL/GENITOURINARY SYSTEM: The baby did exhibit
physiologic jaundice. Blood type is O positive. Coombs
negative. Peak bilirubin was on day of life three at
15.8/0.5; this responded to double phototherapy and
ultimately single phototherapy with a rebound bilirubin on
day of life nine of 6.9/0.36/0.6.
Because of the concern for a tightened foreskin and possible
hypospadias, Urology was consulted; Dr. [**Last Name (STitle) **] at the
[**Hospital3 1810**], who determined that this was not a
hypospadias; it is a shortened foreskin with plan to follow up
in six months. His telephone number is [**Telephone/Fax (1) 45268**]. The
baby is voiding and stooling without issue. The parents
will consider circumcision at that time.
5. HEMATOLOGIC ISSUES: As stated above, the baby's blood
type is O positive. Coombs negative. The baby did not
require any blood products during this admission. His
admission hematocrit on [**1-18**] was 55. Because of
maternal history of protein S deficiency, the recommendation
would be to follow up with Hematology in approximately six
months. We recommend Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46326**], [**Telephone/Fax (1) 46327**].
6. INFECTIOUS DISEASE ISSUES: Initially, the baby had a
sepsis evaluation with a white blood cell count of 23.5 (49
polys, 0 bands), a platelet count was 200,000, and hematocrit
was 55. A blood culture was sent. The baby was started on
48 hours of ampicillin and gentamicin. At 48 hours, cultures
were negative. The baby clinically well, and the antibiotics
were discontinued. He has had no further issues.
7. NEUROLOGIC ISSUES: The baby was appropriate for
gestational age. The baby did not have a head ultrasound
based on gestational age of greater than 32 weeks.
8. MUSCULOSKELETAL SYSTEM: The baby was noted to have
decreased extension of the elbows -45 degrees, in knees of
-40 degrees bilaterally. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38698**] from Occupational
Therapy has been working with him with gentle range of motion
and has achieved positive 10 degrees of motion. She can be
reached at the [**Hospital1 69**] by
calling the page operator at telephone number [**Telephone/Fax (1) 38834**],
beaper number [**Serial Number 46328**]. The plan would be to follow up with
early intervention after discharge to continue physical
therapy.
9. AUDIOLOGY ISSUES: A hearing screen was passed.
10. OPHTHALMOLOGIC ISSUES: Eye examination not indicated
based on gestational age of greater than 32 weeks.
11. PSYCHOSOCIAL ISSUES: The parents have been in visiting
frequently. They are pleased that [**Doctor First Name **] is transferring home
and have been appropriately anxious during this admission.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DISPOSITION: Discharge disposition was home with
family.
PRIMARY PEDIATRICIAN: Primary pediatrician is Dr. [**Last Name (STitle) 46329**]
with Bass River Pediatrics (telephone number [**Telephone/Fax (1) 46330**];
fax number [**0-0-**]).
CARE RECOMMENDATIONS:
1. Feedings: Breast milk 26 supplemented with Enfamil powder
three bottles per day plus ad lib breast feeding.
2. Medications: Fer-In-[**Male First Name (un) **] 0.2 cc p.o. q.d. (which equals 2
mg/kg per day).
3. Car seat position screening was passed prior to
discharge.
STATE NEWBORN SCREENING STATUS: State newborn screens were
sent on [**1-22**], [**2-2**], and at discharge, and in six
weeks will be due on [**2-29**].
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2-4**].
IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial
virus 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 day care during respiratory
syncytial virus season, with a smoker in the household, or
with preschool siblings; and/or (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 care givers should be considered for immunization
against influenza to protect the infant.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. A follow-up appointment with Dr. [**Last Name (STitle) 46329**].
2. A follow-up appointment with Dr. [**Last Name (STitle) **] (Urology) in six
months (telephone number [**Telephone/Fax (1) 45268**]).
3. A follow-up appointment with Hematology to be scheduled
via pediatrician/family in six months; Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46326**],
[**Telephone/Fax (1) 46327**].
4. Early intervention referral; [**First Name (Titles) 407**]
[**Hospital3 **] ([**Telephone/Fax (1) 46331**]).
DISCHARGE DIAGNOSES:
1. A former 33 weeks and 5/7 days premature male.
2. Status post rule out sepsis with antibiotics.
3. Status post physiologic jaundice.
4. Tightened foreskin.
DR [**First Name8 (NamePattern2) 39464**] [**Last Name (NamePattern1) **]
Dictated By:[**Last Name (NamePattern1) 38253**]
MEDQUIST36
D: [**2136-2-7**] 16:18
T: [**2136-2-7**] 16:59
JOB#: [**Job Number 46332**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3930
} | Medical Text: Admission Date: [**2168-5-31**] Discharge Date: [**2168-6-2**]
Date of Birth: [**2093-1-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
History is obtained from the medical records and also from the
patient's daughter due to language barrier.
.
Ms. [**Known lastname 10940**] is a 75-year-old Cantonese-speaking woman s/p
colonoscopy and polypectomy on [**2168-5-13**] showing diverticulosis &
internal hemorrhoids who presents with 4 hours of painless
BRBPR. Per her daughter, the patient was in her usual state of
health until yesterday evening around 9:30pm when she had a
bowel movement mixed with blood. She had 3 more bloody bowel
movements after that and called her daughter. [**Name (NI) **] daughter
brought her to the [**Name (NI) **] for further evaluation. No prior episodes
of bleeding per rectum. No fever, chills, dizziness,
lightheadedness, diarrhea, abdominal pain.
.
In the ED, initial vitals were 98.1 110 184/95 18 100%RA. She
proceeded to have 4 more bloody bowel movements whil in the ED.
Given 2L normal saline, type and cross sent. Hct 38.7--> 34.1.
in ED, initially hypertensive and tachy to 110. BP dropped at
one point to SBP of 85, pt felt lightheaded, diaphoretic, and
notes that her vision went to black briefly. Admitted to the
[**Hospital Unit Name 153**] for closer monitoring.
.
On the floor, she had one large bloody bowel movement about 2
hours after arrival with large blood clots. She has no
complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bladder
habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Diverticulosis
Internal hemorrhoids
HTN
Hyperlipidemia
Osteoporosis
Left hand tremor
Social History:
Originally from [**Country 651**], moved here in [**2119**]. Retired. Was a
nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 651**], has had many jobs in the US including
seamstress, assembly line at [**Company 2267**] (building
stents). Widowed, 5 children, lives alone. No history of
smoking, EtOH, or illicit drug use.
Family History:
Non-contributory.
Physical Exam:
(from admission)
Vitals: T: 97.5, BP: 160/72, P: 73, R: 16, O2: 100% 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, hyperactive bowel
sounds, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2168-5-31**] 11:20PM HCT-35.4*
[**2168-5-31**] 05:15PM HCT-36.6
[**2168-5-31**] 03:23AM HCT-34.1*
[**2168-5-31**] 07:51AM GLUCOSE-119* UREA N-11 CREAT-0.4 SODIUM-136
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-14
[**2168-5-31**] 07:51AM CALCIUM-7.6* PHOSPHATE-2.5* MAGNESIUM-2.0
[**2168-5-31**] 07:51AM WBC-9.4 RBC-3.35* HGB-10.4* HCT-31.6* MCV-94
MCH-31.2 MCHC-33.1 RDW-12.8
[**2168-5-31**] 03:23AM HCT-34.1*
[**2168-5-31**] 12:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2168-5-31**] 12:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2168-5-31**] 12:50AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2168-5-31**] 07:51AM PT-12.5 PTT-29.7 INR(PT)-1.1
Colonoscopy [**5-31**]:
Impression: Diverticulosis of the sigmoid colon
Polyp in the proximal ascending colon
Ulcer in the ascending colon (endoclip)
Otherwise normal colonoscopy to cecum and terminal ileum
Brief Hospital Course:
This is a 75 year-old Cantonese-speaking woman with
diverticulosis and internal hemorrhoids seen on recent
colonoscopy on [**2168-5-13**] who was admitted to the ICU on [**2168-5-31**]
because of 4 hours of painless BRBPR. The etiology was
initially thought to be secondary to diverticulosis, however, a
repeat colonoscopy revealed a bleeding ulcer at the polypectomy
site which was clipped (The patient had a polypectomy x 2 on
[**2168-5-13**]). On this colonoscopy, an additional polyp was noted in
the proximal ascending colon. She will need a follow-up
colonoscopy within 3 months with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] to remove the
ascending colon polyp. She was treated with 2 L IV saline bolus
and 2U PRBCs. She was somewhat hypertensive on admission,
however, HCTZ was held in the setting of GI bleed. During this
hospitalization, she had an abdominal CT for follow up of a
prominent submucosal lymphoid aggregate with mucosal
infiltration found on biopsy of on of the polyps on [**2168-5-13**]
for further characterization of possible lymphatic tumor. The
initial CT results showed normal bowels with no thickening or
abdominal lymphadenopathy. However, it did show an incidental
small pancreatic head lesion that may be followed by MRI/MRCP in
6 months. I communicated the above in details with her daughter
on several occasions. She showed her understanding of the above
issues. The patient did not require further transfusion and her
last bowel movement was yellow/brown (no melena). She denied any
signs or symptoms of GI malignancy including lymphoma. She had
no chronic abdominal pain, weight loss, chronic diarrhea or
malabsorption. However, she was asked to follow up with her PCP
and GI specialist (with referral to oncology) for further work
up, if needed.
Medications on Admission:
HCTZ 25 mg daily
Lipitor 10 mg daily
Fosamax+D 70 mg-2800U weekly
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Alendronate-Vitamin D3 70-2,800 mg-unit Tablet Sig: One (1)
Tablet PO once a week.
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleeding
Discharge Condition:
Excellent
Discharge Instructions:
You had bleeding after your colonoscopy. Your bleeding had
stopped as you had a normal bowel movement on the day of your
discharge. Please monitor your self for recurrent bleeding (dark
stools, fresh blood from the rectum, lightheadedness, dizziness,
weekness, etc). You had a CT of your abdomen because one of the
resected polyps had increased Lymphoctes. The final results of
the CT are pending at the time of your discharge but the bowels
looked fine. You had no findings concerning of lymphoma on this
study. We found a small pancreatic head lesion that may be
followed by MRI/MRCP in 6 months. Please follow up with your PCP
and your GI specialist early next week regarding the results of
the CT. You will need a follow-up colonoscopy within 3 months
with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] to remove the ascending colon polyp seen on
this last colonoscopy.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10492**]
You will need a follow-up colonoscopy within 3 months with Dr.
[**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] to remove the ascending colon polyp
ICD9 Codes: 2851, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3931
} | Medical Text: Admission Date: [**2184-6-5**] Discharge Date: [**2184-7-8**]
Date of Birth: [**2184-6-5**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**Known lastname 42642**] [**Known lastname 1683**] delivered at 32-0/7 weeks
gestation, weighing 1535 grams and was admitted to the
Neonatal Intensive Care Unit for management of prematurity.
Mother is a 27 year old Gravida 1, Para 0, now 1, woman with
estimated date of delivery of [**2184-7-31**].
PRENATAL LABORATORY STUDIES: Her prenatal screens included
blood type O positive, antibody screen negative, RPR
nonreactive, Hepatitis B surface antigen negative, rubella
immune and Group B strep unknown.
The pregnancy was complicated by early cervical funneling
with a cerclage placed on [**2184-3-10**], around 19 weeks
Center at 24-4/7 weeks gestation for progressive cervical
changes and was managed with bed rest and serial monitoring.
She received betamethasone on [**4-9**] and [**4-10**]. Membranes
ruptured prematurely on [**2184-5-24**], and the cerclage was
removed at that time. On [**2184-6-4**], under monitoring, was
noted to have fetal decelerations and concerns for maternal
chorioamnionitis. Labor was induced with spontaneous vaginal
delivery.
The infant had a good cry and respiratory effort at birth
with early respiratory distress treated with mask C-PAP.
Apgar scores were 8 and 8 at one and five minutes
respectively.
PHYSICAL EXAMINATION: On admission, in general, a pink
premature infant. Skin without rashes or lesions. Head and
Neck: Anterior fontanel open, flat and soft. Eyes: Normal
placement. Red reflex occurred. Ears, Nose and Throat:
Palate intact. Thorax with grunting, flaring and retracting.
Lungs with poor aeration. Heart: Regular rate and rhythm
without murmur; normal pulses. Abdomen soft, no
hepatosplenomegaly, no masses. Genitalia: Consistent with
gestational age. Anus patent. Trunk and spine: Straight
without dimple. Extremities: Five fingers, five toes
bilaterally. Hips stable. Reflexes appropriate for
gestational age.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: Was placed on continuous positive airway
pressure of 6 cm of water, 30% oxygen on admission for
respiratory distress that resolved by 18 hours of age. Has
been in room air since that time without any respiratory
distress. Respiratory rate ranges in the 30s to 50s with
comfortable work of breathing. Was treated with caffeine
citrate for apnea of prematurity. Caffeine citrate was
discontinued on [**2184-6-17**]. The last apnea of bradycardia
episode was on [**2184-6-16**].
2. Cardiovascular: Has remained hemodynamically stable
throughout hospitalization with normal blood pressures. A
soft flow murmur was heard around ten days of life that
resolved after she was transfused for a low hematocrit.
3. Fluids, Electrolytes and Nutrition: Initially was NPO
and maintained on intravenous fluids of D10W. Enteral feeds
were started on day of life one and reached full volume feeds
with premature Enfamil, 20 calories per ounce, on day of life
six without problems. The caloric density was increased
gradually to a maximum of 30 calories per ounce of ProMod.
The caloric density was decreased to 26 calories per ounce on
[**2184-7-6**], in preparation for discharge home. At discharge,
the infant is on Enfamil 25 calorie per ounce with corn oil 2
calories per ounce added to equal a total of 26 calories per
ounce. She has taken these feeds ad lib demand. Discharge
weight 2405 grams, length 46.5 cm; head circumference 31 cm.
4. Gastrointestinal: Was treated for indirect
hyperbilirubinemia with phototherapy. Peak bilirubin total
10, direct 0.3.
5. Hematology: The baby's blood type is O positive, direct
Coombs' was negative. The baby received one packed red blood
cell transfusion during hospitalization on [**2184-6-23**], for a
hematocrit of 18.7, hemoglobin 6.2. The most recent
hematocrit on [**2184-7-2**] was 37.9% with a reticulocyte count
of 3.6%.
6. Infectious Disease: Delivered due to concerns for
maternal chorioamnionitis. The infant's initial white blood
cell count was 30.6 with 43 polys and 18 bands. The blood
culture was negative. The spinal fluid showed a red blood
cell count of 3,050 and a white blood cell count of 1,050,
with 97% polys and 3% lymphs.
A follow-up lumbar puncture was done showing red blood cell
count of 125,000 with 167 white blood cells with 80% polys,
2% bands. The infant was treated for 21 days with Ampicillin
and Gentamicin for presumed meningitis. A vesicle was noted
on the baby's abdomen on day of life three and was cultured
for herpes simplex virus and treated with Acyclovir for six
days until the cultures came back negative.
7. Neurology: The initial head ultrasound on day of life
five showed a left intraventricular hemorrhage with mild to
moderate ventriculomegaly. The head ultrasounds were
followed and the most recent head ultrasound was on
[**2184-7-6**], that showed minimal residual dilation of the left
lateral ventricle with complete resolution of the
intraventricular clot; no periventricular leukomalacia.
8. Sensory: Hearing Screening was performed with automated
auditory brain stem responses. The infant passed both ears.
9. Ophthalmology: Eyes were examined most recently on
[**2184-6-23**], revealing mature retinal vessels. A follow-up
examination is recommended at eight months of age.
CONDITION AT DISCHARGE: Stable, growing premature baby, now
33 days old, 36-5/7 post-conceptual age.
DISCHARGE DISPOSITION: Discharged home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37243**], telephone
number [**Telephone/Fax (1) 42643**].
CARE RECOMMENDATIONS:
1. Feeds: Enfamil 24 calories per ounce with corn oil, 2
calories per ounce added to equal a total of 26 calories per
ounce ad lib. Monitor growth and wean calories as indicated.
2. Medications: Fer-In-[**Male First Name (un) **] 0.2 cc p.o. q. day.
3. Car Seat Position Screening pending.
4. State newborn screening status: Normal newborn screen.
5. Received Hepatitis B immunization on [**2184-6-29**].
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 plans for day care during RSV season, with
a smoker in the household or with preschool siblings or, 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 INSTRUCTIONS:
1. Follow-up appointment scheduled with pediatrician on
Monday, [**2184-7-12**].
2. Follow-up head ultrasound is recommended in two to three
weeks to be scheduled by pediatrician.
3. An early intervention [**Year (4 digits) 28085**] was made to First Early
Intervention Program, telephone number [**Telephone/Fax (1) 42644**].
4. [**First Name (Titles) 407**] [**Last Name (Titles) 28085**] was made to [**Hospital1 **]
[**Hospital6 407**]. They will come to the home on
Friday, [**2184-7-9**], telephone [**Telephone/Fax (1) 38388**].
5. Ophthalmology examination is recommended at eight months
of age.
DISCHARGE DIAGNOSES:
1. A 32 week appropriate for gestational age preterm female.
2. Transitional respiratory distress, resolved.
3. Suspected sepsis meningitis, resolved.
4. Anemia of prematurity.
5. Apnea of prematurity, resolved.
6. Indirect hyperbilirubinemia, resolved.
7. Heart murmur, resolved.
8. Interventricular hemorrhage on the left with
ventriculomegaly, resolving.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 37803**]
MEDQUIST36
D: [**2184-7-7**] 16:08
T: [**2184-7-7**] 16:40
JOB#: [**Job Number 42645**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3932
} | Medical Text: Admission Date: [**2100-8-28**] Discharge Date: [**2100-9-2**]
Date of Birth: [**2069-3-10**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 83186**]
Chief Complaint:
Pregnancy
Post-partum hemorrhage
Blood loss anemia
Major Surgical or Invasive Procedure:
Dilation and curettage
Supracervical Hysterectomy
Arterial line placement
Mechanical intubation
Blood Transfusion
History of Present Illness:
This is a 31 year old female presenting at 39 weeks gestation
admitted for induction secondary to worsening gestational
hypertension. She was induced with cytotec x 2 and given an
epidural. She was noted to have fetal bradycardia and was taken
for an urgent c-section. She had an uncomplicated c-section
until about 1 hour following her c-section she was noted to be
passing large clots. She was given cytotec, but continued to
have bleeding and was then taken to the OR. In the OR she was
given hemabate, methergine. pitocin, and cytotec. Her uterus was
noted to be atonic and D&C was performed, but due to persistent
atonic uterus, laparotomy and subsequent supracervical
hysterectomy performed. Laparotomy revealed a hemoperitoneum and
boggy, enlarged, atonic uterus. Her operative course was notable
for IVF 4200, EBL 4 L with urine output 500 with 5 units pRBC, 4
units of FFP, 1 bag of platelet as well as 500 albumin. She
required brief neosynephrine for SBP 60s, then was weaned off
with subsequent elevated SBP to 150s-170s. She was also
reportedly given vercuronium during the procedure.
.
She arrived to the [**Hospital Unit Name 153**] intubated and sedated on propofol. She
had her 5th unit of pRBC hanging at time of transfer.
Past Medical History:
Panic disorder with agoraphobia
Migraine headaches
Social History:
Married, works doing fund raising. Denies tob/EtOH, illicit
substances
Family History:
Non-contributory.
Physical Exam:
Upon admission to the [**Hospital Unit Name 153**]:
VITALS T: 96.2 BP: 149/84 P: 116 R: 18
VENT CMV Fi O2 40%, TV 500, RR 15, PEEP 5
GENERAL Intubated/sedated, pale
LUNGS Clear to auscultation anteriorly
HEART RRR, no m/r/g
ABDOMEN Soft, dressing c/d/i
GU Foley in place, yellow urine in tubing, minimal VB on
[**Male First Name (un) **]
LOW EXT No edema bilaterally
Pertinent Results:
Labs:
Hct preop 32.9 -> 30.7, 30.5 -> 20 -> 25 -> 23 -> 26
Fibrinogen 421 -> 153 -> 220
INR ~1.0
Brief Hospital Course:
31 y/o with gestational hypertension, admitted to L+D for
induction of labor. She was given Cytotec, and progressed
adequately and started on Pitocin. Notably, she had several
elevated BPs during her labor course, to 171/101. During her
labor course, FHT revealed variable decelerations with late
components, followed by a fetal bradycardia for 3 minutes. She
was taken for stat cesarean section, which was complicated by
atonic uterus. A D+C was done, as well as an attempt to place
B-[**Doctor Last Name **] sutures, and ultimately hysterectomy was performed - see
operative notes. The patient was admitted to the [**Hospital Unit Name 153**] initially,
and once extubated and stable, returned to the post-partum
floor. Issues during hospitalization were as follows:
.
1. Vaginal bleeding: Felt to be secondary to atonic uterus.
Perioperative labs were notable for new coagulopathy and
decreasing fibrinogen, concerning for DIC. Estimated intra-op
blood loss was 4 L. Received 7 units pRBC, 4 units of FFP and 1
bag platelets. On POD #1, she was hemodynamically stable, with
elevated blood pressures off neosynephrine, extubated to room
air, normal coags, platelets increased to 90s, and stable HCT
around 23. Pt was called out to OB service and transferred to
the postpartum floor. She remained hemodynamically stable on the
floor through discharge.
.
2. Intubation: Given vecuronium during procedure, felt to last
another ~ 2 hours so patient was intubated overnight in the [**Hospital Unit Name 153**]
but then extubated without any complications in the morning. She
was breathing comfortably on room air upon transfer and
continued to have no issues related to this during her
post-operative recovery.
.
3. Metabolic acidosis: With elevated lactate, full chem panel
not available but likely with elevated AG. Also likely a
component of non-gap acidosis in setting of volume
resuscitation. Upon transfer, gap had closed, and lactate was
down to 1.8. She remained stable in this regard.
.
4. Elevated blood pressures: thought to be a due to her
gestational hypertension. She was started on Labetalol 300 [**Hospital1 **]
on [**8-31**] for systolic BP of 160, and discharged on this
medication. PIH labs remained unremarkable.
Medications on Admission:
PNV
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
Disp:*50 Capsule(s)* Refills:*0*
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H PRN () as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
5. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Post-partum hemorrhage
Anemia
Gestational Hypertension
Uterine Atony
Discharge Condition:
Stable
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] if fever > 100.4, vaginal bleeding, abdominal
pain, leg pain, chest pain. shortness of breath or other
concerning signs.
Call if sadness or feelings of depression.
You may take Percocet for pain
You may take Motrin for pain
You may take Tylenol for pain only if you are not taking
Percocet. Do not take Tylenol and Percocet together.
Followup Instructions:
Call Dr. [**Last Name (STitle) **] to see her in [**1-29**] weeks
Completed by:[**2100-9-24**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3933
} | Medical Text: Admission Date: [**2116-3-22**] Discharge Date: [**2116-4-7**]
Date of Birth: [**2064-12-5**] Sex: F
Service: PLASTIC
Allergies:
environmental
Attending:[**First Name3 (LF) 36263**]
Chief Complaint:
MVC
Major Surgical or Invasive Procedure:
[**2116-3-22**] EUA R knee, Closed treatment of Right tibial plateau fx
with manipulation, Closed Treamtment of Right Proximal Fibula
Fracture with manipulation, EUA Left Knee, Irrigation and
Debridment of Traumatic Wound Left Knee (Skin, soft tissue and
Muscle), Complex Wound Closure Left Knee, Application of
Negative pressure dressing Left Knee(100 cm^2), Closed Reduction
Left Metatarsal Fractures (x3) with manipulation. [**Doctor Last Name **]
[**2116-3-24**] I&D of Left Leg and Vac Dressing Change Left Leg
[**Location (un) **]
[**2116-3-26**] 1. I AND D LEFT LEG. APPLICATION OF WOUND VAC SPONGE
[**2116-3-31**] 1. Gastrocnemius flap reconstruction.
2. Split-thickness skin graft (20 x 40 sq cm).
History of Present Illness:
52 F s/p MVC w/ SDH, b/l rib fx's, pulmonary contusions, and b/l
lower extremity fractures and an associated degloving injury of
the LLE.
Past Medical History:
PMH: DMII, HTN, HLD, OSA
.
PSH: c section
Social History:
Married with adult children and grandchildren.
Family History:
NC
Physical Exam:
A&O x 3, but sleepy
Calm and comfortable
Left lower extremity with large almost complete circumferential
soft tissue defect over the anterior/lateral aspect of her left
knee. Knee unstable on exam. Unable to assess infiltration of
joint give large pieces of glass within wound. Dopplerable DP/PT
pulses. [**Month/Day/Year 2189**] Saph Sural DPN SPN MPN LPN. [**Last Name (un) 938**] FHL GS TA PP Fire
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U [**Last Name (un) 2189**]
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
BLE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN [**First Name9 (NamePattern2) 2189**]
[**Last Name (un) 938**] FHL GS TA PP Fire
1+ PT and DP pulses
Pertinent Results:
[**2116-3-22**] 06:15AM BLOOD WBC-20.6* RBC-2.78* Hgb-7.9* Hct-25.0*
MCV-90 MCH-28.2 MCHC-31.4 RDW-13.0 Plt Ct-298
[**2116-3-23**] 02:11AM BLOOD WBC-10.7 RBC-2.51* Hgb-7.3* Hct-22.7*
MCV-91 MCH-29.0 MCHC-32.0 RDW-14.5 Plt Ct-230
[**2116-3-24**] 01:38AM BLOOD WBC-13.2* RBC-3.14*# Hgb-9.1* Hct-27.7*
MCV-88 MCH-28.8 MCHC-32.7 RDW-15.2 Plt Ct-190
[**2116-3-25**] 01:55AM BLOOD WBC-12.9* RBC-2.39* Hgb-6.8*# Hct-20.5*#
MCV-86 MCH-28.5 MCHC-33.2 RDW-15.0 Plt Ct-203
[**2116-3-25**] 09:04AM BLOOD Hgb-9.6*# Hct-29.0*#
[**2116-3-25**] 01:55AM BLOOD PT-14.2* PTT-24.3* INR(PT)-1.3*
CT head [**3-22**]: Hyperdense material layering along the left
frontoparietal
temporal region measuring 5 mm from the inner table of the skull
represents acute subdural hematoma with mild mass effect.
CT head [**3-22**] PM: No significant change from the study performed
at 6:42 a.m.(under a different MRN).
LLE ankle film - There is a comminuted fracture of the distal
fibula with some apparent angulation of the tibiotalar
articulation on both frontal and lateral views. There is a large
inferior calcaneal spur. There are also fractures of the fourth
and fifth metatarsals as well as an intra-articular fracture of
the base of the first metatarsal and probably a
corner fracture of the distal medial aspect of the cuboid. No
definite fracture of the talus is appreciated. However, CT would
be necessary to unequivocally exclude a fracture of this bone.
CTA Chest [**3-24**] - 1. No evidence of central pulmonary embolism.
2. Moderate [**Hospital1 **]-basal atelectasis.
3. Multifocal, small ground-glass opacities in both upper and
middle lobe
could be infectious or fat emboli. These opacities are beyond
the resolution of the chest radiograph. 4. Undisplaced fracture
at posterior right fifth rib.
.
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2116-3-28**]
1:13 PM
IMPRESSION: Somewhat limited study due to patient habitus with
no evidence of DVT in both lower extremities.
.
Radiology Report ANKLE (2 VIEWS) LEFT PORT Study Date of
[**2116-4-1**] 4:33 AM
FINDINGS: A posterior plaster splint obscures the bony detail.
Tubing
overlies the distal tibia and fibula. Skin staples are seen
within the
lower leg soft tissues. No dislocation identified. There is
syndesmotic widening and medial clear space widening. The
lateral malleolus fracture is not as well seen. The medial talar
fracture is not as well seen. Again seen is the fourth and fifth
metatarsal fracture.
IMPRESSION: Ankle and foot fractures as above. If further
evaluation is
needed, recommend CT when patient is able.
.
MICROBIOLOGY
[**2116-3-29**] 12:14 pm URINE Source: Catheter.
**FINAL REPORT [**2116-4-2**]**
URINE CULTURE (Final [**2116-4-2**]):
MORGANELLA MORGANII. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
MORGANELLA MORGANII
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R <=16 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S
Brief Hospital Course:
52 F s/p MVC with the following injuries:
- degloving injury of LLE
- Non-displaced fx of the distal left tibia
- Comminuted fracture of the left talus
- Multiple left foot fractures
- Right tibial plateu fx
- Right proximal fibula fx
- Rib fx: Rt 6th rib fx; Lt 4, 5, & 10fx
- fronto-parietal SDH 5mm, 3mm rightward shift.
In the emergency room she had significant blood loss from her
left lower extremity degloving injury. She became hypotensive
and tachycardic in the ED and recieved 2 U PRBC and 4 liters of
LR. A central venous line was placed and she was transferred to
the TICU for further care. The following are the major events in
the ICU by systems:
Neuro: For her SDH the pt was taken to the TICU for Q1H neuro
checks. A follow up HCT on HD 1 showed a stable HCT. She was
started on keppra, which was continued for 10 days total. On the
evening of HD 1 the pt developed a facial droop and was again
taken for a repeat HCT which showed no significant increase in
hemorrhage. Along with the facial droop the patient also became
altered. By HD 2 her facial droop had resolved but she remained
altered until HD 4 when her pain medications were titrated and
her pain better controlled.
CV: The patient was persistently tachycardic through HD 4. She
was transfussed 2 U PRBC on HD 1, 1 U PRBC HD 2, and 2 UPRBC on
HD 4. She was also resuscitated with LR. She continued to lose a
significant amount daily from her degloving injury even after it
was vac'ed. An Echo was obtained on HD 3 which showed an EF of
55%. She was started on lopressor for her tachycardia on HD 3
and she was continued to be resuscitated apropriately. Her
tachycardia resolved by the time of transfer to the floor.
Pulm: For her rib fractures and pulmonary contusions the pt was
placed on pulmonary toilet and her pain was controlled.
GI: The patient was kept NPO after her first washout because of
her AMS, as this improved her diet was advanced to a diabetic
diet. She was administered famotidine for stress ulcer ppx until
she was transferred to the floor.
Endocrine: The patient was maintained on Glargine 25 units at HS
and a regular insulin sliding scale.
GU: A foley was placed in the ED and UOP monitored hourly in the
TICU. She made appropriate urine while in the TICU. Foley was
maintained while patient on strict bedrest immediately post flap
and skin grafts and then discontinued on [**2116-4-6**].
Heme: The pt lost a significant amount of blood from the LLE.
She was trasfused multiple times in the TICU and appropriately
resuscitated. SQH was started on HD 3. Given her change in MS [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]A of her chest was obtained to assess for PE which was
negative.
ID: the patient was kept on Ancef through HD 4 at which point
all antibiotics were discontinued. Patient was maintained on
keflex post-operatively from her flap/skin graft. Patient was
treated with ciprofloxacin x 5 days for a UTI.
Extrem: Her multiple LE fractures were followed by orthopedic
surgery. She was taken to the OR on [**3-22**] and [**3-24**] and [**3-26**] for
washout, debridement, and vac placement of her LLE degloving
injury. The wound was the evaluated by the plastic surgery team
who took patient to the OR on [**2116-3-31**] for a Gastrocnemius flap
reconstruction and skin graft to left lower extremity defect.
Patient had VAC dressing in place over skin graft site until
[**2116-4-6**] when it was removed to reveal viable skin graft to left
lower extremity defect.
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. cephalexin 500 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 7 days.
4. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous QPM (once a day (in the evening)).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed for sob/wheeze.
6. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours).
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime.
14. regular insulin sliding scale
sliding scale QACHS
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
Non-displaced fracture of distal left tibia
Comminuted fracture of left talus
Right tibial plateau fracture
Right proximal fibula fracture
Rib fractures: Right 6th; Left 4, 5, & 10
Fronto-parietal subdural hemorrhage 5mm w/ 3mm shift
Bilateral pulmonary contusions
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
ICD9 Codes: 2851, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3934
} | Medical Text: Admission Date: [**2107-7-20**] Discharge Date: [**2107-8-11**]
Date of Birth: [**2036-4-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Transferred for evaluation of left piriform sinus mass
Major Surgical or Invasive Procedure:
Chest Tubes
Surgical Biopsy
Gastric Tube
Tracheostomy
Thoracentesis
History of Present Illness:
71M with multiple medical problems including a 59 pack year
smoking history, 45 year alcoholic hx and CABG, recently
discharged from [**Hospital3 **] for pneumothorax s/p chest tube
placement, now transferred from the same hospital for work-up
for a left piriform sinus mass, after presenting with difficulty
swallowing. Patient reports gradual dysphagia for 5 months,
first to solids, later to liquids. Immediately prior to
presentation to [**Hospital3 **], he was regurgitating baby food
(all he could tolerate) through his nasal passages. Subsequent
to this dysphagia, the patient experienced a 45 pound weight
loss over the past 5 months. He denied hematemesis, chest pain,
sob, palpitations, abd pain, hematuria or dysuria. CT of the
neck at [**Hospital3 **] showed a 3.6 cm mass in the L piriform
sinus. An EGD was unable to be completed due to severe
esophageal stricture. A modified barium study showed achalasia
and severe esophageal narrowing. The patient's course there was
additionally complicated by hypertension requiring IV meds,
given his intolerance for PO. The patient was transferred to
[**Hospital1 18**] for further work-up of this mass.
Past Medical History:
Diabetes
Hypertension
Coronary Artery Disease, s/p CABG x 5
Permanent Pacemaker for ?sick sinus/tachy brady
Peripheral Vascular Disease (AAA s/p repair)
COPD
Spontaneous Pneumothorax s/p chest tube
Colon Cancer s/p resection in approximately [**2102**]
Social History:
Patient is not married. He does not have any children. He
reports he has been an alcoholic for the past 45 years. He now
drinks 2 glasses of wine per day. He has a 59 pack year smoking
history.
Family History:
NC
Physical Exam:
VS T98.3 BP 180/84 HR 76 R18 O2sat 92%RA
GEN Cachetic male in NAD, able to speak in full sentences
HEENT extremely poor dentition, few teeth in mouth, blackened
tongue; hardened immobile mass measuring about 2 inches can be
appreciated along the R lateral neck ( may be displacement of
anatomy)
HEART nl rate, S1S2, no gmr; due to emaciated status heart can
appreciate every heart
LUNGS CTA b/l no RRW
ABD sunken, concave, surgical scar, otherwise benign
EXT no cce
Pertinent Results:
[**2107-7-21**] 06:15AM BLOOD Digoxin-0.7*
[**2107-7-21**] 06:15AM BLOOD Triglyc-72
[**2107-7-22**] 06:15AM BLOOD %HbA1c-5.7
[**2107-7-25**] 05:09AM BLOOD calTIBC-189* Hapto-155 Ferritn-300
TRF-145*
[**2107-7-29**] 06:33AM BLOOD Hapto-163
[**2107-7-21**] 06:15AM BLOOD Albumin-3.7 Calcium-9.4 Phos-2.8 Mg-1.4*
[**2107-7-22**] 12:40AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2
[**2107-7-22**] 06:15AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
[**2107-7-23**] 09:07AM BLOOD Calcium-9.4 Phos-2.5* Mg-2.5
[**2107-7-24**] 05:28AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0
[**2107-7-25**] 05:09AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9 Iron-23*
[**2107-7-26**] 05:34AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.3
[**2107-7-27**] 04:31AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.2
[**2107-7-28**] 05:59AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.0
[**2107-7-29**] 06:33AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9
[**2107-7-29**] 03:13PM BLOOD Calcium-PND Phos-PND Mg-PND
[**2107-7-21**] 06:15AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2107-7-21**] 03:40PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2107-7-22**] 12:40AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2107-7-21**] 06:15AM BLOOD CK(CPK)-58
[**2107-7-21**] 03:40PM BLOOD CK(CPK)-55
[**2107-7-22**] 12:40AM BLOOD CK(CPK)-86
[**2107-7-25**] 05:09AM BLOOD TotBili-0.4
[**2107-7-29**] 06:33AM BLOOD TotBili-0.5
[**2107-7-21**] 06:15AM BLOOD estGFR-Using this
[**2107-7-29**] 06:33AM BLOOD estGFR-Using this
[**2107-7-21**] 06:15AM BLOOD Glucose-129* UreaN-6 Creat-1.0 Na-139
K-2.9* Cl-101 HCO3-26 AnGap-15
[**2107-7-22**] 12:40AM BLOOD Glucose-158* UreaN-16 Creat-1.0 Na-141
K-3.9 Cl-104 HCO3-24 AnGap-17
[**2107-7-22**] 06:15AM BLOOD Glucose-146* UreaN-17 Creat-1.0 Na-141
K-3.8 Cl-105 HCO3-26 AnGap-14
[**2107-7-23**] 09:07AM BLOOD Glucose-153* UreaN-27* Creat-1.0 Na-144
K-3.6 Cl-109* HCO3-29 AnGap-10
[**2107-7-24**] 05:28AM BLOOD Glucose-195* UreaN-21* Creat-0.9 Na-141
K-3.6 Cl-106 HCO3-29 AnGap-10
[**2107-7-25**] 05:09AM BLOOD Glucose-224* UreaN-16 Creat-0.7 Na-142
K-3.5 Cl-107 HCO3-28 AnGap-11
[**2107-7-26**] 05:34AM BLOOD Glucose-193* UreaN-16 Creat-0.8 Na-141
K-4.0 Cl-109* HCO3-28 AnGap-8
[**2107-7-27**] 04:31AM BLOOD Glucose-121* UreaN-16 Creat-0.8 Na-142
K-4.0 Cl-109* HCO3-30 AnGap-7*
[**2107-7-28**] 05:59AM BLOOD Glucose-161* UreaN-15 Creat-0.8 Na-139
K-4.0 Cl-106 HCO3-30 AnGap-7*
[**2107-7-29**] 06:33AM BLOOD Glucose-160* UreaN-13 Creat-0.8 Na-137
K-4.3 Cl-104 HCO3-30 AnGap-7*
[**2107-7-29**] 03:13PM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
[**2107-7-25**] 05:09AM BLOOD Ret Aut-0.8*
[**2107-7-29**] 06:33AM BLOOD Ret Aut-1.2
[**2107-7-21**] 06:15AM BLOOD Plt Ct-209
[**2107-7-22**] 06:15AM BLOOD Plt Ct-233
[**2107-7-23**] 09:07AM BLOOD Plt Ct-175
[**2107-7-23**] 09:35PM BLOOD PT-11.5 PTT-47.5* INR(PT)-1.0
[**2107-7-24**] 05:28AM BLOOD Plt Ct-151
[**2107-7-25**] 05:09AM BLOOD PT-11.8 PTT-29.8 INR(PT)-1.0
[**2107-7-25**] 05:09AM BLOOD Plt Ct-136*
[**2107-7-26**] 05:34AM BLOOD Plt Ct-136*
[**2107-7-27**] 04:31AM BLOOD Plt Ct-158
[**2107-7-28**] 05:59AM BLOOD PT-11.6 PTT-27.8 INR(PT)-1.0
[**2107-7-28**] 05:59AM BLOOD Plt Ct-153
[**2107-7-29**] 06:33AM BLOOD Plt Ct-135*
[**2107-7-29**] 03:13PM BLOOD Plt Ct-PND
[**2107-7-21**] 06:15AM BLOOD WBC-7.2 RBC-3.90* Hgb-11.7* Hct-34.0*
MCV-87 MCH-29.9 MCHC-34.4 RDW-15.8* Plt Ct-209
[**2107-7-22**] 06:15AM BLOOD WBC-12.8*# RBC-3.62* Hgb-10.7* Hct-31.2*
MCV-86 MCH-29.6 MCHC-34.4 RDW-15.9* Plt Ct-233
[**2107-7-23**] 09:07AM BLOOD WBC-9.3 RBC-3.06* Hgb-9.2* Hct-26.7*
MCV-87 MCH-30.1 MCHC-34.5 RDW-16.1* Plt Ct-175
[**2107-7-23**] 12:00PM BLOOD Hct-30.6*
[**2107-7-23**] 09:35PM BLOOD Hct-28.0*
[**2107-7-24**] 05:28AM BLOOD WBC-7.6 RBC-3.12* Hgb-9.3* Hct-27.6*
MCV-89 MCH-29.7 MCHC-33.6 RDW-15.8* Plt Ct-151
[**2107-7-24**] 11:39AM BLOOD Hct-28.8*
[**2107-7-24**] 11:03PM BLOOD Hct-28.0*
[**2107-7-25**] 05:09AM BLOOD WBC-6.2 RBC-3.02* Hgb-9.0* Hct-26.8*
MCV-89 MCH-29.7 MCHC-33.4 RDW-15.7* Plt Ct-136*
[**2107-7-25**] 04:47PM BLOOD Hct-28.5*
[**2107-7-26**] 05:34AM BLOOD WBC-6.0 RBC-2.64* Hgb-7.7* Hct-23.3*
MCV-88 MCH-29.2 MCHC-33.1 RDW-15.8* Plt Ct-136*
[**2107-7-26**] 09:37AM BLOOD Hct-22.0*
[**2107-7-27**] 12:13AM BLOOD Hct-25.7*
[**2107-7-27**] 04:31AM BLOOD WBC-7.5 RBC-2.82* Hgb-8.4* Hct-25.7*
MCV-91 MCH-29.9 MCHC-32.9 RDW-16.1* Plt Ct-158
[**2107-7-28**] 05:59AM BLOOD WBC-7.6 RBC-2.89* Hgb-9.1* Hct-25.6*
MCV-89 MCH-31.4 MCHC-35.4* RDW-15.8* Plt Ct-153
[**2107-7-28**] 12:54PM BLOOD Hct-27.4*
[**2107-7-29**] 06:33AM BLOOD WBC-5.7 RBC-2.68* Hgb-8.2* Hct-23.7*
MCV-88 MCH-30.5 MCHC-34.6 RDW-16.0* Plt Ct-135*
[**2107-7-29**] 03:13PM BLOOD WBC-PND RBC-PND Hgb-PND Hct-PND MCV-PND
MCH-PND MCHC-PND Plt Ct-PND
.
CXR ([**7-21**]): Single chest AP performed to evaluate pneumothorax,
the heart and mediastinum are midline. A pacer pack is noted in
the left infraclavicular area. The left lung is expanded. There
is the large pneumothorax on the right with total collapse of
the right lower lobe, partial collapse of the left middle lobe
and the right upper lobe. There has not been a significant shift
in the mediastinum however. There are no previous films for
comparison.
.
CXR ([**7-23**]): Two views. Comparison with the previous study done
[**2107-7-22**]. A second chest tube has been inserted on the right. The
second chest tube terminates medially near the right lung apex.
A right pneumothorax is no longer apparent. There is interval
increase in subcutaneous emphysema on that side. The lungs
appear clear. There is interval decrease in a small right
effusion. The heart and mediastinal structures are unchanged. A
bipolar transvenous pacemaker remains in place. A PICC line has
been pulled back and now terminates at the level of the superior
vena cava.
IMPRESSION: Right pneumothorax no longer apparent post placement
of a second right chest tube. PICC line has been pulled back.
.
CXR ([**7-29**]): CHEST, PA AND LATERAL: Comparison is made to the
prior day. Patient is status post CABG. A right-sided PICC line
and dual lead pacemaker are unchanged. Cardiac and mediastinal
contours are also unchanged. There is no pneumothorax.
Density along the right lateral chest wall, at the site of the
recent catheter tract, has a similar appearance. More
inferiorly, there is greater right lower lobe opacity which may
represent loculated effusion, atelectasis, or consolidation. In
addition, free-flowing bilateral pleural effusions are
increased.
IMPRESSION: No evidence of pneumothorax. Increased effusions and
right lower lobe opacity.
.
Rest MIBI ([**2107-7-22**]): Following injection of MIBI while patient
was at rest and experiencing chest pain, static and gated SPECT
images were obtained and analyzed. Gated images and the rest of
the test including stress images were not performed due to
patients pulmonary and blood pressure problems.
Imaging Protocol:
This study was interpreted using the 17-segment myocardial
perfusion model. The image quality is good. The left ventricular
cavity size is normal. There are no perfusion defects seen in
the rest images.
IMPRESSION: Normal rest myocardial perfusion. Ejection fraction
and stress
images not obtained.
.
CT Neck ([**2107-7-27**]): FINDINGS: There is an ill-defined,
heterogeneous, enhancing mass filling the left piriform sinus
with the bulk centered at the C5 level on the lateral scout
film. This mass extends into the left tonsillar space and has
several central areas of hypodensity consistent with necrosis.
There is associated narrowing and compression of the airway at
the level of the hyoid bone and more inferiorly at the
valleculae. At its largest size at the C5 level, this mass
measures 4.8 x 3.0 cm in the axial plane. The inferior portion
of the mass abuts the superior aspect of the thyroid gland.
There is no associated neck pathologic lymphadenopathy. There is
diffuse atherosclerotic calcification at the aortic arch and of
the carotid arteries bilaterally. The cavernous portions of the
carotid arteries are especially calcified. Limited views of the
inferior portion of the brain are unremarkable. Incidental note
is made of extensive degenerative, multilevel disease with mild
narrowing of the spinal canal at the C5 level secondary to
posterior osteophytosis. Limited views of the lung apices
demonstrate striking centrilobular emphysematous changes with
several peripheral bullae noted. Furthermore, there is a
partially imaged tubular structure extending along the anterior
aspect of the right lobe.
IMPRESSION: Large, heterogeneously enhancing suspicious mass
centered within the left piriform sinus at the C5 level
suspicious for underlying malignancy such as squamous cell
carcinoma. Encroachment of the airway at the inferior border of
the hyoid bone. No pathologic associated lymphadenopathy within
the neck.
.
CTA Abdomen & Pelvis ([**2107-7-27**]): IMPRESSION:
1. No evidence for retroperitoneal hematoma.
2. Status post abdominal aneurysm repair. This likely explains
the unusual appearance of the aorta at the level of the renal
arteries where a waist is seen as well as a left lateral
wide-mouthed focal outpouching. Comparison with prior outside
studies would be helpful to ensure stability of this finding.
High grade stenosis of the left renal artery and celiac trunc as
described above.
3. Small-to-moderate bilateral pleural effusions.
4. Small left kidney with perfusion abnormality likely due to
compromise of the left renal artery by the aneurysm.
5. Calcified granulomas in the spleen and liver.
6. Left hydrocele and presacral fluid of uncertain clinical
significance.
7. 3D reformations were not available at the time of this
dictation. An addendum will be added once they have become
available.
.
Echo ([**2107-7-26**]): Conclusions:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
5-10 mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size and systolic function (LVEF>55%).
Regional left ventricular wall motion is normal. 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. There is no mitral valve prolapse. Mild to
moderate ([**2-8**]+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved
biventricular systolic function. Mild-moderate mitral
regurgitation. Moderate pulmonary hypertension. Mildly dilated
ascending aorta.
PLEURAL FLUID: exudative, negative for malignant cells.
Brief Hospital Course:
71 y.o. male w/ MMP including extensive alcohol and smoking hx,
transferred from an outside hospital with a 3.5 cm piriform
sinus mass and right tension PTX. The following issues were
investigated during this hospitalization:
.
# PTX: Patient had had a spontaneous PTX at the OSH, which per
CXR report on transfer, had resolved s/p chest tube placement.
Thus, the PTX observed on arrival was felt to be recurrent
rather than persistent. Thoracic surgery was consulted and the
patient eventually received two chest tubes with resolution of
the pneumothorax after removal of the chest tubes. Patient was
maintained on supplemental oxygen with appropriate saturation
for the remainder of his hospitalization.
.
# Pirifrom Mass: Per pathology, squamous cell carcinoma, patient
has history of heavy smoking and alcohol. ENT was consulted and
though determined to be a high risk surgical candidate given
cardiac history, but otherwise medically cleared, the patient
underwent biopsy. Tracheostomy was perfomed as well. Given the
patient's inability to swallow, he was made NPO and started on
TPN before eventual G tube placement. The tracheostomy was
uncomplicated; but it was decided to transfer the patient to the
MICU for close oxygen monitoring given his multiple
comorbidities. Upon transfer back to the floor, he underwent
several speech and swallow evaluations. Although initially he
was deemed safe for comfort POs (coffee, water sips), subsequent
evaluations demonstrated that he has a high risk of aspiration.
Thus, he is NPO with only mouth swabs and ice chips.
The patient must see radiation oncology (Dr [**Last Name (STitle) 35885**] [**Telephone/Fax (1) 73095**]), Dr [**First Name (STitle) **] (ENT) and Dr [**Last Name (STitle) **] (Oncology) at discharge.
.
Respiratory failure: The patient did well after his tracheostomy
and quickly transitioned to trach mask. There was concern for
developing pneumonia on the R lobe of the lung and for this
reason unasyn and vancomycin were started. He completed a 10
course of vancomycin and zosyn, although all cultures remained
negative: urine, blood, sputum, and pleural fluid. He underwent
thoracentesis which yielded exudative fluid with [**Numeric Identifier 73096**] RBCs and
no malignant cells.
.
# Anemia: Hematocrit gradually trended down from admission with
no clear source. Patient had brown, heme negative stool. He did
not have hematemesis or hemoptysis. Hemolysis labs were
negative. Given abdominal bruit on exam with history of AAA s/p
repair, an endoleak was considered, but there was no evidence of
RP bleed on CTA. Iron studies pointed to anemia of chronic
disease. The patient received several blood transfusions for
continuously dropping hematocrit. For the past 14 days prior to
discharge, his hematocrit stabilized and had no further changes.
.
# HTN: Poorly-controlled and chronically elevated. Furthermore,
patient was unable to tolerate PO medications [**3-11**] mass. Patient
was not symptomatic with this hypertension and was continued on
IV/TD antihypertensives with SBP goal of 160-
170: permissive hypertension given chronic elevation as an
outpatient.
.
# Arrythmia: Patient has pacemaker and was on Digoxin. The
indication was not documented in his transfer paperwork, but
according to the history given by the patient, the indication
appeared to be tachy-brady/sick sinus. Patient was on Digoxin as
an outpatient and serum levels were appropriate. The patient
remained rate-controlled and in sinus on successive EKGs. On
telemetry, he had occasional PVCs. He had one run of 7 beats VT
which resolved spontaneously and during which the patient
remained asymptomatic.
.
# Diabetes: Well-controlled with HbA1C of 5.7 during this
hospitalization. Patient was continued on an Insulin sliding
scale as well as received Insulin in his TPN. After TPN was
discontinued, once his tube feeds were at goal, his sugars
became elevated >200. He was then transitioned to glargine as
well as RISS, with better sugar control.
.
# Fevers: In the week prior to d/c, he spiked fevers to 101
twice. He was pancultured but all cultures were negative. He was
asymptomatic. It was thought that these were most likely tumor
fevers. He has remained afebrile for >48 hours and is ready for
discharge.
Medications on Admission:
(Unsure of doses)
Amlodipine
Isosorbide
Digoxin
Toprol - XL
Lipitor
Actos
Metformin
KCl
Metformin
Percocet
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q8H
(every 8 hours) as needed for fever,pain.
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours).
3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q2H (every 2 hours) as needed.
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 14 days.
5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
6. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. HydrALAzine 20 mg IV Q6H:PRN SBP > 160
8. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal Q6H
(every 6 hours) as needed for BP>150.
13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. Budesonide 0.25 mg/2 mL Solution for Nebulization Sig: One
(1) ML Inhalation [**Hospital1 **] ().
16. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily) for 14 days.
17. Insulin sliding scale
18. Tracheostomy care per protocol
19. Lortab Elixir 2.5-167 mg/5 mL Solution Sig: [**2-8**] PO every
4-6 hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Left Piriform Sinus Mass: Squamous Cell Carcinoma
Right Pneumothorax
Diabetes
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were seen and evaluated for a tumor in your throat as well
as a collapsed lung. A biopsy was performed of this tumor and it
is a cancer that has not spread (squamous cell carcinoma). You
had two chest tubes placed in order to treat your collapsed lung
and this was successful. A tracheostomy was placed in your
throat so you can breathe easily. You cannot take anything per
mouth except ice chips, as you run the risk of a fatal pneumonia
if you do that. You are now being discharged.
Take all of your medications as directed. You need to see
radiation oncology as directed, as well as the other doctors
that saw [**Name5 (PTitle) **] in the hospital. See the appointments below.
Keep all of your follow-up appointments.
Call your doctor or go to the ER for any of the following:
fevers/chills, nausea/vomiting, chest pain, shortness of breath
or any other concerning symptoms.
Followup Instructions:
Call your primary care physician and schedule an appointment in
[**8-16**] days.
You need also to see:
DR [**Last Name (STitle) **] (radiation Oncology) [**Telephone/Fax (1) 73097**]
DR [**First Name (STitle) **] : [**8-25**], at 1 pm. (ENT) An appointment has been made
for you.
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2107-8-18**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7706**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2107-8-18**] 10:30
ICD9 Codes: 496, 5119, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3935
} | Medical Text: Admission Date: [**2158-11-28**] Discharge Date: [**2158-12-6**]
Date of Birth: [**2091-9-13**] Sex: M
Service: SURGERY
Allergies:
Equine Protein / Penicillins
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD, pre-emptive Living related kidney transplant
Major Surgical or Invasive Procedure:
[**2158-11-28**]: living related kidney transplant
History of Present Illness:
67M with longstanding diabetes maintained on oral agents for 17
years. Approximately one year ago, his creatinine was
increasing. In [**2158-4-14**], his creatinine went up fairly acutely
to 7.4. Since that time, he has had some
problems with edema, but this has been managed recently with
Lasix. He feels remarkably well for someone with advanced renal
disease. He has no pain and is
able to perform his daily activities without any problem. This
includes a fairly rigorous teaching schedule as well as other
activities. He now presents for kidney transplant.
Past Medical History:
HTN, [**Doctor Last Name **] [**Location (un) **] exposure in [**Country 3992**], anemia, diabetic
retinopathy, s/p lens procedure, granulomatous disease of the
bone marrow.
Social History:
He is a former hospital administrator. He was the former
president and CEO of [**Hospital 84680**] Hospital. He is married with
three children ages 38, 34 and 34.
Family History:
His father died of congestive heart failure at age 83. Mother
died of myocardial infarction at age 66. She also had diabetes.
Physical Exam:
On day of discharge:
Afebrile, vital signs stable and within normal limits.
Gen: alert and oriented, no obvious discomfort.
Pulm: CTA b/l
CVS: RRR
Abd: soft / min distended / non tender / bowel sounds present
Incision: minimal swelling with ecchymosis, minimal
serosanginous drainage
Pertinent Results:
[**2158-12-6**] 02:52PM BLOOD Hct-26.9*
[**2158-12-6**] 04:52AM BLOOD PT-17.3* PTT-26.5 INR(PT)-1.5*
[**2158-12-6**] 04:52AM BLOOD Glucose-61* UreaN-30* Creat-1.3* Na-139
K-5.0 Cl-113* HCO3-21* AnGap-10
[**12-5**] Renal transplant u/s: normal blood flow and normal
resistive indices, large fluid collection adjacent to the upper
pole of the transplant kidney measuring 13 x 6 x 9 cm, no mass
effect on kidney
Brief Hospital Course:
The patient was admitted to the PACU following his surgery. He
tolerated the procedure well. Following the procedure, he had a
PCA for pain control, foley in place, IVF at 50cc per hour plus
cc per cc replacement of urine output, MMF [**12-15**] started, bactrim,
valcyte, tacrolimus [**1-16**] started, lopressor, hydralazine given,
diet advanced to clear liquids.
[**11-29**]: vancomycin and levofloxacin x 1, diet advanced to a
regular diet, replacement fluid discontinued, ATG 100 mg given,
ASA 81 mg started, Tacro [**1-16**], steroid taper started
[**11-30**]: the patient reported chest pain, EKG performed
demonstrating atrial fibrillation, lopressor and nitroglycerin
given without relief, digoxin 0.25 mg IV x1 given, 2 units RBC
transfused, ATG 100 mg IV x 1, tacro [**3-18**], transferred to the ICU
for continued monitoring. Cardiology consult obtained
[**12-1**]: ATG 100 mg IV x1, ASA increased to 325 mg, continued
digoxin, tacrolimus [**3-18**]
[**12-2**]: coumadin 4 mg started, heparin drip started, tacro [**3-18**],
foley discontinued, PCA stopped, PO medication started,
transferred to the floor, amiodarone started
[**12-3**]: continued coumadin and heparin drip, continued regular
diet, amio continued, tacro [**3-18**]
[**12-4**]: transfused 2 units RBC, continued heparin drip and
coumadin, tacrolimus [**2-14**], continued valcyte
[**12-5**]: renal ultrasound performed which demonstrated a hematoma,
heparin drip stopped, continued coumadin 1 mg, tacro [**12-15**],
transfused one unit rbc
[**12-6**]: ambulating without assistance, cont coumadin, tacrolimus
[**12-15**], discharged to home
Medications on Admission:
amlodipine 10', lipitor 20', epo, vit D2, pepcid 20', lasix 40',
glipizide 5', hydralazine 100''', lopressor 100", renagel 1600",
januvia 25'. asa
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
6. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400 mg daily x 1 week
200 mg daily x 1 month
[**Hospital 1326**] clinic will assist with transition off amiodarone.
Disp:*60 Tablet(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.
Disp:*2 bottles* Refills:*1*
11. Insulin Syringe Ultrafine [**12-16**] mL 29 x [**12-16**] Syringe Sig: One
(1) Miscellaneous once a day.
Disp:*1 box* Refills:*1*
12. Januvia 50 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*2*
13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Trough Prograf level
PT/INR
Results to transplant coordinator (pager [**Numeric Identifier 28794**])
15. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
16. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
17. Insulin/finger sticks
Increase Lantus by 2 units every 3 days for fasting blood sugars
> 150.
Monitor finger stick blood sugars at least twice daily Fasting
and 4 PM. More often as necessary. Bring record to [**Hospital **] clinic
and transplant clinic appointments
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD now s/p living related kidney transplant
atrial fibrillation
Hyperglycemia post transplant
Discharge Condition:
Stable/Good
A+Ox3
Ambulatory
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, inability to
take or keep down food, fluids or medications
Monitor the incision for redness, drainage or bleeding
Labwork will be done every Monday and Thursday at the [**Hospital **]
Medical Building lab until further notice. Labs to be drawn are
CBC, Chem 7, Ca, Phos, AST, T Bili, UA and trough Prograf level,
PT/INR.
Bring Prograf with you and take once the blood is drawn.
No heavy lifting, nothing heavier than a gallon of milk
Increase your phosphorous intake with whole grains, skim milk,
nuts.
Drink enough fluids to keep urine light yellow. Several liters
of fluid daily are recommended.
No driving if taking narcotic pain medication
[**Month (only) 116**] not shower due to hemodialysis line being in place. [**Month (only) 116**] use
handheld shower below the waist. Do not spray directly on
incision.
Pat incision dry. You may leave the incision open to air or
cover for comfort with a dry gauze. Staples will be removed in
clinic.
Labs will be additionally drawn on Saturday [**12-9**] at 8AM in the
[**Hospital Ward Name 1826**] Lab ([**Hospital Ward Name 516**])
**** Please follow the amiodarone taper as prescribed:
400 mg daily x 1 week
200 mg daily x 1 month
[**Hospital 1326**] clinic will assist with transition off amiodarone due
to interaction with Prograf and Coumadin
INR per transplant clinic recommendations. [**Hospital 1326**] clinic
will prescribe coumadin dosing
Follow [**Last Name (un) **] recommendations for insulin regime/ oral
medication for blood sugar control and monitoring and recording
blood sugars
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2158-12-7**] 10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2158-12-11**]
1:10
[**Last Name (LF) **],[**First Name3 (LF) **] TRANSPLANT SOCIAL WORK Date/Time:[**2158-12-18**] 10:00
[**Last Name (un) **] Appointment: Dr [**Last Name (STitle) **] [**2157-12-18**] 2:00
ICD9 Codes: 5856, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3936
} | Medical Text: Admission Date: [**2120-6-18**] Discharge Date: [**2120-6-25**]
Date of Birth: [**2045-10-23**] Sex: F
Service: CARDIAC S.
CHIEF COMPLAINT: Worsening dyspnea on exertion.
HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname **] is a 74-year-old
female who presents with aortic stenosis. Over the past year
she has been having worsening symptoms of dyspnea on
exertion. She became short of breath after climbing one
flight of stairs or walking two blocks on a flat surface.
She also had some lightheadedness when she was walking, but
denied any syncope. The last echocardiogram was in [**2120-1-9**], which showed mild left ventricular hypertrophy with
normal wall motion and ejection fraction of 60% and a
severely stenotic aortic valve with a mean gradient of 43
mmHg and a peak gradient of 65 mmHg. The calcified valve
area was 0.6 cm squared.
PAST MEDICAL HISTORY: History is notable for the following:
1. Hypertension.
2. Arthritis.
3. Urinary frequency.
4. Status post hysterectomy.
5. Status post cholecystectomy.
6. Status post bladder suspension.
MEDICATIONS:
1. Premarin 0.625 mg PO q.d.
2. Miconazole 12.5 mg P.o.q.d.
3. Detrol 4 mg P.o.b.i.d.
4. Calcium 600 mg p.o.q.d.
5. Multivitamin PO q.d.
6. Tylenol arthritis p.r.n.
ALLERGIES: NAPROSYN GIVES HER HIVES AND LOPID GIVES HER
INCREASED LIVER FUNCTION TESTS.
PHYSICAL EXAMINATION: On physical examination, the blood
pressure is 136/65; heart rate 72. NECK: Without carotid
bruit. HEART: Regular rate and rhythm with a systolic
murmur. LUNGS: Lungs were clear to auscultation
bilaterally. ABDOMEN: Soft, nontender. EXTREMITIES:
Palpable peripheral pulses with no varicosities. Cardiac
catheterization demonstrated moderate-to-severe aortic
stenosis with nonobstructive coronaries and normal pulmonary
artery pressures along with a preserved left ventricular
ejection fraction.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service on [**2120-6-18**], following her cardiac
catheterization. The following day she was taken to the
operating room, where she had an aortic valve replacement
with a tissue prosthetic valve. She received a #21 CE valve.
The procedure was remarkable for a transfusion requirement of
5 units of packed red blood cells, 4 units of fresh-frozen
plasma and two units of platelets. Total cardiopulmonary
bypass time was 92 minutes. Cross-clamp time was 70 minutes.
Postoperatively, the patient was taken intubated to the
Cardiac Surgery Intensive Care Unit. In the Cardiac Surgery
Intensive Care Unit she was extubated overnight, but required
a Neo-Synephrine drip to maintain her blood pressure. She
was slowly weaned off this drip throughout the course of the
first postoperative day. By the morning of the second day
she was stable enough to be transferred to the floor.
However, that evening, she became tachycardiac to a pulse
rate of approximately 120 to 130. The EKG at that time
demonstrated a junctional tachycardia that was narrow complex
in nature and very regular. She required significant doses
of intravenously Lopressor in order to control her rate. She
ultimately required 25 units of Lopressor IV and she was also
transfused with one more unit of packed red blood cells. She
remained stable overnight, but the following morning she had
a recurrence of her tachycardia. In addition, she started to
have some bronchospasm that was secondary to the IV Lopressor
and she may have also had an element of congestive heart
failure. She was given intravenous Lasix and treated with IV
Diltiazem. She converted after 15 mg bolus and she was
started on a drip at 10 mg an hour. After this time, she
remained stable. All of beta blockers were discontinued.
The following day, she started to be loaded with oral
Diltiazem. By the 5th postoperative day, the oral Diltiazem
dosage increased and her drip was decreased. In addition, it
became apparent at this time that she was going to need rehab
following her surgery. She was started on subcutaneous
heparin and screening for rehabilitation was initiated.
During this time, she continued to be diuresed. She was
essentially without complaint. She did require some
intravenous doses of Diltiazem for heart rates between 100
and 110 as her drip was being weaned and her oral doses were
taking effect.
On [**2120-6-24**], the hospitalization was dictated in
anticipation of her transfer to rehabilitation. We are
anticipating that she is transferred to rehabilitation on
[**6-25**], off her Diltiazem drip, taking 90 mg PO q.i.d.
DISCHARGE MEDICATIONS:
1. Diltiazem anticipated to be 90 mg PO q.i.d.
2. Colace 100 mg p.o.b.i.d.
3. Zantac 150 mg PO b.i.d.
4. Lasix 20 mg b.i.d. times seven days.
5. Potassium chloride 20 mEq b.i.d. times seven days.
6. Premarin 0.625 mg PO q.d.
7. Percocet 5/325 one to two PO q.4h. to 6h.p.r.n.
8. Tylenol 650 mg PO q.4h. to 6h.p.r.n.
9. Heparin 5000 units subcutaneously b.i.d.
10. Oxazepam 10 mg PO q.h.s.p.r.n.
11. Milk of Magnesia 30 cc PO q.6h.p.r.n.
On the afternoon of this dictation, a diabetes mellitus
consultation was obtained as the patient has had some
elevated blood sugars during this hospitalization and it
could be that she has undiagnosed diabetes mellitus at which
time she will likely be placed on an oral [**Doctor Last Name 360**].
The patient is to followup with her family physician,
[**Last Name (NamePattern4) **]. [**Last Name (un) **] in approximately two weeks. In addition, she
is to followup with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in approximately
four weeks.
DISCHARGE DIAGNOSES: Aortic stenosis now status post tissue
aortic valve replacement.
SECONDARY DIAGNOSIS:
1. Hypertension, controlled.
2. Previously undiagnosed adult onset diabetes mellitus.
3. Junctional tachycardia, controlled.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2120-6-24**] 15:56
T: [**2120-6-24**] 16:10
JOB#: [**Job Number 18558**]
ICD9 Codes: 4241, 9971, 4280, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3937
} | Medical Text: Admission Date: [**2178-7-31**] Discharge Date: [**2178-8-12**]
Date of Birth: [**2119-2-9**] Sex: F
Service: MICU
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
female with type 1 renal tubular acidosis, history of
ischemic cardiomyopathy complicated by failure (with an
ejection fraction of 25%), coronary artery disease (status
post right coronary artery stent placement in [**2178-2-14**]),
and other comorbidities who presented with abdominal pain and
diarrhea times four days.
The patient is a poor historian. She says that the pain is
dull, constant, and nonradiating, and is located below the
umbilicus. Her diarrhea is nonbloody, and she denies black
or tarry stools. She says she has also had some nausea and
shortness of breath over the past four days and recently
chills. She denies the following; fevers, headaches, chest
pain, palpitations, flank pain, dysuria, change in urination
or frequency, arthralgias, or myalgias. She also denies
recent changes in her medications or recent alcohol or drug
use. Of note, she had an abdominal computed tomography
yesterday with intravenous contrast. At that time, her blood
urea nitrogen was 49, and her creatinine was 4.5.
In the Emergency Department, she was started on normal saline
infusion at 75 mL per hour. She also received one ampule of
glucose for a fingerstick blood glucose in the 60s. Serum
electrolyte panel revealed her blood urea nitrogen was 59.
Her creatinine was 5.3 (her baseline is 20 to 30/1.1 to 1.3;
respectively). This revealed hyponatremia and acidemia that
had been stable over the past one to two months.
Electrocardiogram revealed inferolateral ST-T wave changes
not seen on the last study from [**2178-2-14**]; which could be
consistent with myocardial ischemia. Her cardiac enzymes
were not elevated on the first draw. An abdominal computed
tomography revealed a pan-colitis. A head computed
tomography was negative.
She was transferred to the floor for management of her
pan-colitis and acute renal failure.
PAST MEDICAL HISTORY:
1. Type 1 renal tubular acidosis; complicated by
hypokalemia, acidemia, and recently hyponatremia (126 to 128
in [**2178-6-16**]). She is on a low-salt diet with a 1-liter
per day fluid restriction.
2. Ischemic cardiomyopathy complicated by congestive heart
failure diagnosed in [**2178-2-14**]. An echocardiogram at
that time revealed an ejection fraction of 25% with akinesis
of the inferior and basilar walls. Since then, she has been
stable with [**State 531**] Heart Association class II symptoms.
3. Coronary artery disease; cardiac catheterization in [**2178-2-14**] revealed a 100% occlusion of the right coronary
artery which was stented.
4. Chronic obstructive pulmonary disease/asthma.
5. Anxiety and depression.
6. Attention deficit disorder.
7. Osteoporosis.
8. Gastroesophageal reflux disease.
PAST SURGICAL HISTORY:
1. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
2. Status post cholecystectomy.
ALLERGIES: MEPERIDINE (rash).
MEDICATIONS ON ADMISSION: (Preadmission medications
included)
1. Albuterol meter-dosed inhaler 1 to 2 puffs inhaled q.6h.
as needed.
2. Alendronate 10 mg by mouth once per day.
3. Aspirin 325 mg by mouth once per day.
4. Captopril 25 mg by mouth three times per day
5. Carvedilol 3.125 mg by mouth twice per day
6. Citrates (polycitra) 1 mL by mouth once per day.
7. Clopidogrel 75 mg by mouth once per day (until
[**Month (only) 1096**]).
8. Furosemide 20 mg by mouth once per day.
9. Ipratropium meter-dosed inhaler 2 puffs inhaled q.6h.
10. Iron supplements 150 mg by mouth twice per day.
11. Levothyroxine 50 mcg by mouth every day.
12. Lorazepam 1 mg by mouth once per day.
13. Methylphenidate 5 mg by mouth twice per day.
14. Montelukast 10 mg by mouth once per day.
15. Omeprazole 20 mg by mouth once per day.
16. Potassium supplements 10 mEq by mouth once per day.
17. Sertraline 58 mg by mouth once per day.
18. Simvastatin 40 mg by mouth q.h.s.
19. Sodium bicarbonate 650 mg by mouth once per day.
20. Trazodone 50 mg by mouth once per day.
SOCIAL HISTORY: The patient works as a secretary and has
recently quit smoking. She previously smoked one pack per
day for 25 years. She denies alcohol use. The patient is
single with no children and lives alone.
FAMILY HISTORY: Mother died at the age of 67 with
cerebrovascular accident and also with coronary artery
disease. Father died at the age of 40 from a motor vehicle
accident. Sister has diabetes and breast cancer.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed vital signs with a temperature of 97.6
degrees Fahrenheit, her blood pressure was 113/60, her heart
rate was 88, her respiratory rate was 22, and her oxygen
saturation was 96% on room air. In general, the patient was
shivering, lying in bed. Head, eyes, ears, nose, and throat
examination revealed normocephalic and atraumatic. Pupils
were equal, round, and reactive to light. No nystagmus. The
oral mucosa was pink and slightly dry. No lesions. Neck
examination revealed a large soft tissue mass. No
lymphadenopathy appreciated. Chest examination revealed
coarse breath sounds bilaterally with decreased breath sounds
at the right base. Cardiovascular examination revealed
normal first heart sounds and second heart sounds. A regular
rate and rhythm. A 2/6 systolic murmur. Abdominal
examination revealed hypoactive bowel sounds. The abdomen
was soft, nontender, and nondistended. No organomegaly or
masses appreciated. Guaiac-negative in the Emergency
Department. Extremity examination revealed the lower
extremities were cool to touch. Posterior tibialis pulse
were 1+ bilaterally. Neurologic examination revealed cranial
nerves II through XII were intact. Sharp discrimination poor
over the upper and lower extremities bilaterally. Oriented
to person and place but not to time. Skin examination
revealed mild reaction of turgor over hand, small lesions
over body.
PERTINENT LABORATORY VALUES ON PRESENTATION: Admission
laboratory data revealed her white blood cell count was 8.7,
her hematocrit was 31.9, and her platelets were 202. Her
sodium was 124, potassium was 3.7, chloride was 95,
bicarbonate was 13, blood urea nitrogen was 59, creatinine
was 5, and blood glucose was 166. Prothrombin time was 13.3,
partial thromboplastin time was 26.1, and her INR was 1.3.
Her ALT was 5, AST was 16, alkaline phosphatase was 97, total
bilirubin was 0.3, amylase was 164, and her lipase was 66.
Albumin was 3.5. Calcium was 8.2. Lactate was 1.1.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram from [**7-31**] showed first-degree atrioventricular block, poor R wave
progression, inferolateral ST-T changes which may represent
myocardial ischemia.
An abdominal computed tomography with contrast on [**7-30**]
showed pan-colitis.
A head computed tomography from [**7-31**] showed no acute
pathological intracranial process.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. PAN-COLITIS ISSUES: On admission, the patient was made
nothing by mouth. Stool studies were sent. Cultures for
Clostridium difficile, Salmonella, Shigella, Campylobacter,
Yersinia, and ova and parasites all were negative. She was
started on antibiotics with ciprofloxacin 200 mg
intravenously q.24h. and metronidazole 500 mg intravenously
q.8h. She was also stool guaiaced which were all negative.
During the course of her hospitalization, she was switched to
a course of ampicillin, levofloxacin, and Flagyl and
completed a 10-day course of levofloxacin and Flagyl.
Gastroenterology saw the patient in consultation and agreed
with the plan to treat with antibiotics and recommended a
flexible sigmoidoscopy after resolution of her symptoms.
On [**8-11**], she had a repeat abdominal computed tomography
which showed resolution of her pan-colitis. Throughout the
course of her hospital stay, her abdominal pain subsided; now
only intermittent and only with deep palpation.
2. ACUTE RENAL FAILURE ISSUES AND TYPE I RENAL TUBULAR
ACIDOSIS ISSUES: Acute renal failure was presumed to be
predominantly prerenal and perhaps some component of acute
tubular necrosis secondary to the computed tomography dye
load that she received on [**7-30**]. At baseline, this
patient has hyponatremia and acidemia secondary to her type I
renal tubular acidosis for which she takes 650 mg twice per
day of bicarbonate.
The patient was gently hydrated on the floor. Her
electrolytes were repleted, and her medications were renally
dosed. Her ACE inhibitors and nonsteroidal antiinflammatory
agents were held during the course of her hospitalization.
In the Intensive Care Unit, the patient remained oliguric
with an average urine output of 200 cc to 300 cc per day.
3. SEIZURE ISSUES: The patient had a seizure after being
admitted to the floor on [**8-1**]. She was stabilized, and
the seizure resolved with Ativan and Dilantin.
She was seen in consultation by Neurology. She had a lumbar
puncture which was negative. She also had a head computed
tomography at that time which showed edema. She had magnetic
resonance imaging as well which showed decreased perfusion in
her right frontal lobe as well as a nonspecific increased T2
signal on the pons. She had an electroencephalogram which
was negative.
Neurology felt that her seizure was caused by a metabolic or
toxic abnormality. She was loaded with Dilantin and was
continued on Dilantin in the Intensive Care Unit. She did
not have any additional seizures during the course of her
hospitalization.
4. CARDIOVASCULAR ISSUES: Congestive heart failure with an
ejection fraction of 20% to 25% and coronary artery disease,
status post stent placement.
After the seizure she suffered on the floor, the patient had
a cardiac enzyme leak and mild electrocardiogram changes;
likely representing demand ischemia.
After her transfer to the Intensive Care Unit, she became
hypotensive which necessitated volume resuscitation. While
in the Intensive Care Unit, she was diuresed with Lasix and
Diuril. She was placed on a nitroglycerin drip. She also
began hemodialysis because she was relatively refractory to
Lasix treatment.
Regarding her congestive heart failure, eventually the
patient was placed on Isordil, hydralazine, and most recently
metoprolol was added to her regimen. Hemodialysis has been
the most effective treatment in terms of volume reduction.
She continued to receive Lasix 100 mg intravenously three
times per day (per Renal instructions).
5. RESPIRATORY FAILURE ISSUES: After the patient's seizure
on the floor, she became overwhelmingly acidotic and was
transferred to the Intensive Care Unit for her respiratory
failure and was placed on a ventilator. She was extubated on
[**8-3**] for six hours until she went into flash pulmonary
edema and was reintubated. At that time, she was started on
Natrecor and then switched to dialysis and received her first
dialysis treatment on [**8-5**]; which she continued to have
on an as needed basis (per Renal directive).
The patient was extubated on [**8-11**] and continued to do
well status post extubation; currently using a 50% shovel
mask with oxygen saturations of 95% to 100% with a
respiratory rate of around 12. The patient was not
complaining of shortness of breath.
6. ANISOCORIA/WEAKNESS ISSUES: The patient has had noted
anisocoria during her hospitalization with the right pupil
being larger than the left pupil.
However, on the morning of [**8-12**], she was noted to have a
larger left pupil at 4 mm and a right pupil of 2 mm as well
as marked left upper extremity weakness. At that time,
Neurology was consulted again regarding this new finding.
She was seen today by Neurology and was scheduled for a
magnetic resonance imaging/magnetic resonance angiography
later today (on [**8-12**]).
7. HYPOTHYROIDISM ISSUES: The patient was continued on
levothyroxine.
8. CHRONIC OBSTRUCTIVE PULMONARY DISEASE/ASTHMA ISSUES:
The patient was on Atrovent q.4h. and was started on a
fluticasone steroid inhaler today for continued wheezing and
some chest tightness.
9. ANXIETY/DEPRESSION ISSUES: During the course of her
Intensive Care Unit stay, sertraline was held and she
received Ativan with her propofol sedation. As she was
extubated, we have restarted Ativan 1 mg by mouth every day
as well as her trazodone 50 mg by mouth once per day.
10. CODE STATUS: Full code.
11. COMMUNICATION ISSUES: Communication with the family has
been through the patient's sisters.
CONDITION AT TRANSFER TO THE FLOOR: Condition on transfer to
the floor was fair.
NOTE: This dictation is up to the point of Medical Intensive
Care Unit transfer to CC7 on [**2178-8-12**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 2706**]
MEDQUIST36
D: [**2178-8-12**] 13:27
T: [**2178-8-12**] 13:39
JOB#: [**Job Number 107630**]
ICD9 Codes: 5845, 2765, 2761, 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3938
} | Medical Text: Admission Date: [**2178-12-30**] Discharge Date: [**2179-1-14**]
Date of Birth: [**2139-2-28**] Sex: F
Service: MEDICINE
Allergies:
Zocor
Attending:[**First Name3 (LF) 49413**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
permenant tunneled line placement
picc placement
temporary dialysis line placement
EGD x 2
History of Present Illness:
39 yo F with PMH significant for ESRD on HD [**3-12**] diabetic
nephropathy, type I DM, HTN, hypercholesterolemia who presents
today with fever at dialysis. The pt states she was in USOH when
she went to dialysis today at [**Hospital1 3494**]. She reports she was
"just hooked up to the machine" when she had a fever to 103 F
associated with rigors and myalgias. Given Vancomycin 1 gm X 1
at HD and transferred to ED for further evaluation. The pt
denies pain, redness, swelling, discharge from R SCV HD line
which she has had for 7 months after her AVF "stopped working".
Denies recent sick contacts, travel, headache, nausea, vomiting,
diarrhea, abominal pain, chest pain, shortness of breath.
.
In the ED, T 104.2, BP 172/68, HR 112, RR 20, O2 sat 98% on RA.
Given 2L IVF, 1 gm tylenol and motrin 600 mg X 1 with
defervescence, ciprofloxacin 400 mg IV X 1, and gentamicin 30 mg
IV X 1. Seen by renal and transplant surgery. Admitted to
medicine for likely line infection and treatment with IV abx.
Past Medical History:
1. Type 1 DM
2. Hypercholesterolemia
3. HTN
4. ESRD [**3-12**] DM - pre-op for renal transplant
5. blindness in Right eye
6. Left leg weakness
7. Goiter
Social History:
Lives at home with her mother, stepfather and sister. She denies
tobacco, alcohol, and IVDU.
Family History:
Multiple family members on father's side with DM II. Denies
family h/o CAD, CA.
Physical Exam:
PE: Tm 104.2 Tc 98.9 BP 125/62 HR 95 RR 18 100% on room air FS
417
Gen: thin female, laying comfortably in bed. No acute
distress. Alert and
oriented to person, place, and date.
HEENT: Yellow dentition. Left pupil reactive to light. Sclerae
anicteric. Right eye blind. MMM, OP clear, neck supple, no LAD,
R SCV permacath with dressing c/d/i, no overlying warmth,
erythema, non-tender to palpation, no drainage.
CV: RRR. Normal S1 and S2. II/VI systolic murmur heard over
LSB (not documented on prior d/c summary)
Chest: CTA bilaterally. no w/r/r.
Abd: Soft, NT, ND, normoactive BS
Ext: no LE edema, + 2 DP pulses b/l, no palpable thrill over
site of L arm AVF, no bruit appreciated.
Pertinent Results:
Initial labs:
[**2178-12-30**] 01:20PM WBC-10.3# RBC-4.45 HGB-12.1 HCT-34.8*#
MCV-78* MCH-27.1 MCHC-34.7 RDW-16.1*
[**2178-12-30**] 01:20PM NEUTS-93.0* BANDS-0 LYMPHS-4.8* MONOS-1.7*
EOS-0.4 BASOS-0
[**2178-12-30**] 01:20PM PLT SMR-NORMAL PLT COUNT-257
[**2178-12-30**] 01:20PM PT-13.4* PTT-47.9* INR(PT)-1.2*
[**2178-12-30**] 01:20PM CALCIUM-7.9* PHOSPHATE-1.8*# MAGNESIUM-1.6
[**2178-12-30**] 01:20PM GLUCOSE-245* UREA N-19 CREAT-3.2*# SODIUM-137
POTASSIUM-3.2* CHLORIDE-94* TOTAL CO2-29 ANION GAP-17
[**2178-12-30**] 01:39PM GLUCOSE-241* LACTATE-1.5 NA+-137 K+-5.6*
CL--99*
[**2178-12-30**] 09:21PM POTASSIUM-3.5
.
EKG: NSR @ 86 bpm, nl axis, nl intervals, LVH, TWI I, aVL,
V2-V6, no peaked T waves. (new TWI V4-V6 compared to prior EKG
[**8-13**])
.
Imaging:
[**12-30**] CXR - There has been interval placement of a large bore
dual lumen
catheter from right internal jugular approach. The distal tip
is near the cavoatrial junction. The lungs are clear. The
mediastinum is otherwise unremarkable. No pleural effusion or
pneumothorax is seen. The visualized osseous structures are
unremarkable.
TTE:
The left atrium is normal in size. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF 60%). Right
ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
No masses or vegetations are seen on the aortic valve. The
mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no
mitral valve prolapse. No mass or vegetation is seen on the
mitral valve.
There is moderate pulmonary artery systolic hypertension. No
vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
TEE
1. There is mild symmetric left ventricular hypertrophy with
normal cavity
size and systolic function (LVEF>55%). Regional left ventricular
wall motion
is normal.
2. The mitral valve leaflets are structurally normal. Mild (1+)
mitral
regurgitation is seen. There are multiple, mobile, very thin,
fibrinous
strands on the mitral annulus and valve, which probably do not
represent
infective endocarditis.
3. Compared with the prior study (images reviewed) of
[**2179-1-1**], there is no
significant change.
[**1-7**] CXR:
1. No free air.
2. New small left lower lobe opacity, most likely atelectasis,
although pneumonia cannot be excluded.
3. Appearance suggesting a small new left loculated pleural
effusion.
Findings discussed with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **].
RUQ US
1. Cholelithiasis without cholecystitis
2. Large right pleural effusion.
3. Echogenic and small right kidney consistent with the given
history of renal failure.
[**1-13**] CXR
1. New patchy left lower lobe opacity, concerning for infectious
process such as pneumonia.
2. Right-sided PICC line croses midline into the left
brachiocephalic vein.
.
Micro:
Blood culture drawn off HD line at HD center - 4/4 bottles Staph
Aureus sensitive to naficillin
Blood culture [**12-30**] on admission - 1/4 bottles MSSA
Blood cultures 11/23, [**1-1**] negative
Blood culture [**1-2**]: CAPNOCYTOPHAGA SPECIES}; ANAEROBIC
BOTTLE-FINAL {LACTOBACILLUS SPECIES, VEILLONELLA SPECIES,
PREVOTELLA SPECIES}
Blood cultures: [**Date range (1) 49484**], [**1-11**], [**1-12**]: negative
Discharge labs:
wbc 11.6 hgb 10.5 hct 30 plt 225
141 101 15
-----------< 106
4 29 3.5
Brief Hospital Course:
39 yo F c ESRD on HD with R SCV permacath HD line X 7 months, DM
type I, HTN presents with fevers to 104.2 at dialysis, here with
line infection and MSSA bacteremia.
.
1) Fever - Pt with elevated temperature, tachycardia, and
relative hypotension on admission concerning for peri-septic
picture. Was placed on IV Vancomycin, dosed by level, IV Cipro,
and IV Gentamicin dosed at HD for broad-spectrum coverage. BP
meds were held on admission. Seen by both transplant surgery and
renal consult in ED who recommended that HD line be kept in the
interim until blood cultures positive off line. [**Name (NI) **] pt's
HD center who confirmed that blood cultures drawn at HD center
off HD line significant for 4/4 bottles of staph aureus
sensitive to oxacillin, 1/2 blood cultures also positive here
for staph aureus sensitive to oxacillin. As BPs stable, AF, and
WBC stable, line was kept and pt dialyzed through line on the
third hospital day to maintain her usual HD schedule. At HD,
spiked temperature to 101.5 and became tachycardic and BPs
elevated. Given dose of IV Vancomycin. The following day, blood
cultures on admission with MSSA and vancomycin switched to IV
Nafcillin. On [**1-2**] surveillance cx were positive for
prevotella, lactobacillus, capnocytophagia and speciations were
not done. Patient was already on zosyn which was continued for
total of 14 days. Meropenem was briefly added for 1-2 doses when
pts blood pressure dropped, but zosyn was resumed. Multiple
surveillance cx were negative thereafter. Patient had a new
permenant dialysis catheter placed.
.
2) ESRD on HD - Seen by renal and transplant [**Doctor First Name **] consult. Pt
usually on M/W/F HD schedule. Was dialyzed on third hospital day
as above with spike in temperature. Given blood cultures off
line at HD center and blood cultures on admission here positive
for MSSA, R SCV tunneled line d/c'd. Patient had temporary line
placed and then a permenant tunneled line. Pt with L AVF and per
op note [**6-13**], thrombectomy of thrombosed AVF performed; however
pt has had tunneled HD cath since [**6-13**] and reports her HD center
being unable to access graft.
.
3) DM type I - HbA1c 7.9 [**11-13**]. Reports taking lantus 8 U qam at
home with HISS. Initially had a very elevated FS in 400s on
admisison without anion-gap metabolic acidosis which resolved
with 14 U Humalog. Placed on 10 U lantus qam for increased
glycemic control in setting of infection, FS qid, and HISS. As
infection cleared, patient had low blood sugars on this regimen
and lantus was decreased to 5 units.
.
4) HTN - Pt with relative hypotension on admission and BP meds
held. During hospital course, BPs increased and BP meds were
restarted, including metoprolol 100 mg [**Hospital1 **], lisinopril 40 mg qd,
and nifedipine 60 mg qd. ASA continued. After TEE, pt had
esophagitis and upper GI bleed which caused hypotension. All BP
meds were again stopped. After bleeding was under control,
metoprolol, nifedipine, lisinopril and diovan were restarted.
.
5) Hypercholesterolemia - Pt refused lipitor stating that
lipitor was "killing her liver" and her MD told her to d/c it.
Deferred to outpt management and d/c lipitor.
.
6) Anemia - Baseline Hct mid 30s. Hct currently at baseline.
Iron studies suggest anemia of chronic disease. On epo at HD.
.
7.) UGIB- this occurred in setting of elevated coags (DIC labs
negative) and TEE trauma. Patient was hypotensive and had
several episodes of hemoptysis. Transferred to unit. Given FFP,
PRBCs, DDAVP, and protamine. Patient had EGD which showed
erosive esophagitis and clot, but no active bleeding. Protonix
[**Hospital1 **] started. Follow-up EGD showed no active bleeding. Patient
should have EGD in one month. Hematocrit stable after 2nd EGD.
Medications on Admission:
Sevelamer 800 mg tid
Calcium Acetate 667 mg tid
Pravastatin 40 mg qd
Ursodiol 500 mg [**Hospital1 **]
Nifedical 60 mg qd
Metoprolol 100 mg [**Hospital1 **]
Lisinopril 40 mg qd
Losartan 25 mg qd
Aspirin 325 mg qd
Folic Acid 1 mg qd
Docusate Sodium 100 mg [**Hospital1 **]
Multivitamin,Tx-Minerals 1 tab qd
Pantoprazole 40 mg qd
Lantus 8 U qam
Epogen 3700 qHD
Hectoral 5 mg qHD
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Epoetin Alfa 10,000 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
Disp:*qs qs* Refills:*2*
5. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
1 months.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
10. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous once a day: take in am.
Disp:*qs qs* Refills:*2*
12. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: see sliding scale.
Disp:*qs qs* Refills:*2*
13. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Line sepsis
2. UGIB [**3-12**] esophagitis
3. HTN
4. DM
5. ESRD
Discharge Condition:
HD stable and afebrile.
Discharge Instructions:
You were admitted with fever and elevated white count and found
to have an infection of your dialysis line. You were treated for
14 days with antibiotics IV. While in the hospital, you had a GI
bleed from your esophagus requiring protonix therapy twice daily
and a follow-up EGD in 1 month. Your blood counts have been
stable. In addition, you have a small infiltrate on chest xray
which may suggest pneumonia. You were already on antibiotics and
Dr. [**Last Name (STitle) 4888**] wants to follow you closely and not add additional
antibiotics at this time.
Please take all medications as directed.
Please follow-up with all outpatient appointments.
Please return to the ED or call Dr. [**Last Name (STitle) 4888**] if you experience
fevers, chills, shortness of breath, cough, chest pain,
worsening diarrhea or any other concerning symptoms.
Please be sure to take the protonix twice a day and avoid spicy
foods for the next few weeks.
Please take to Dr [**Last Name (STitle) 4888**] about scheduling a bilateral upper
extremity venogram to assess your veins for dialysis access.
Followup Instructions:
Dr [**Last Name (STitle) 4888**] would like to see you in her office tomorrow, Friday
[**2179-1-15**] at 1:45.
Please see Dr. [**Last Name (STitle) 4888**] on Monday [**1-18**] at 1:30. Her
phone number is [**Telephone/Fax (1) 6820**].
.
You also need a follow-up EGD in one month. Please go to your
appointment on [**3-1**] and arrive at 7am on the [**Location (un) **] of
the [**Hospital Ward Name 121**] Building with Dr. [**First Name (STitle) 2643**].
.
Please go to dialysis tomorrow. ([**Doctor First Name **] please call her unit and
tell them she will be back tomorrow).
ICD9 Codes: 5856, 7907, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3939
} | Medical Text: Admission Date: [**2107-4-27**] Discharge Date: [**2107-5-11**]
Date of Birth: [**2078-1-31**] Sex: M
Service: NME
CHIEF COMPLAINT: Tingling, dizziness, diplopia, speech
problems and fatigue.
HISTORY OF PRESENT ILLNESS: This is a 29 year old right-
handed male with multiple sclerosis who presents with
tingling, dizziness, diplopia, speech problems and fatigue.
Two days ago, the patient noted that his right arm was weak.
His right fingers started tingling up to the elbow and his
left fingers also started to tingle. Then he noted that his
mouth and tongue were tingling. Yesterday, the patient had
vertigo that was much worse with standing and moving his
head. He also noted diplopia which was worse with staring to
the left and with far vision. He also noted his speech was
quite slurred. Today he noticed his mouth and neck were
swollen. During these days he has had fatigue and anorexia.
On review of systems the patient denies any fever, chills,
nausea, vomiting, headache, neck pain, hearing changes, chest
pain, shortness of breath, abdominal pain, dysuria,
hematuria, diarrhea, bright red blood per rectum or
bowel/bladder problems.
PAST MEDICAL HISTORY:
1. Migraine; 2. Without pain, multiple sclerosis.
FAMILY HISTORY: Sister with hypothyroidism, mother with
migraine and hypothyroidism, father with generalized
tonoclonic seizure since childhood, on Trileptal. There is
no family history of multiple sclerosis.
SOCIAL HISTORY: He is a disabled tool maker and is married
with one child. He lives at home with his pregnant wife,
prior to being in the rehabilitation center. He denies
tobacco, drug or alcohol use.
MEDICATIONS: Medications at the rehabilitation center were
valium 10 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., Senna
prn, Folate 1 mg p.o. q.d., Methotrexate 12.5 mg p.o. q.
week, Zoloft 75 mg p.o. q.d.
ALLERGIES: Penicillin which causes anaphylaxis.
PHYSICAL EXAMINATION: Examination on admission revealed
temperature 99.2, pulse 89, blood pressure 122/79,
respiratory rate 29, 96 percent on room air. Generally, a
pleasant man in moderate discomfort. Neck is supple without
Lhermitte sign. Heart has regular rate and rhythm with no
murmurs. Lungs are clear to auscultation bilaterally.
Abdomen is soft, nontender, nondistended. Extremities showed
no cyanosis, clubbing or edema.
On neurologic examination he is awake, alert and cooperative
to examination. He is oriented times three and is able to do
the months of the year backwards. He is recall 3 out of 3
after 30 seconds and 5 minutes. His language is fluent with
good comprehension and repetition. His naming is intact. He
has significant dysarthria. He has no apraxia or neglect.
On cranial nerve examination his pupils are equally round and
reactive to light, 4 to 3 mm bilaterally. Visual fields are
full to confrontation. There is no relative afferent
pupillary defect or red desaturation. He has a left sixth
nerve palsy with esotropia on primary gaze. His facial
sensation is intact bilaterally. He has a right facial
droop. His hearing is intact to finger rub bilaterally.
Palate elevates symmetrically and tongue deviates to the
right without fasciculation. Sternocleidomastoid and
trapezius are normal bilaterally. On motor tone he has
normal tone in the upper extremities. He has increased tone
in the lower extremities with a five beat clonus in the right
ankle. There is also one beat clonus in the left ankle.
There is no tremor. On the motor examination he had a right
deltoid that 4-/5. He had wrist flexors and finger flexors,
adductors and abductors which were 4+/5. His right biceps,
wrist extensor, hamstring, ankle extensor, toe extensors,
everters were 4 out of 5. His iliopsoas was very weak at 2
out of 5 on the right and 4 out of 5 on the left. On his
left side, his deltoid, triceps were 4 out of 5 with the rest
of the muscle group being 5 out of 5. On sensory examination
he is intact to light touch, pinprick, cold temperature,
vibration and proprioception. He is hyporeflexive throughout
and symmetric. His toes are upgoing bilaterally. On
coordination examination he has dysmetria on the finger-to-
nose test, right greater than left. Gait was not assessed at
this time.
HOSPITAL COURSE: Given the patient's history and past
medical problems, it is likely that he has reexacerbation of
his multiple sclerosis and likely has new demyelinating
disease, likely in the thalamocapillar region to produce the
right-sided weakness and subjective sensory losses. He may
also have effective pontocerebellar tracts which give him the
vertigo and the weakness. Given this suspicion, an magnetic
resonance imaging of the brain was done which showed
enlarging focus of T2 hyperintensity involving the left
lateral plug and the left middle cerebellar peduncle which
demonstrates minor peripheral and central nodular enhancement
following gadolinium administrations. The other T2
hyperintensity in the periventricular white matter and corpus
collasum were unchanged. The patient was then started on
high dose intravenous steroids at this time, but within 24
hours, he worsened to the point that he had a dysphagia,
increasing diplopia and increasing right-sided weakness. He
reported that neither his right arm or leg was antigravity.
At this point, it was decided in conjunction with his
multiple sclerosis doctor that he receives plasmapheresis in
addition to the intravenous steroids. He did slowly improve
with these two treatment regimens. The patient was also
continued on his Methotrexate. It was later decided he
should be switched over to p.o. Cytoxan for adjunctive
therapy. His complete blood count was checked one day prior
to discharge and his white count was stable at 23.1.
Infectious disease - The patient came in with a urinalysis
showing abundant [**Last Name (LF) 23087**], [**First Name3 (LF) **] he started on Fluconazole for a
[**First Name3 (LF) 23087**] infection. A repeat urinalysis later showed no
evidence of [**First Name3 (LF) 23087**] but evidence of bacteria so he started on
three day Levaquin. The patient also complained of ear pain
and otoscopic examination showed that there was some erythema
and swelling of the tympanic membrane. It is likely that he
had otitis media so he was started on Zithromax.
Pulmonary, central apnea - On the first day of
plasmapheresis, the patient had an episode of tachypnea and
desaturation. he was sent to the Intensive Care Unit for 24
hour observation. It was felt that this was due to his
demyelinating lesions in the central nervous system so he was
monitored with a continuous pulse oximetry while on the
medical floor. He no longer had any other problems with his
respiratory status as his treatment for multiple sclerosis
were in progress.
DISCHARGE DIAGNOSIS: Multiple sclerosis.
Urinary tract infection.
Otitis media
Central apnea.
DISCHARGE MEDICATIONS:
1. Cytoxan 50 mg p.o. q.d.
2. Zoloft 75 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Prevacid 30 mg p.o. q.d.
5. Folate 1 mg p.o. q.d.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with physical therapy.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 8760**] in
three weeks.
The patient is to follow up with his primary care doctor in
one week.
The patient is to have urinalysis repeated and a complete
blood count checked q. week and sent to Dr. [**Last Name (STitle) 8760**].
[**First Name11 (Name Pattern1) 16376**] [**Last Name (NamePattern4) 16377**], MD [**MD Number(2) 16378**]
Dictated By:[**Last Name (NamePattern1) 11265**]
MEDQUIST36
D: [**2107-5-12**] 07:05:08
T: [**2107-5-12**] 08:43:47
Job#: [**Job Number **]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3940
} | Medical Text: Admission Date: [**2111-2-1**] Discharge Date: [**2111-2-4**]
Date of Birth: [**2049-3-16**] Sex: F
Service: MEDICINE
Allergies:
Reglan
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61F with chronic headaches and symptoms of hypopituitarism since
[**10-20**], s/p multiple evaluations, recently discharged from [**Hospital1 18**]
[**2111-1-23**] for symptoms of severe headache, nausea, and vomitting,
at which time she underwent largely unremarkable LP, and was
evaluated by neurosurgery and neuro-oncology who recommended
discharge home with plan for outpatient biopsy of her mass.
.
Since her discharge, the patient describes feeling quite well,
with good control of her headaches with tylenol and prn
fioricet. She has ongoing symptoms of nausea, but notes no
vomitting. She otherwise denied any fevers, abdominal pain.
.
She did note 2-3 episodes of "feeling wobbly" when looking to
the left only, which she attributed to her celexa, though she is
certain she has not missed any dosages. These symptoms have
resolved completely at present.
.
She also describes an episode of syncope ~2 weeks PTA. She rose
from her bed, and while walking to the kitchen, "saw black
spots" and found herself on the floor. Her husband witnessed
the fall, notes LOC lasting <1-2 seconds, no head trauma.
.
She was doing well until 1d PTA, when she awoke in her USOH,
then developed gradually worsening HA over the course of the
evening, starting between her eyes, then spreading to behind
both eyes, sharp, stabbing pain, eventually spreading over the
top of her head, and into the upper neck. She notes a 3-4min
period of a "film over my right eye" but otherwise denies other
visual or auditory changes (has chronic ringing in her ears).
She also notes intermittent episodes of dizziness when looking
towards the left.
.
Over the course of the night she took tylenol x 2, then fioricet
x 2, then dilaudid 2mg po x 1, then fioricet, without releif.
Her headache was worse with vagal maneuvers. She presented to
the ED in the morning, having been unable to sleep.
.
In ED VS= 98.1 133/86 933 20 95%RA. She received 1L IVF,
reglan 10mg iv, benadryl 25mg iv x 1, ativan 0.5mg x 1, with
some improvement of her pain from [**9-20**] to ~[**7-21**]. She is
admitted to the medical service for pain control.
During her most recent admission, which tme MRI of the head
demonstrated a 9x10mm pituitary mass.
Past Medical History:
Past Medical History:
- restless leg syndrome
- breast CA s/p R mastectomy with reconstruction, s/p chemo, has
had normal mammograms annually since
- hypercholesterolemia
- pituitary mass
.
Past Surgical History:
- R mastectomy with reconstruction
- hip surgery
- R knee surgery
- s/p appendectomy
- s/p tonsillectomy
Pituitary mass
R breast ca (s/p breast reconstruction) 15 years ago
Microscopic Colitis with intermittent diarrhea
Hyperlipidemia
Depression
Restless legs syndrome
hip and knee surgeries in the past
tonsillectomy during childhood
Family History:
Mother had breast cancer, father had [**Name (NI) 2481**] disease.
Physical Exam:
VS: 98.7 160/92 100 18 99%RA
GEN: initially uncomfortable, after receiving dilaudid/ativan,
sleepy.
HEENT: PERRL (3->2mm bilaterally), no overt papilledema (exam
limited by pt participation). no cervical LAD.
CV: RR, no murmurs, rubs, [**Last Name (un) 549**].
PUL: CTA bilaterally, no rales, ronchi, wheezing.
ABD: soft, non-tender, nondistended, normal bowel sounds.
EXT: no edema.
SKIN: no rash.
NEURO: A&Ox3. CN 2-12 intact. pupils 4-2mm bilaterally. no
gross horizontal nystagmus. 5/5 strength at biceps, triceps,
delts, wrist extension, hip flexion, dorsoflexion,
plantarflexion. visual [**Last Name (un) 18100**] grossly intact. normal finger to
nose coordination. gait not assessed [**1-13**] just receiving
dilaudid. visual [**Last Name (un) 18100**] grossly intact.
Pertinent Results:
[**2111-2-1**] 07:55AM BLOOD WBC-13.8* RBC-4.72 Hgb-14.1 Hct-42.8
MCV-91 MCH-29.9 MCHC-32.9 RDW-14.7 Plt Ct-500*#
[**2111-2-1**] 07:55AM BLOOD Neuts-55.6 Lymphs-36.7 Monos-5.0 Eos-1.4
Baso-1.4
[**2111-2-1**] 07:55AM BLOOD Plt Ct-500*#
[**2111-2-1**] 07:55AM BLOOD PT-12.0 PTT-24.6 INR(PT)-1.0
[**2111-2-1**] 07:55AM BLOOD ESR-40*
[**2111-2-1**] 07:55AM BLOOD Glucose-85 UreaN-12 Creat-0.9 Na-139
K-5.9* Cl-100 HCO3-28 AnGap-17
[**2111-2-1**] 07:55AM BLOOD CRP-7.2*
[**2111-2-1**] 11:00AM BLOOD Glucose-93 K-4.4
[**2111-2-1**] 08:03AM BLOOD Lactate-1.5
[**2111-2-1**] 11:00AM BLOOD Hgb-14.0 calcHCT-42
Brief Hospital Course:
This is a 61 year-old woman with known pituitary hypofunction
and inflammation of unknown etiology who represented with severe
headache, nausea, and vomiting. The etiology of headache was not
entirely clear but could be secondary to the undiagnosed
pituitary process as the symptoms of panhypopituitarism
(fatigue, polyuria, polydipsia, etc) were coincident with
headache onset. There was no evidence of intracranial hemorrhage
or increased intracranial pressure. She had no visual changes to
suggest temporal arteritis and a biopsy in the past month was
negative. In regards to the etiology of the pituitary
inflammation, she was seen by endocrine and neurosurgery during
last admission. The DDX was wide and included inflammatory or
granulomatous process, or metastasis (h/o breast cancer). During
that admission, she had LP with CSF findings of elevated protein
with negative protein electrophoresis (no oligoclonal banding)
and negative flow cytometry for malignant cells. She also had
negative beta-2-microglobulin, CEA, LDH, ACE, routine culture,
AFB stain, gram stain, cryptococcal antigen, and HSV. The CSF
VDRL was still pending. The patient will have transsphenoidal
pituitary surgery for definite diagnosis this Friday. During
this admissiom, she had conservative management with pain
control with Dilaudid and Tylenol and anti-emetics with Zofran
and Compazine.
Medications on Admission:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Pramipexole 0.25 mg Tablet Sig: Two (2) Tablet PO daily ().
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ketoconazole 2 % Cream Sig: One (1) application Topical [**Hospital1 **]
(2 times a day).
5. Desonide 0.05 % Cream Sig: One (1) application Topical [**Hospital1 **] (2
times a day).
6. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): This medicine is for nausea, you may take around the
clock to prevent nausea.
Disp:*75 Tablet(s)* Refills:*0*
8. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for severe
nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
9. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-13**]
Tablets PO Q6H (every 6 hours) as needed for head ache.
Disp:*60 Tablet(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for pain: This is only for severe headaches
that are not responsive to fiorcet.
Disp:*10 Tablet(s)* Refills:*0*
11. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
12. Lorazepam 0.5 mg Tablet Sig: [**12-13**] Tablet PO BID (2 times a
day): you may take 1 extra dose per day as you need for nausea.
Disp:*30 Tablet(s)* Refills:*2*
13. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for diarrhea.
Disp:*30 Tablet(s)* Refills:*0*
14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
4. Desonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
10. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for headache/neck pain.
11. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO QDAILY ().
12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for headache.
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Severe headache
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You had headache that was treated conservatively with
medications hoping that a trans-sphenoidal biopsy (brain biopsy)
will reveal the etiology for the inflammation in the pituitary
region. Please do not take aspirin or NSAIDS (like Ibuprofen)
for headache until after your surgery.
Followup Instructions:
Please see your Neurosurgeon on Friday for the brain biopsy
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3941
} | Medical Text: Admission Date: [**2154-4-9**] Discharge Date: [**2154-4-18**]
Date of Birth: [**2084-12-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
BiPap
Intubation, extubation ([**2154-4-13**])
History of Present Illness:
69 year old male with history of HIV (CD4 116 [**2154-4-8**]), COPD
(2-4L at home), DVT on coumadin, hypertension, chronic lower
back [**Last Name (un) 2187**], osteoporosis who presents with respiratory distress.
The patient had been recently admitted 5/13-16/[**2153**] for COPD
exacerbation and treated with nebs, azithromycin, prednisone
(slow taper). The patient presented to the ED on [**2154-4-2**] for
dyspnea but left AMA before admission. He was sent to the ED on
[**2154-4-8**] but left AMA again, with prednisone and azithromycin
prescriptions which he never filled. He had seen Dr. [**Last Name (STitle) **] in
pulmonary clinic yesterday and had been non-compliant with
prednisone taper. He endorsed "exhaustion" at the appointment
but was stable 93% on 3.5L nasal cannula. The patient had also
been at [**Hospital **] Clinic with Dr. [**Last Name (STitle) 2185**] prior to Pulmonary
appointment.
.
The patient re-presented to the ED today with worsening dyspnea
and was brought in by EMS in respiratory distress (enroute CO2
50). He responded to nebulizers enroute and arrived looking very
uncomfortable, using accessory muscles. He was tight on
pulmonary exam with minimal breath sounds and speaking few word
sentences. The patient was started on BiPap (50%, PSV 15, PEEP
5), which he tolerated well. He was briefly weaned off to 4L NC
but decompensated, tripoding despite Methylprednisolone 125mg IV
X1, Azithromycin 500mg, more nebulizers and ativan 2mg IV.
.
ROS: Patient denies fevers/chills, nausea/vomiting, myalgias,
changes in bowel movement or urination.
Past Medical History:
* HIV (diagnosed [**2135**], s/p multiple HAART regimens, no history
of opportunistic infections, CD4 nadir [**2154-4-8**] 116)
* COPD (chornic O2 therapy at home 2-4L PRN, intubated recently
at [**Hospital6 **] and was DNR/DNI in the past)
* DVT (left lower extremity, [**2152-3-17**]; still on Coumadin therapy
- for sedentary lifestyle)
* h/o Rectal bleeding
* Chronic lower back pain s/p numerous back surgeries
* Hypertension
* Basilar aneurysm s/p clipping by Dr. [**Last Name (STitle) 1338**] ([**2134**])
* h/o substance abuse with cocaine
* Anemia of chronic disease
* Osteoporosis
* s/p ileocecetomy for ?cancer. SBO in [**2136**] with lysis of
adhesions
Social History:
Denies alcohol, smoking or illicit drugs (since [**2135**]). Previous
80 pack year smoker. Lives alone, uses wheelchair.
Family History:
Hypertension and throat cancer in brother (smoker)
Physical Exam:
Temp: 97.0 BP: 132/80 HR: 89 RR: 18 O2sat 100% on Bipap (15/5,
50%)
GEN: Pleasant, comfortable, NAD, mildly anorexic
HEENT: PERRL, EOMI, anicteric, MMM,
RESP: CTA b/l with good air movement throughout, ?prolonged
expiratory phase, barrel chested with increased AP diameter
CV: Regular rate, rhythm; S1 and S2 wnl, no murmurs/gallops/rubs
ABD: Nontender, nondistended, +BS, soft
EXT: No cyanosis/ecchymosis, [**11-18**]+ bilateral lower extremity
edema (symmetric)
SKIN: No rashes/no jaundice/no splinters
NEURO: AAOx3. CN 2-12 intact. Strength and sensation intact.
.
Discharge Exam:
No vitals (cmo)
Gen: Cachectic in NAD, no jaundice, no palor
HEENT: NCAT PERRL MMMs OP clear
Neck: No JVP elevation supple
Pulm: Very poor air movement wheezes throughout; no rhonci no
crackles
CV: RRR nml S1 S2 no m/r/g
Ab: +BS NTND
Ext: No edema
Neuro: Grossly intact AO x 3 responding appropriately to
questions
Pertinent Results:
[**2154-4-9**] 06:47PM O2-100 PO2-244* PCO2-53* PH-7.44 TOTAL
CO2-37* BASE XS-10 AADO2-426 REQ O2-73
[**2154-4-9**] 06:13PM LACTATE-1.9
.
CXR [**4-9**]:
Patchy opacity in left lung base, similar to the prior study,
which remains concerning for infection. Severe emphysema.
.
CXR [**4-13**]:
An endotracheal tube lies at the level of the
clavicular heads, appropriately positioned. A nasogastric tube
courses into the stomach. Severe emphysema is noted. The
cardiomediastinal silhouette is stable. There are small
bilateral pleural effusions. The left lower lobe opacity has
mildly improved and reflects resolving infection. No new focal
consolidation is appreciated.
.
Discharge Labs:
None
Brief Hospital Course:
69 year old male with history of HIV (CD4 116 [**2154-4-8**]), COPD
(2-4L at home), DVT on coumadin, hypertension, chronic lower
back [**Last Name (un) 2187**], osteoporosis who presents with respiratory distress.
.
# Respiratory Distress: Most likely due to ongoing COPD
exacerbation. Trigger unclear given lack of pneumonia on initial
CXR, no fevers/chills, productive cough. Patient has been
non-compliant with medications, however, since discharge; this
includes prednisone and antibiotics. ?compliance with nebulizers
and has supplemental O2 at home. The patient has had CTA
recently to rule out pulmonary emboli given ongoing dyspnea
despite therapy. He was treated with azithromycin for 5 days and
methylprednisolone. He intermittently required BiPap. A plan was
made to use bipap at night once the patient was able to leave
the ICU. However on the morning of [**4-13**] patient was anxious,
tachypneic and desatted and required intubation. The patient
was extubated on [**4-14**]. He did well overnight but subsequently
had further respiratory distress and his steroids were increased
to full burst. He ultimately decided to be DNR/DNI and came to
the understanding that he wasn't going to get better; the
patient decided to become CMO and was discharged to home hospice
after discussing with Palliative Care in-house.
- Continue long steroid taper at home (Prednisone 60mg X 7 days,
40mg X 7 days, 20 mg X7 days, 10mg X 7 days, off)
- Continue supplemental oxygen, albuterol and ipratropium nebs
- Continue MS contin and morphine liquid PRN for air hunger,
shortness of breath
- Continue lorazepam PRN for air hunger, shortness of breath,
anxiety
.
# HIV: Down trending CD4 count, ?due to acute illness. Continued
abacavir, lamivudine, fosamprenavir, and atazanavir. Continued
Bactrim SS daily. Patient does have history of Bactrim needing
to be held in [**10/2153**] for bone marrow suppression. The need for
ongoing HAART medication and PCP prophylaxis was discussed with
the patient. It was felt that he likely will not succumb to
HIV/AIDS or an opportunistic infection before he succumbs to his
end-stage COPD. However, taking these medications are not a
hardship for the patient and he would prefer not to risk
increasing HIV viral load and chance of opportunistic infection,
especially in the setting of ongoing steroids.
- The patient will be discharged home on hospice with
continuation of his HAART medications and Bactrim PCP
[**Name Initial (PRE) 1102**].
.
# DVT: LENI the day prior to admission as outpatient was
negative for DVT. Patient has been therapeutic and followed by
[**Hospital3 **] here at [**Company 191**]. He missed several doses of
Coumadin in the settting of being on Bipap and developed a
subtherapeutic INR. He was bridged with Lovenox. Anticoagulation
held [**4-13**] for concern for GIB but coumadin was resumed when hct
was stable for 24 hrs. Upon discharge home with hospice,
however, anticoagulation was discussed with the patient. As he
had a DVT in [**2152-3-17**] and ultimately completed treatment but was
continued given his sedentary/immobile nature, the indication
for ongoing anticoagulation and risk of DVT/PE is not high.
- Given this information, the patient chose to be discharged off
of coumadin. His primary care provider and the [**Name9 (PRE) 191**]
anticoagulation nurses were informed of his decision, and the
fact that he no longer needs INR checks.
.
#GIB: Patient noted to have guaic positive stool. T+S sent, PPI
started, PICC placed, transfused 1 unit of blood but did not
bump appropriately, so given 2nd unit. Hct then increased
appropriately and remained stable.
- PPI was stopped given the absence of frank melena on discharge
and to minimize medications for hospice.
.
# Multifocal atrial tachycardia: Seen in the ED during patient's
hospitalization [**2154-3-28**]. Patient was started on diltiazem in
this setting but did not have MAT last admission either. The
patient can continue on home diltiazem on discharge to prevent
discomfort from breakthrough tachycardia.
.
# Anemia: Slightly lower than baseline Hct close to 30.
Normocytic and previously thought due to chronic disease. HAART
medications may be contributing to marrow suppression. In
addition, pt noted to have guaic positive stools which are
discussed above.
.
# Hypertension: Stable, mildly hypertensive, continued [**Last Name (un) **]
diltiazem and doxazosin. -- doxazosin was stopped on discharge
for hospice to streamline medications.
.
# Osteoporosis: On Calcium and Vitamin D.
- These medications were stopped on discharge to streamline
medications.
.
# GERD: Admitted on famotidine. Stable, started on PPI as above
while intubated as famotidine can also interact with HIV
medications; also in setting of guaiac positive stools per
above.
- Famotidine was stopped on discharge to streamline medications.
.
# Other transitional issues:
- Continue home O2 as prescribed
- Oral suction as prescribed
- Maintain PICC with appropriate heparin flushes as a provision
for morphine infusion if patient's air hunger is refractory to
PO morphine elixir and he requires IV morphine
Medications on Admission:
* Atazanavir 400mg daily
* Fosamprenavir 1400mg twice daily
* Aspirin 325mg daily
* Abacavir 600mg daily
* Lamivudine 300mg daily
* Albuterol nebs every 2 hours PRN SOB, wheezing
* Ipratropium nebs every 6 hours
* Warfarin 3mg daily six times weekly, 2mg on Friday
* Doxazosin 2mg qHS
* Diltiazem 30mg three times daily
* Famotidine 20mg daily
* Bactrim 400-80 daily
Discharge Medications:
1. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for constipation.
5. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours:
Standing.
Disp:*30 nebs* Refills:*2*
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for wheezing, shortness of breath.
10. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours): standing.
Disp:*30 nebs* Refills:*2*
11. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): x7days, 2 tablets daily X7d, 1 tab daily X 7d, half tab
daily X 7d, then off.
Disp:*46 Tablet(s)* Refills:*0*
12. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for shortness of breath, air hungry, anxiety.
Disp:*60 Tablet(s)* Refills:*0*
13. MS Contin 15 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO every eight (8) hours.
Disp:*90 Tablet Extended Release(s)* Refills:*2*
14. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
Ten (10) mg PO q2h as needed for shortness of breath, air
hunger, pain.
Disp:*500 mL* Refills:*2*
15. Supplemental oxygen Sig: 1-5 liters once a day: via nasal
cannula, titrate to comfort PRN.
Disp:*1 tank* Refills:*2*
16. Admit to [**Hospital 2188**] Sig: One (1) once a day.
Disp:*1 unit* Refills:*2*
17. Maintain PICC at home
Maintain PICC at home with hospice for use with morphine
infusion if need for SOB, air hunger
18. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 ML(s)* Refills:*2*
19. Oral suction
As needed for secretions
20. Supplemental Home Oxygen
Oxygen 5-10L as needed
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary: COPD exacerbation
Secondary: HIV, prior DVT on anticoagulation, chronic lower back
pain, anemia of chronic disease, osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with difficulty breathing. You were found to
be having a COPD exacerbation. You were treated with steroids
(oral and intravenous), antibiotics, nebulizers. You were also
put on a breathing machine called BiPap to make it easier for
you to breath. With your very sick lungs, you did become very
tired at one point, and were intubated to use a machine to help
you breath. Once you were extubated, we discussed your prognosis
and the severity of your condition with you. You made the
decision to change your code status to Do Not Resuscitate/Do Not
Intubate. The goals of your medical care was made for comfort.
.
You are being discharged home with hospice, who will oversee
your care going forward and address all of your symptoms with
the goal of making you comfortable.
.
It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> Stop Coumadin and INR checks
--> Stop Aspirin
--> Stop Doxazosin
--> Stop Famotidine
--> Continue prednisone 60mg daily X 1 weeks, with a slow taper
--> Start Lorazepam as needed for shortness of breath, air
hunger, anxiety
--> Start MS Contin 30mg three times daily for air hunger
--> Start Morphine liquid 5-10mL every 2 hours as needed for air
hunger
--> Start Prednisone and take as directed according to the
prescribed taper
--> Continue Albuterol nebs every 4 hours standing
--> Continue Albuterol nebs every 2 hours as needed for
shortness of breath, wheeze
--> Continue Ipratropium nebs every 6 hours standing
.
Contact your hospice organization if you need help controlling
your symtoms.
Followup Instructions:
Please feel free to contact your hospice nurses and physicians
with any questions or concerns.
.
Also feel free to contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], your new primary care
doctor, at [**Hospital3 **] at [**Telephone/Fax (1) 250**].
.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2154-4-24**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2154-5-22**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2760, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3942
} | Medical Text: Admission Date: [**2168-7-19**] Discharge Date: [**2168-7-26**]
Date of Birth: [**2115-11-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Bactrim Ds / Sandostatin Lar / Sulfa
(Sulfonamides)
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy, mediastinoscopy, thoracotomy for RUL & RML
lobectomy
History of Present Illness:
53 yo F w/ history of sigmoid colectomy in 11/00 for colon
cancer since, s/p resection of liver metastases in [**2-3**], who
presents w/ hemoptysis in [**2-6**]. CT scan reveals 2 pulmonary
nodules: in R upper lobe and in R middle lobe. Biopsy
demoanstrated adenocarcinoma consistent w/ past colon ca.
Patient is administered chemotherapy with consequent tumor
shrinkage and patient is admitted on [**2168-7-19**] for surgical
excision of the pulmonary nodules.
Past Medical History:
1. Colon cancer status post sigmoid colectomy in 11/[**2162**]. Lymph
nodes were positive and she received adjuvant 5-FU and
leukovorin. She was found to have a liver metastases in [**2-3**] and
underwent resection of this. Her most recent colonoscopy and EGD
from [**9-5**] were unremarkable. However CT done for hemoptysis in
[**2-6**] revealed 2 pulmonary nodules within the right upper lobe
and right middle lobe. The right upper lobe nodule appears to
abut a subsegmental bronchus. These were biopised and confirmed
to be adenoCA. Patient may begin chemo in near future.
2.HOCM and resultant diastolic dysfunction, hyperdynamic EF of
70%, 3+ MR
3. Hypertension
4. IHSS
5. IDDM
6. PAF
7. OSA not on cpap
8. Anxiety and depression
9. Chronic sinusitis
10. Pituitary tumor resection in [**2144**].
11. Sinus surgery in [**2149**].
12. Abnormal PAP smear in 11/91.
13. Pacemaker DDD
14. obesity
Social History:
Lives alone; SSI since [**2160**]; worked 25 years in the Polaroid
plant.
Smoking: none
OH: none
Family History:
Her father died at 45 from an MI, mother died at 64
from a CVA. She has one sister who is a breast cancer
survivor, another sister who died at 47 from an MI and two of
her
sisters are alive and well.
Physical Exam:
Patient alert and oriented, NAD;
VS: 98.2 / 72 / 122/63 / 22 / 96 RA
Pulm: vesicular bilat.
Cardio: RRR
Wound: dry and clean; no erythema, no drainage, no sign of
infection;
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2168-7-25**] 09:50AM 8.0 3.68* 10.7* 32.3* 88 29.0 33.1 16.4*
176
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT) [**Name (NI) 11951**]
[**2168-7-26**] 05:55AM 13.4* 1.2
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2168-7-26**] 05:55AM 3.4
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2168-7-26**] 05:55AM 9.2 1.5*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2168-7-25**] 8:55 AM
CHEST (PA & LAT)
Reason: ?PTX/interval change
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman s/p RUL/RML lobectomy for metastatic colon CA.
CT now out
REASON FOR THIS EXAMINATION:
?PTX/interval change
TWO VIEW CHEST OF [**2168-7-25**]
COMPARISON: [**2168-7-23**].
INDICATION: Pneumothorax.
Examination is limited by underpenetration and low lung volumes.
A previously reported right lateral pneumothorax has nearly
resolved in the interval, with only a tiny residual lateral
pneumothorax remaining. Cardiac and mediastinal contours are
stable. There is increasing hazy increased opacity within the
lower portion of the right hemithorax. There is also a probable
small right pleural effusion. Allowing for technical factors,
the left lung is grossly clear, and there is no evidence of
significant left pleural effusion.
IMPRESSION:
1. Resolving right pneumothorax.
2. Increasing hazy opacity in lower right hemithorax. In the
appropriate clinical setting, evolving pneumonia should be
considered.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2168-7-25**] 12:34 PM
Brief Hospital Course:
Patient is operated on [**2168-7-19**] under general anesthesia for
felxible bronchoscopy, mediastinoscopy, R upper lobectomy and R
middle wedge lobectomy. Immediate post op period is spent in
PACU. On [**2168-7-20**], CXR reveal R hemothorax. Patient is transfused
with PRBC and thoracotomy is performed on the same day to stop
the bleeding. An epidural cath is placed by anesthesia for pain
control. Chest tubes are withdrawn on [**2168-7-23**].
Cardio: on [**7-25**] AM, patient went into atrial fibrillation; a
cardiology consult is requested and patient is treated with
amiodarone 400mg x4 weeks, then 200mg qd.
Afib recurred at 1800 for 1hour, therefore started on coumadin
upon d/c [**7-26**]- 2mg x3days. To be followed by [**Hospital 197**] clinic at
[**Company 191**]- [**Telephone/Fax (1) **]. Dr.[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2450**], [**Doctor Last Name 665**] and Smentana emailed for
re-referral to clinic. Dose to be managed by appropriate [**Hospital 191**]
clinic.
Patient discharged to home [**7-26**] in company of brother w/ [**Name2 (NI) 269**]
services with f/u appt by [**Doctor Last Name **] in 2 weeks, [**Name8 (MD) **], MD-
Cardiology in 4 weeks. [**Hospital 197**] Clinic draw [**7-29**], with dose f/u
by [**Hospital 191**] clinic.
Medications on Admission:
Amiodorone 200mg', Diovan 160'', Furosemide 80'', ranitidine
150'', atenolol 100'', KCl 10', ASA 325', Traizolam 0.25 qhs,
Lantus 24U qhs, [**Name (NI) 3435**] SS, MOM 2 tab qhs, flonase 50mcg'
Plan: home [**7-25**]
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
begin after you have completed the 4 weeks of 400mg.
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Triazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO DAILY (Daily).
12. Diovan 160 mg Capsule Sig: One (1) Capsule PO twice a day.
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24)
units Subcutaneous at bedtime.
14. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
unit Subcutaneous four times a day as needed for for blood
sugar: [**Month/Year (2) 3435**] Insulin- per Blood sugar need 4times/day.
15. Atenolol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
16. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day for 3
days: at bedtime.
Take 2 pill for [**7-26**], [**7-27**], [**7-28**] then as per Dr.[**Name (NI) 10427**] office
directs.
Disp:*30 Tablet(s)* Refills:*1*
17. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
four times a day as needed for shortness of breath or wheezing.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pulmonary nodules (metastatic colon cancer)
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office for: fever, shortness of breath, chest
pain, drainage from incision site.
You may shower. No tub baths or swimming for 3-4 weeks.
You may change bandaids on chest tube sites as needed.
Do not remove small strips on incision site, let them fall off.
No lifting more than 5 pound for 2 weeks, them as per lung
surgery booklet.
Restart regular medicine as previous.
Take new medication as directed for pain. No driving if taking
narcotic medication. Can transition to tylenol when able
Followup Instructions:
Call for appointment w/ Dr. [**Last Name (STitle) **] in [**9-16**] days. [**Telephone/Fax (1) 170**].
Call for an appointment to see Dr. [**Last Name (STitle) **] in 4 weeks.
[**Telephone/Fax (1) 285**].
Completed by:[**2168-7-26**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3943
} | Medical Text: Admission Date: [**2104-8-21**] Discharge Date: [**2104-8-26**]
Service: MEDICAL
HISTORY OF PRESENT ILLNESS: This is a 78 year old woman with
a history of severe chronic obstructive pulmonary disease,
ulcerative colitis, status post ileostomy in [**2097**], aortic
stenosis, status post valvuloplasty in [**2097**], and then aortic
valve replacement with a porcine aortic valve in [**2098**], and a
left below the knee amputation in [**2065**], who has had one week
of cough and sputum production that was treated with Levaquin
and Flagyl.
Two days prior to admission, the patient developed nausea and
vomiting and stopped taking her Flagyl but still had nausea.
She stopped being able to eat well and had some respiratory
distress and had diarrhea. She was sent to the Emergency
Department for evaluation. She denied any chest pain, denied
any blood in the diarrhea, denied any blood in her vomit,
denied fever, chills.
PHYSICAL EXAMINATION: On arrival in the Emergency
Department, the patient's examination revealed she was an
uncomfortable dyspneic woman on oxygen via nasal cannula who
had to pause while speaking secondary to her dyspnea. She
was afebrile. Her blood pressure was 116/60 with a pulse of
86, respiratory rate 20s with oxygen saturation of 95% in
room air. Head, eyes, ears, nose and throat - She was
normocephalic and atraumatic with no icterus. Her mucous
membranes were dry. She had no jugular venous distention.
Her chest had basilar crackles bilaterally, diffusely
decreased breath sounds. The heart was regular. She had a
III/VI midsystolic murmur. Her abdomen was obese, soft,
nontender, no hepatosplenomegaly. The ileostomy bag was in
place. Her extremities revealed status post left below the
knee amputation. Her right lower extremity was cool with
chronic erythema and venous stasis changes and trace edema.
LABORATORY DATA: On admission, white count 13.9, hematocrit
42.5, platelets 308,000. INR 2.1. Chem7 revealed a sodium of
136, potassium 5.7, chloride 111, bicarbonate 6, blood urea
nitrogen 120, creatinine 3.0, glucose 110. A troponin was
less than 0.3. Urinalysis had 30 protein, specific gravity
of 1.016, three white cells, two red cells and a few
bacteria. ALT was 8, AST 20, alkaline phosphatase 102, total
bilirubin 0.4, amylase 111, CK 53.
Her chest x-ray showed no congestive heart failure and no
pneumonia. Arterial blood gases at that time revealed pH
7.21, pCO2 22, pO2 153.
Electrocardiogram showed sinus rhythm at 90 beats per minute.
Q wave in III, aVF and V2, 1.[**Street Address(2) 2811**] depressions in
II, V3 through V6. T wave inversions in I, II, aVL, V4
through V6 and biphasic in V3.
HOSPITAL COURSE: She was admitted to the Medical Intensive
Care Unit for correction of her metabolic acidosis and acute
renal failure and for ruling out acute myocardial infarction.
1. Metabolic acidosis - She was given three amps of
bicarbonate in one liter of fluid. She had blood cultures
drawn. She was treated with oxygen. Calcium, phosphorus and
magnesium levels were drawn and found to be low. She was
repleted with those intravenously and her acidosis responded
so that on the day of transfer to the floor, her bicarbonate
was 19 and she was able to tolerate p.o.
2. Acute renal failure - She had a creatinine of 3.0 when
her baseline is 1.1. This responded well to intravenous
fluid hydration so that on the day of transfer to the floor
her creatinine was 1.8 and on the day of discharge from the
hospital her creatinine was 1.3.
It was thought that both metabolic acidosis and the acute
renal failure were secondary to severe volume depletion from
diarrhea and decreased p.o. intake. She has responded well
to intravenous rehydration and repletion of her electrolytes.
3. Rule out myocardial infarction - Serial CKs were done
which were negative. Her troponin was always less than 0.3.
Despite the changes on the electrocardiogram, she was found
not to have had a myocardial infarction. It was thought that
these changes were secondary to some ischemia probably
induced by the volume depletion.
4. Respiratory - She began to have some increasing shortness
of breath on the day of transfer to the floor and stated that
at home she takes Albuterol nebulizer twice a day. These
were started on the floor and her breathing improved. She
continued on her normal respiratory medications, inhalers and
was continued on b.i.d. nebulizers.
5. Gastrointestinal - The patient presented with nausea,
vomiting, diarrhea and decreased p.o. intake. Over her
hospital stay, the diarrhea decreased and her stools became
more formed. She was able to tolerate p.o. and hydrate
herself and replete her electrolytes through p.o. Amylase and
lipase were within normal limits throughout her hospital
stay.
6. Infectious disease - The patient was diagnosed with
pneumonia prior to admission and stopped her antibiotics
during her illness. No consolidation was seen on chest x-ray
but it was decided to treat her with Levaquin and Flagyl.
Flagyl was discontinued two days prior to discharge and she
will be continued on Levaquin for a total of ten days and
will stop her course on [**2104-9-1**]. Her blood cultures have
been negative throughout as has a urine culture and she has
been afebrile since her transfer from the Medical Intensive
Care Unit.
7. Hematology - Her INR was 2.1 on admission and it was
subsequently checked and found to be 1.9. Her liver function
tests were normal and it was felt that this was due to
Vitamin K depletion from poor nutrition. She was given
Vitamin K p.o. for three days and her INR will be checked
again as an outpatient.
She will follow-up with her regular primary care physician
when she gets home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: She will be discharged to a rehabilitation
facility for further assistance with her activities of daily
living, respiratory status and her p.o. repletion.
MEDICATIONS ON DISCHARGE:
1. Albuterol and Atrovent nebulizers b.i.d.
2. Atrovent MDI two puffs b.i.d.
3. Vanceril MDI four puffs b.i.d.
4. Humibid 600 mg p.o. b.i.d.
5. Zantac 150 mg p.o. q.d.
6. Isordil 10 mg p.o. t.i.d.
7. Metoprolol 25 mg p.o. b.i.d.
8. Levofloxacin 250 mg p.o. q.d. to finish on [**2104-9-1**].
9. Heparin 5000 units subcutaneous q.d.
10. Magnesium Oxide 420 mg p.o. t.i.d.
11. Elavil 10 mg p.o. q.h.s. p.r.n.
12. Calcium Carbonate one gram p.o. q.d.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease.
2. Ulcerative colitis, status post ileostomy.
3. Left below the knee amputation.
4. Aortic stenosis, status post porcine aortic valve
replacement.
5. Acute renal failure which is resolving.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**]
Dictated By:[**Last Name (NamePattern1) 6857**]
MEDQUIST36
D: [**2104-8-25**] 18:28
T: [**2104-8-25**] 19:36
JOB#: [**Job Number 6858**]
ICD9 Codes: 5849, 496, 2765, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3944
} | Medical Text: Admission Date: [**2153-9-20**] Discharge Date: [**2153-9-25**]
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Sulfa (Sulfonamides) /
Buspar / Haldol / Levaquin / Sulfamethoxazole/Trimethoprim /
Trazodone / Percocet
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Tracheostomy change, bronchoscopy
History of Present Illness:
This 83 year old female with a history of metastatic thyroid
cancer, asthma, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with tracheostomy on ventilator at
home presents with three weeks increasing shortness of breath.
Three weeks ago she had a stomach flu followed by a cold at
which time she was producing tan colored sputum. Her cold
resolved however since that time she has had increased shortness
of breath. At home she is on a ventilator at night and she was
needing the ventilator during the day as well. She desatted to
60s when she was walking and has lots of trouble with any
exertion. She has had no chest pain with this SOB but does note
some tachycardia. She has felt hot and had cold sweats at times
but no documented fever. At this time she has no sputum
production.
She was scheduled for an appointment to have her tracheostomy
changed here by Dr. [**Last Name (STitle) **] to see if that improved her shortness
of breath. At the IP appointment she was found to have a sat of
78% which improved on the ventilator. Her tracheostomy was
changed with no improvement in her saturation or her shortness
of breath. She was transfered to the MICU for further
evaluation.
At this time she is on our ventilator and is comfortable with
no shortness of breath, no chest pain, no abdominal pain. Of
note she has recently had a flair of her Ulcerative colitis
notable for blood in her stools and loose stools. She has
increased her Asacol dosage as she normally does when her UC
flairs. She also notes increased hoarseness of her voice.
Past Medical History:
thyroid cancer, mets, thyroidectomy, history of iodine
treatments, cataract, a-fib on coumadin, ulcerative colitis,
bilateral dvt, greefield filter, mitral regurgitation, asthma,
history of PEG removed, hypertension, ocular migraines, normally
on trach support at night.
Social History:
Lives with daughter, two sons, and husband in [**Name (NI) 5583**]. No
history of smoking, no history of drinking
Family History:
History of lung and ovarian cancer
Physical Exam:
Vitals Temp 98.6 Pulse 75 BP 111/77 91% on A/C 500X15, FIO2
0.25, Peep 5
Gen: alert, oriented, cooperative, female with tracheostomy in
place on ventilator
HEENT: MMM, OP clear, PERRL
Lungs: scattered rhonchi, no wheezes, good air movement
throughout
CV: RRR, nl S1S2, 3/6 systolic murmer loudest at the apex
Abd: soft, non-tender, non-distended, positive BS
Ext: no edema, no clubbing or cyanosis
Neuro: grossly intact
Pertinent Results:
[**2153-9-20**] 09:10PM TYPE-ART PO2-67* PCO2-51* PH-7.43 TOTAL
CO2-35* BASE XS-7
[**2153-9-20**] 06:12PM GLUCOSE-200* UREA N-10 CREAT-0.6 SODIUM-138
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-35* ANION GAP-11
[**2153-9-20**] 06:12PM ALBUMIN-3.9 CALCIUM-9.1 PHOSPHATE-3.2
MAGNESIUM-1.7
[**2153-9-20**] 06:12PM TSH-0.69
[**2153-9-20**] 06:12PM WBC-5.2 RBC-4.15* HGB-12.0 HCT-37.6 MCV-91
MCH-28.9 MCHC-31.9 RDW-14.9
[**2153-9-20**] 06:12PM NEUTS-67 BANDS-0 LYMPHS-18 MONOS-10 EOS-3
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2153-9-20**] 06:12PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2153-9-20**] 06:12PM PLT COUNT-204
[**2153-9-20**] 06:12PM PT-18.4* PTT-36.1* INR(PT)-2.4
[**2153-9-21**] 04:15AM BLOOD PT-17.7* PTT-32.6 INR(PT)-2.2
[**2153-9-22**] 04:36AM BLOOD PT-23.4* PTT-34.9 INR(PT)-4.0
[**2153-9-23**] 11:56AM BLOOD PT-37.5* PTT-41.0* INR(PT)-10.8
[**2153-9-21**] 04:15AM BLOOD WBC-3.5* RBC-4.01* Hgb-11.8* Hct-35.7*
MCV-89 MCH-29.4 MCHC-33.1 RDW-15.1 Plt Ct-198
[**2153-9-22**] 04:36AM BLOOD WBC-6.0# RBC-4.32 Hgb-12.4 Hct-39.1
MCV-91 MCH-28.7 MCHC-31.7 RDW-15.1 Plt Ct-229
[**2153-9-24**] 06:07AM BLOOD WBC-5.6 RBC-3.98* Hgb-11.5* Hct-35.5*
MCV-89 MCH-28.8 MCHC-32.3 RDW-15.2 Plt Ct-174
[**2153-9-25**] 03:38AM BLOOD WBC-5.7 RBC-4.02* Hgb-11.6* Hct-36.5
MCV-91 MCH-28.8 MCHC-31.8 RDW-15.1 Plt Ct-179
[**2153-9-20**] 06:12PM BLOOD Plt Ct-204
[**2153-9-21**] 04:15AM BLOOD Plt Ct-198
[**2153-9-22**] 04:36AM BLOOD Plt Ct-229
[**2153-9-24**] 06:07AM BLOOD Plt Ct-174
[**2153-9-25**] 03:38AM BLOOD Plt Ct-179
[**2153-9-24**] 06:07AM BLOOD PT-30.2* PTT-43.8* INR(PT)-6.8
[**2153-9-24**] 04:40PM BLOOD PT-26.6* PTT-41.9* INR(PT)-5.2
[**2153-9-25**] 03:38AM BLOOD PT-18.0* PTT-36.2* INR(PT)-2.3
[**2153-9-21**] 04:15AM BLOOD Glucose-158* UreaN-12 Creat-0.5 Na-137
K-4.1 Cl-99 HCO3-30 AnGap-12
[**2153-9-22**] 04:36AM BLOOD Glucose-145* UreaN-17 Creat-0.5 Na-137
K-4.2 Cl-99 HCO3-29 AnGap-13
[**2153-9-24**] 06:07AM BLOOD Glucose-93 UreaN-16 Creat-0.6 Na-141
K-3.2* Cl-103 HCO3-31 AnGap-10
[**2153-9-25**] 03:38AM BLOOD Glucose-97 UreaN-14 Creat-0.5 Na-137
K-4.2 Cl-103 HCO3-30 AnGap-8
[**2153-9-21**] 04:15AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.6
[**2153-9-22**] 04:36AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.8
[**2153-9-24**] 06:07AM BLOOD Albumin-3.1* Calcium-8.0* Phos-3.0 Mg-1.6
[**2153-9-25**] 03:38AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.8
[**2153-9-20**] 06:12PM BLOOD TSH-0.69
[**2153-9-21**] 07:42AM BLOOD Type-ART pO2-66* pCO2-47* pH-7.44
calHCO3-33* Base XS-6
[**9-21**] CTA: FINDINGS: The tracheostomy tube in situ.
There are multifocal rounded soft tissue masses in the right and
left lung, the largest at the right upper zone measures up to 5
cm, multiple others measuring over 3 cm in size. Increased
opacification of the right lower zone and to a lesser extent
left lower zone which previous CT has shown due to gross
consolidation and multiple masses. Small to moderate size
effusion at the right base.
[**9-21**] ECHO: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50-55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
84 year old female with history of thyroid cancer, asthma, and
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with increased shortness of breath and increased
ventilator requirement, high lung tumor load on CT of chest.
1. Respiratory distress - Most likely from worsening metastatic
lung disease by airway compression or lymphangitic spread by CT.
Her underlying muscular weakness due to her history of [**Last Name (un) **]
[**Location (un) **] may also be contributing somewhat. No evidence for
infection given lack of fevers and normal WBC count. There was
no pulmonry aemolism on CT angiogram. CT shows mutiple B lung
tumors. Bronchoscopy showed open airways but distortion of
airway in right middle lobe - ? due to external lung mass vs
stricture. Supra- and sub-glottic stenosis as well. CTA showed
large tumor load in lung, ? some compression of trachea. The
results were discussed with Mrs. [**Known lastname 57942**] and her daughter by Dr.
[**Last Name (STitle) **], and it was felt that there was nothing that could be done
at this time therapeutically. ECHO showed a normal EF (50-55%),
mild AR and MR, but no other abnormalities. We continued to
support her breathing on the ventilator with PSV ([**11-26**]) during
the day and AC at night (400 X 12, 0.3, PEEP 5). She was treated
with albuterol nebulizers, and discharged with an albuterol
inhaler. She was instructed to use AC at home per the settings
we used here. These settings can be changed with Dr. [**Last Name (STitle) 55911**] per
her ongoing respiratory function changes/needs.
.
2. Hypothyroidism - Mrs. [**Known lastname 57942**] has hypothyroidism secondary to
her thyroid cancer and the resulting treatment. She recently had
her thyroid medication increased which could be contributing to
her feelings of warmth and cold sweats. Her TSH was normal, and
we continued her on Levoxyl at current dosage for now -
alternating 137/150.
.
3. Ulcerative collitis - Mrs. [**Known lastname 57942**] was currently having UC
flair while hospitalized. She was continued on Asacol at her
home dose, and given a low residue diet.
.
4. HTN: Mrs. [**Known lastname 57942**] was treated with dilt, and continued on
Cardizem CR for her home regimen as prior to hospitalization.
.
5. GERD: Mrs. [**Known lastname 57942**] was continued on a PPI, and shoulf continue
her home Zantac.
.
6. A.fib: Mrs. [**Last Name (STitle) **] was continued on DIltiazem. Her INR was
elevated transiently, so her coumadin was held for 2 days. Her
INR had returned to 2.3 on day of discharge, and she should
continue her previous regimen of 2.5 6 days a week. SHe will
have Mondsay and Thursday lab draws at home for INR, with the
results called to Dr. [**Last Name (STitle) 55911**].
.
7. PPx: Mrs. [**Known lastname 57942**] is anticoagulated with Coumadin, and on
Zantac.
.
8. FEN: NRs [**Known lastname 57942**] was continued on her home diet of low residue,
and her electrolytes were followed and repleted as needed.
.
9. Access: Mrs [**Known lastname 57942**] was maintained with PIVs.
.
10. FULL code
.
11. UTI: On the day prior to discharge MRs. [**Known lastname 57942**] complained of
burning with urination, and had a positive UTI. She was treated
with one dose of IV ceftriaxone, and discharged with 14 days of
po cefpodixime to treat a foley-associated UTI.
.
12. Dispo: Mrs. [**Known lastname 57942**] is dicharged home to follow up with Dr.
[**Last Name (STitle) 55911**] within a week. We called his office for an appointment,
they told us they would call the patient with an appointment
time.
Medications on Admission:
1. Coumadin 2.5mg 6X/week
2. Asacol 100mg [**Hospital1 **]
3. Ranitidine 150mg daily
4. Cardiazem CR 240mg daily
5. Levoxyl 137/150 alternating days
6. Albuterol nebs q2-3 hours
7. Vitamin E, Vitamin C, MVI
8. Citrucal
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
Disp:*1 month's supply* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q1-2H () as needed.
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
QOD ().
5. Levothyroxine Sodium 137 mcg Tablet Sig: One (1) Tablet PO
QOD ().
6. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Six
days a week, with one day off as per your routine prior to
hospitalization.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Cardizem LA 240 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
9. Cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO twice a day
for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
infusion and Respiratory Care
Discharge Diagnosis:
Primary:
metastatic thyroid cancer
Secondary:
tracheotomy, with ventilator support
atrial fibrilation
ulcerative colitis
deep vein thrombosis, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] filter
mitral regurgitation
asthma
[**First Name9 (NamePattern2) **] [**Location (un) **]
mitral regurgitation
Discharge Condition:
Stable, on ventilator in daytime and at night with good oxygen
saturations and no shortness of breath.
Discharge Instructions:
Please call your doctor or return to the hospital if you become
acutely short of breath or have low oxygen saturations at home,
have a fever and chills, chest pain, nausea and vomiting, or any
other health concern.
Please measure your oxygen saturations, and maintain at > 92%.
Your ventilator settings for day and night should be assist
control, tidal volume 400, repiratory rate 12, oxygen 30%, PEEP
5.
Please complete your full course of antibiotics for your urinary
tract infection.
Please follow up with Dr. [**Last Name (STitle) 55911**].
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 55911**] ([**Telephone/Fax (1) 57946**]). The office was
contact[**Name (NI) **] yesterday and will be calling you with an appointment
time within the next week.
Please call your endocrinologist for an appointment in the next
2 weeks.
Completed by:[**2153-9-25**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3945
} | Medical Text: Admission Date: [**2139-12-9**] Discharge Date: [**2139-12-12**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]M with known metastatic colon cancer to lungs had reported
syncopal event on toilet at home, called EMS, went to [**Last Name (un) 1724**].
Mental status declined there requiring intubation. Head CT done
showed large right thalamic hemorrhage with likely underlying
mass. Transferred to [**Hospital1 18**] for further management.
Past Medical History:
colon cancer with lung mets, arthritis
Social History:
non smoker. armenian
Family History:
non- contributory
Physical Exam:
O: T: BP: 200/81 HR:86 R 18 O2Sats 96 vent
Gen: cachetic appearing, intubated, examined in ED
HEENT: Pupils:2mm NR
Lungs: ventilated
Cardiac: RRR
Abd: Soft
Extrem: Warm and well-perfused.
Neuro:
intubated, on propofol.
no eye opening. decerebrate posturing UEs, triple flexion
LEs,+cough/gag, + corneals
Toes upgoing bilaterally
Pertinent Results:
[**12-9**] Head CT: Right basal ganglia intraparenchymal hemorrhage
with 12mm leftward shift(previously 7mm) of midline structures.
There is intraventricular extention into the lateral, 3rd and
4th ventricles, which has increased since OSH CT.
Brief Hospital Course:
Pt admitted to the ICU with medical management for a large right
thalamic hemorrhage. The patient was treated with Mannitol and
decadron. The patient's prognosis was discussed in detail with
the family. He was made DNR per the family's request but was ok
to have chemical resuscitation. They wanted to await the arrival
of more family members from out of state, prior to making him
CMO. On [**12-11**] the family agreed to make the CMO. He died on [**12-12**].
Medications on Admission:
xeloda, hydrocodone
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Right thalamic hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2139-12-15**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3946
} | Medical Text: Admission Date: [**2132-6-13**] Discharge Date: [**2132-6-15**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Prochlorperazine / Tramadol
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Nausea and vomiting, one episode of coffee ground emesis
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
History of Present Illness: Ms. [**Known lastname **] is a 27yo F with history
of DM type 1, known grade 1 esophageal varices, status post
exploratory laparoscopy from trauma presenting with frequent
emesis with episode of coffee grounds and abdominal pain.
.
In the ER, initial vitals were 141, 133/96, 16, 99% 3L. Patient
was profusing vomiting and R femoral CVL was placed for access.
She had a very tender abdomen on exam and CT showed signs of
pneumobilia. Surgery was consulted who recommended admission to
medicine with serial abdominal exams. GI and liver were also
consulted. She was started on PPI and octreotide drips, and also
received dilaudid, zofran, insulin (home dose), zosyn,
metoclopramide and metoprolol. Her initial labs showed an anion
gap which later closed and small amount of ketones. Hct was
stable since prior on [**5-29**]. NG lavage cleared after 20 cc flush
and guaiac was negative. Vitals on transfer were 98.0 85 125/88
12 100% RA. FSBS 132.
.
In the MICU, patient is initially coughing/retching up clear
liquid. Soon after receiving IV dilaudid and reglan, she appears
comfortable and is fixing her hair. She reports being in her
usual state of health yesterday but awoke with a FSBS in the 60s
and has been vomiting throughout the day. The vomitus looked
like coffee grounds at one point so she came to the ER. Her
abdominal pain resolved in the ER but she continued to have n/v.
She has been unable to eat today.
Past Medical History:
- Diabetes mellitus type I: diagnosed age 16 in [**2120**] after her
first pregnancy.
- Severe anxiety/panic attacks
- Previous admissions for nausea/vomiting with h/o esophagitis
and with concern for diabetic gastroparesis on metoclopramide
- Esophagitis / H. Pylori [**6-/2128**] and again [**8-/2130**]
- Stage I diabetic nephropathy
- Grade I esophageal varices seen on scope in [**2132-1-1**],
negative liver ultrasound, normal LFTs, hep panel negative
- Anxiety/panic attacks
- Depression
- Hyperlipidemia
- S/P MVA [**5-3**] - lower back pain since then.
- S/P MVA [**2130**], ex-lap
- G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
- Genital Herpes
- H pylori, s/p 2-week triple therapy on [**2132-1-24**]
Social History:
She was born and raised in [**Location (un) 669**] but currently lives in her
own apartment with her son. She is currently unemployed and
received disability. Her mother and sisters live nearby. She had
to drop out of school for becoming a medical assistant due to
her multiple hospitalizations. She does not smoke and reports
rare alcohol use on holidays. She denies drug use.
Family History:
Grandmother with type 1 diabetes, no history of CAD,
hypertension, celiac disease, IBD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, initially retching but later NAD and
comfortable appearing
[**Location (un) 4459**]: NC/AT, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, midline well healed scar, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
Physical exam:
General: pt appears comfortable, A&Ox3
[**Location (un) 4459**]: PERRL, moist MMM
CV: Tachycardic, no m/r/g
Resp: CTAB
Abd: soft/NT/mildly distended, midline abdominal scar s/p ex-lap
Extr: no edema, cyanosis or clubbing, femoral line on right side
appears clean and non-erythematous
Pertinent Results:
Admission:
[**2132-6-12**] 06:10PM BLOOD WBC-7.7 RBC-3.54* Hgb-10.2* Hct-31.0*
MCV-88 MCH-28.9 MCHC-32.9 RDW-14.1 Plt Ct-282#
[**2132-6-12**] 06:10PM BLOOD Neuts-81.6* Lymphs-16.5* Monos-1.1*
Eos-0.1 Baso-0.6
[**2132-6-12**] 06:10PM BLOOD Plt Ct-282#
[**2132-6-12**] 06:10PM BLOOD Glucose-355* UreaN-18 Creat-1.1 Na-138
K-3.7 Cl-99 HCO3-22 AnGap-21*
[**2132-6-12**] 08:30PM BLOOD Glucose-236* UreaN-14 Creat-0.9 Na-141
K-3.7 Cl-105 HCO3-24 AnGap-16
[**2132-6-12**] 06:10PM BLOOD ALT-20 AST-30 AlkPhos-76 TotBili-0.4
[**2132-6-12**] 06:10PM BLOOD Lipase-32
[**2132-6-12**] 06:10PM BLOOD Calcium-9.9 Phos-2.0* Mg-1.7
[**2132-6-12**] 10:54PM BLOOD Lactate-2.0
Discharge:
[**2132-6-15**] 12:00PM BLOOD WBC-5.8 RBC-3.13* Hgb-9.1* Hct-27.6*
MCV-88 MCH-29.2 MCHC-33.2 RDW-14.0 Plt Ct-229
[**2132-6-15**] 12:00PM BLOOD Plt Ct-229
[**2132-6-15**] 12:00PM BLOOD Glucose-289* UreaN-6 Creat-1.0 Na-134
K-4.2 Cl-101 HCO3-27 AnGap-10
[**2132-6-15**] 04:52AM BLOOD ALT-13 AST-15 AlkPhos-59 Amylase-95
TotBili-0.4
[**2132-6-15**] 12:00PM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9
EGD ([**2132-6-13**]):
Erosion in the fundus compatible with NG tube trauma/suction
Erosion in the gastroesophageal junction compatible with
retching
CXR ([**2132-6-12**]): The lungs are clear without consolidation or
edema. The
mediastinum is unremarkable. The cardiac silhouette is within
normal limits for size. No effusion or pneumothorax is noted.
The osseous structures are unremarkable.
CT abdomen/pelvis ([**2132-6-12**]):
1. Esophageal wall thickening could reflect esophagitis or
reactive changes from emesis.
2. Focus of pneumobilia, correlate with history for ERCP or
sphincterotomy.
3. No additional acute abdominal process to explain the
patient's pain and
her symptomatology.
Brief Hospital Course:
27F with T1DM c/b gastroparesis and anxiety who presented to the
ED with nausea, vomiting and one episode of coffee ground
emesis.
#Nausea/vomiting and coffee ground emesis - Had an EGD which
showed no source of active bleeding. No note of esophageal
varices as previously reported on last EGD, some erosion of
gastroesophageal junction which was thought to be [**1-2**] retching.
Coffee ground emesis thought to be caused by [**Doctor First Name **]-[**Doctor Last Name **] tear
from vomiting. Received Zofran and Ativan for nausea with
improvement. Pt was continued on PPI 40mg daily on discharge.
#T1DM - While in MICU, Lantus dose was held on night of [**2132-6-13**]
because pt was not taking PO. Was then given 8 units of lantus
during the afternoon of [**2132-6-14**] in the MICU. She received an
additional 12 units of Lantus on the evening of [**2132-6-14**] to equal
her normal nightly dose of Lantus 20 units. She was
additionally covered with Humalog per her home sliding scale.
She did not have any episodes of significant hyper- or
hypoglycemia despite the changes in her insulin regimen. At
discharge, she will be continued on her home doses of Lantus 20
units at night and Humalog pre-meal and sliding scale after
meals.
#Anxiety/Tachycardia - Prior to transfer from MICU, she was
noted to be tachycardic to the 140s and hypertensive to the 160s
systolic. When left alone, she calmed down and her HR and BP
returned to [**Location 213**]. The anxiety improved after transfer to the
floor, she was significantly less anxious at the time of
discharge.
#Electrolytes - Required repletion of potassium and phosphorus
on multiple occasions. At discharge, both are back to normal
levels.
#Access - A peripheral line was unable to be placed and she
received a femoral line in the MICU. This was removed prior to
discharge and hemostasis was ensured with 5 minutes of pressure
to the groin. No erythema or welling noted around the catheter
site.
#Transitional issues:
-Will need monitoring of glucose control after discharge given
disruption to her insulin dosing schedule
-Will need monitoring of electrolytes given low potassium and
phosphorus during admission
Medications on Admission:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
3. Lantus 100 unit/mL Solution Sig: Seventeen (17) units
Subcutaneous at bedtime.
4. Humalog 100 unit/mL Solution Sig: 1-10 units Subcutaneous
with meals: as directed by your sliding scale.
5. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): may increase slowly up to 2 Capsules twice daily
if tolerated.
Disp:*100 Capsule(s)* Refills:*2*
7. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous three times a day: per sliding scale.
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lantus 100 unit/mL Solution Sig: Seventeen (17) units
Subcutaneous at bedtime.
3. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous
with meals.
4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO with meals
and before bed.
5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO twice a
day.
6. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Vomiting with coffee ground emesis, likely small [**Doctor First Name **]-[**Doctor Last Name **]
tear
Secondary diagnoses:
Type 1 diabetes
Gastroparesis
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital with nausea and vomiting with
one episode of coffee ground appearing vomit. You were in the
intensive care unit for one day and had an upper endoscopy which
did not show any active bleeding. It is thought that the coffee
ground vomit was caused by your repeated vomitng. Please
continue to take Zofran at home as needed for nausea.
For your diabetes, we continued you on insulin. Your doses were
temporarily decreased while you weren't eating. However, at
home you should continue to take your normal doses of insulin as
printed on your medication sheet. This includes Lantus 20 units
tonight as well as your normal pre-meal and sliding scale
humalog insulin.
Followup Instructions:
Please make a follow-up appointment with your primary care
physician for next week, we have contact[**Name (NI) **] your [**Name (NI) 6435**] office so
that you can be seen this week.
Department: REHABILITATION SERVICES
When: FRIDAY [**2132-6-20**] at 11:10 AM
With: [**Name (NI) 29835**] [**Name (NI) 29836**], PT [**Telephone/Fax (1) 2484**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2768, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3947
} | Medical Text: Admission Date: [**2177-3-28**] Discharge Date: [**2177-4-18**]
Date of Birth: [**2113-7-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2177-3-28**] Cardiac Catheterization
[**2177-4-2**] Three Vessel Coronary artery bypass grafting(LIMA to
LAD, SVG to OM, SVG to PDA
[**2177-4-17**] Colonoscopy with biopsy
History of Present Illness:
The patient is a 63 yo male with h/o COPD, chronic bronchitis,
tobacco use and CAD who presented to [**Hospital3 **] on [**3-25**]
with c/o progressively worsening SOB x 2 weeks. He also c/o
intermittent CP in the left ant chest that was mild and lasted
for a few minutes and would disappear. At admission he was
found to have evidence of pulmonary edema on CXR, ? LLL
infiltrate and BNP was >5000. He had intial troponin I of 0.24
with CK [**Street Address(2) 66197**], Twave changes on EKG. He
required bipap and was treated with morphine,Lasix and NTG. He
diuresed well on this regimen. Wheezing also improved with
Spiriva and Advair. While being diuresed his Cr went to 1.9 from
1.6 at admission. Lasix and Mavik were held after that and NTG
gtt was continued. Per report he an echo with EF of 25-30% (EF
of 46% in [**2170**]). Peak troponin I was 0.36. The patient notes
that PTA he has had a productive cough with occ pale green
sputum that has been present for months to years. In [**2177-1-12**] he
was diagnosed with bronchitis. He then developed a spontaneous
rib fracture, thought to be [**2-13**] to coughing. More recently, he
was thought to have PNA and was treated with 21 days of levaquin
with no improvement. 2 days PTA at OSH he was started on Ketek.
Currently patient feels well with no CP, SOB, N/V, abd pain,
fevers, chills, constipation or diarrhea. He denies orthopnea or
recent LE edema.
Past Medical History:
Bronchitis diagnosed in [**January 2177**] and spontaneous rib fx [**2-13**] to
cough, developed PNA and started on levaquin for 21 days with no
improvement. Then started on Ketek on [**3-24**].
COPD
HTN
Hyperlipidemia
Ao Aneurysm (per pt is 5-5.5 cm)
PVD and claudication,
Chronic bronchitiS
CHF - EF 25%
Gout
Kidney stones
OA
Social History:
Works at a plastics corporation as an executive. Actively smokes
- 2 ppd smoker x 46 years. Quit ETOH 15 years ago. Lives with
wife, son and daughter.
Family History:
Denies heart disease, HTN or DM
Physical Exam:
PE: BP 124/78 HR 85 R 20 O2 sat 96% 2L
Gen: well appearing male in NAD, lying in bed post cath
HEENT: normocephalic, anicteric sclera, MMM, pupils equal and
round
Neck: supple, no JVP
Pulm: CTA B anteriorly
Cardio: RRR, nl S1 S2, no m/r/g
Abd: soft, NT, ND, + BS
Groin: dressing c/d/i, no bruit, no hematoma
Ext: no lower ext edema
2+ PT/DP pulses b/l
Neuro: A&Ox3, neuro exam grossly intact
Pertinent Results:
[**2177-4-17**] 07:50AM BLOOD WBC-8.3 RBC-3.88* Hgb-12.1* Hct-34.4*
MCV-89 MCH-31.1 MCHC-35.1* RDW-17.1* Plt Ct-305
[**2177-4-16**] 09:35AM BLOOD Glucose-105 UreaN-28* Creat-1.2 Na-133
K-5.1 Cl-95* HCO3-27 AnGap-16
[**2177-4-13**] 05:20AM BLOOD ALT-15 AST-19 LD(LDH)-202 AlkPhos-70
TotBili-1.2
[**2177-4-16**] 09:35AM BLOOD Mg-2.1
[**2177-3-28**] 03:00PM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
Admitted on [**3-28**] to the cardiology service with PMH as above.
Referred to Dr. [**Last Name (STitle) **] from CT [**Doctor First Name **] for surgical evaluation
after cardiac cath revealed LM and 3VD. Pre-op evaluation
included room air ABG, PFTs, carotid US, additional labs and and
echo. CXR at OSH showed a large right pleural effusion, but here
revealed a small left effusion. RUQ ultrasound was negative.
Echo showed EF 25-30% with 2+MR and 2+TR. Creatinine was
monitored as well as continued improvement of CHF. Left ICA was
occluded, right less than 40%. LFTs remained elevated likely due
to congestion. PFTs showed elements of COPD. Underwent CABG x3
with Dr. [**Last Name (STitle) **] on [**4-2**]. Transferred to the CSRU on milrinone,
epinephrine, levophed and propofol drips. These were weaned
slowly over the next few days. He was extubated the next
afternoon. Amiodarone was started for frequent ectopy given his
recent MI. Chest tubes were removed in the CSRU. Foley and
pacing wires were removed on POD #4 and he was transferred to
the floor on POD #5. Converted to SR and swan removed.
Transfused one unit PRBCs prior to transfer. Presumed gout flare
started on both knees and an ankle on POD #6. Colchicine and
steroids with taper started per rheumatology consult. ACE-I was
eventually started given his poor EF.
Heparin and coumadin started for AFib and ectopy on POD #8.
Colchicine ultimately stopped for a rise in creatinine again.
Vomited blood and clots on [**4-10**], transferred back to CSRU for
hypotension. Heparin was stopped. Femoral venous line started
with rapid IV fluids and stablization. GI consulted, NGT placed,
and transfused 3 units PRBCs. EGD in the AM showed a probable
healing [**Doctor First Name **]-[**Doctor Last Name **] tear with no active bleeding. PPI's were
continued. He re-bled the next day. INR reversed with FFP.
Transferred back to the floor on POD #13 with stable Hct of 29.
He had small melanotic stools and also had intermittent Afib.
Amiodarone was increased. Colonoscopy done on [**4-17**] which showed
some rectal ulcers and sigmoid diverticulosis. High fiber diet
recommended. He had a brief episode of sinus brady overnight and
beta-blockade decreased. Rheumatology consulted for transiton to
oral steroids for continued taper. His hematocrit remained
stable and he continued to maintain good hemodynamics. Medical
therapy was optimized and he was eventually discharged to home
on postoperative day 16.
Medications on Admission:
ASA 325
lopressor 25 tid
IV nitro
lasix 40 qd
Mavik 4 qd
nicotine patch
Lovenox 30 mg sq qd
Mucinex 600 po BID
ALbuterol nebs
Rocephin 1 gm IV qd
Advair Diskus 500/50 mg one puff [**Hospital1 **]
Spiriva one capsule qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): one IH
twice a day; dispense one month's supply.
Disp:*1 Disk with Device(s)* Refills:*2*
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily): one cap IH daily.
Disp:*30 Cap(s)* Refills:*2*
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed: dispense one bottle.
Disp:*100 ML(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
15. Methylprednisolone 4 mg Tablet Sig: Two (2) Tablet PO once a
day for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
16. Methylprednisolone 2 mg Tablet Sig: One (1) Tablet PO once a
day for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
CAD
? aortic aneurysm
COPD
HTN
elev. chol.
rectal ulcers
gout
nephrolithiasis
PVD with claudication
?PCI 8 years ago
[**Doctor First Name **]-[**Doctor Last Name **] tear
AFib
Postop GIB
Discharge Condition:
Good.
Discharge Instructions:
Shower, no baths, no lotions, creams or powders to incisions. No
driving for one month. No lifting greater than 10 pounds for 10
weeks. Call with fever, redness or draiange from incision or
weight gain more than 2 pounds in one day or five in one week.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 2 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 66198**] in 1 week
Dr. [**Last Name (STitle) 11493**] in 1 week
F/u Colonoscopy Biopsy results with PCP
Completed by:[**2177-5-9**]
ICD9 Codes: 4240, 496, 4254, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3948
} | Medical Text: Admission Date: [**2125-4-16**] Discharge Date: [**2125-4-24**]
Date of Birth: [**2048-6-6**] Sex: M
Service: VASCULAR SURGERY
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2125-4-23**] 14:56
T: [**2125-4-23**] 16:24
JOB#: [**Job Number 29387**]
ICD9 Codes: 4280, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3949
} | Medical Text: Admission Date: [**2128-4-16**] Discharge Date: [**2128-4-16**]
Service: SURGERY
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Nausea, syncope, epigastric pain, and mental status changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a [**Age over 90 **] y/o female with h/o CAD, AS, Afib, chronic GI
symptoms with nausea, who experienced a syncopal episode
yesterday after a hot shower, and then became incontinent of
stool and urine. Systolic BP was 112 on subsequent evaluation,
but patient developed 3 episodes of nausea and vomiting.
Following the last episode, the pt remained home, but the family
reported that last night at 2:30 am she had increased nausea,
significantly worsened cognitive condition, and weakness. The
pt was transferred to the ED where she complained of epigastric
pain radiating to her shoulders.
In the ED, the pt was found to have elevated amylase and lipase
and urinalysis demonstrated cloudy urine with many bacteria.
U/S of the abdomen showed stones in the gall bladder and dilated
intrahepatic ducts, but common bile duct was not well
visualized. Pt was started on levo/flagyl and admitted to the
floor.
Past Medical History:
1. Frequent urinary tract infections
2. dropped bladder not responsive to a pessary
3. atrial fibrillation (currently off Norpace and coumadin)
4. coronary artery disease
5. appendectomy
6. MR
7. anemia
8. anxiety
9. chronic nausea/vomiting, achlorhydria, known pancreatic
abnormalities on CT since [**2126**]
10. hiatal hernia
11. kyphosis
12. macular degeneration and cataracts
13. recurrent episodes of syncope
14. groin hernia
Social History:
Lives alone in a senior housing, does not smoke, drink alcohol
or coffee. Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] is HCP.
Family History:
Noncontributory
Physical Exam:
T 98.0 P 110 BP 99/70 R 28 SaO2 96%
Gen - cachetic, frail, uncomfortable, toxic appearing elderly
woman
Heent - no scleral icterus, perrl, mucous membranes dry
Lungs - clear
Heart - irregular rhythm with SEM
Abd - tenderness in epigastric area
Ext - warm, well perfused
Pertinent Results:
[**2128-4-16**] 05:17PM BLOOD WBC-14.2*# RBC-4.21 Hgb-12.7 Hct-39.1
MCV-93 MCH-30.2 MCHC-32.5 RDW-14.0 Plt Ct-214
[**2128-4-16**] 05:17PM BLOOD Glucose-167* UreaN-23* Creat-1.6* Na-135
K-4.4 Cl-102 HCO3-18* AnGap-19
[**2128-4-16**] 03:55AM BLOOD ALT-22 AST-47* CK(CPK)-50 AlkPhos-147*
Amylase-101* TotBili-0.6
[**2128-4-16**] 03:55AM BLOOD Lipase-147*
[**2128-4-16**] 05:17PM BLOOD Calcium-8.9 Phos-4.7* Mg-1.9
[**2128-4-16**] 08:10AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.009
[**2128-4-16**] 08:10AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
[**2128-4-16**] 08:10AM URINE RBC-[**6-13**]* WBC->50 Bacteri-MANY Yeast-NONE
Epi-0-2
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2128-4-16**] 6:18 AM
IMPRESSION:
1) Thickening of the gallbladder wall secondary to edema
associated with cholelithiasis that might represent acute
cholecystitis, however, generalized third spacing and edema
secondary to pancreatitis might also cause gallbladder wall
edema.
2) Small area of fluid density located anterior to the pancreas
which most likely represent fluid filled stomach, however, fluid
collection in this area cannot be excluded.
Brief Hospital Course:
A general surgery consult was obtained and discussion was
undertaken with the pt's PCP and the family regarding treatment
options. The pt's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**] had had long discussions
with the pt regarding end of life issues. He recommended that
the pt be made comfort measures only. Discussion was made with
the family and they wished to proceed with comfort measures per
pt wishes. The pt passed away on the evening of [**2128-4-16**].
Autopsy was refused by family.
Medications on Admission:
1. Ambien 2.5mg qHS
2. Ativan 0.5mg [**Hospital1 **] prn
3. gabapentin 100mg TID prn
4. atenolol 12.5mg daily
5. folic acid 800mcg daily
6. vitamin E 400unit daily
7. prilosec 20mg daily
8. prochlorperazine 5mg prn
9. lasix 20mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cholecystitis
Pancreatitis
Atrial fibrillation
Coronary artery disease
Urinary tract infection
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 5990, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3950
} | Medical Text: Admission Date: [**2200-7-17**] Discharge Date: [**2200-7-29**]
Date of Birth: [**2132-6-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2200-7-18**] Cardiac Catheterization
[**2200-7-21**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary artery to diagonal, vein grafts to left
anterior descending and obtuse marginal). Mitral Valve Repair
utilizing a 28mm CE Annuloplasty Ring.
[**2200-7-21**] Re-Exploration for Bleeding
History of Present Illness:
[**Known firstname 25368**] [**Known lastname 73102**] is a 68-year-old man with a past medical history of
coronary artery disease, congestive heart failure, hypertension
and hypercholesterolemia who was admitted for prehydration prior
to cardiac catheterization.
His main complaint is of dyspnea. He gets moderate dyspnea with
exertion that is readily relieved with rest. This occurs nearly
every day. It got somewhat better after starting Lasix. He
also has thigh pain with exertion that is relieved with sitting
down. This also occurs nearly every day. He denies orthopnea,
PND, leg edema, lightheadedness, syncope, and palpitations. He
otherwise feels well. All other systems were reviewed and
negative.
He brought with him his medical records from [**State 4565**]. He had
an anterior myocardial infarction on [**2199-1-13**] that was
complicated by cardiogenic
shock and managed expectantly. His expectant management was
apparently due to esophageal bleeding (possibly variceal, but no
evident liver disease) that occurred two days prior to this. He
underwent angiography a month later. There was no report, but
some images are included in his papers. There is LAD and LCx
disease evident, but the clinical notes only refer to the LCx
disease. Echocardiograms variously showed LVEFs from 15% to
30%, generally around 20%. He also underwent a cardiac MR. The
report is not included in his paperwork, but the clinic notes
describe it as showing an LVEF of 10% with anterior scar. No
mention is made of viability in the other territories. He was
considered for an ICD but was apparently turned down. He was
told that it wasn't worth it for him.
Past Medical History:
Ischemic Cardiomyopathy, Systolic Congestive Heart Failure,
Coronary Artery Disease, Mitral Regurgitation, Prior MI [**2198**]
complicated by cardiac arrest, Chronic Renal Insufficiency,
COPD, History of Upper GI Bleed secondary to esophogeal varices
- s/p cauterization, History of ETOH abuse
Social History:
Former smoker, 50 pack year history of tobacco. Former heavy
alcohol abuse, none since [**2198**]. He is a former carpenter and
Marine Corp Veteran. Lives in [**State 4565**] and is here visiting
for the summer. Currently living with his daughter.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: T 96.6, BP 112/58, HR 66, RR 20, SAT 97% on room air
General: Well developed man, no distress
Eyes: PERRL, pink conjunctivae, no xanthelasma
ENT: MMM without pallor or cyanosis
Neck: Normal carotid upstrokes, no carotid bruits, no jugular
venous distention, no goiter
Lungs: Clear, normal effort
Heart: RRR, normal S1 and S2, no m/r/g, lateral PMI, precordium
quiet
Abd: Soft, NTND, NABS, no organomegaly, normal aorta without
bruit
Msk: Normal muscle strength and tone, normal gait and station,
no
scoliosis or kyphosis
Ext: No c/c/e, normal femoral and absent pedal pulses
Skin: No ulcers, xanthomas or skin changes due to arterial or
venous insufficiency
Neuro: A and O to self, place and time, appropriate mood and
affect
Pertinent Results:
[**2200-7-18**] 06:05AM BLOOD WBC-4.9 RBC-3.23* Hgb-10.4* Hct-31.6*
MCV-98 MCH-32.2* MCHC-32.8 RDW-18.2* Plt Ct-142*
[**2200-7-18**] 06:05AM BLOOD PT-13.7* PTT-37.4* INR(PT)-1.2*
[**2200-7-18**] 06:05AM BLOOD Glucose-79 UreaN-34* Creat-2.0* Na-135
K-4.3 Cl-104 HCO3-24 AnGap-11
[**2200-7-18**] 10:00AM BLOOD ALT-7 AST-12 AlkPhos-87 Amylase-62
TotBili-0.7
[**2200-7-18**] 10:00AM BLOOD %HbA1c-5.9
[**2200-7-18**] 06:05AM BLOOD Triglyc-37 HDL-57 CHOL/HD-2.1 LDLcalc-53
[**2200-7-18**] Cardiac Cath: 1. Selective coronary angiography of this
right dominant system revealed 3 vessel coronary artery disease.
The LMCA had no angiographically apparent flow limiting lesions.
The LAD had a proximal 70% stenosis and a 60% ostial D1. The
vessel was heavily calcified. The LCX was a heavily calcified
vessel with a 90% ostal lesion and mid vessel stenosis of 70%
into the OM. The RCA was a dominant vessel adn was occluded
proximally and filled via bridging and left to right
collaterals. 2. Resting hemodynamics revealed markedly elevated
left and right sided filling pressures, severe pulmonary
hypertension and a preserved cardiac index. 3. Left
ventriculography was deferred.
[**2200-7-19**] Echocardiogram: The left atrium is moderately dilated.
No atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 11-15mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. No masses or thrombi are seen in
the left ventricle. Overall left ventricular systolic function
is severely depressed with global hypokinesis, inferior akinesis
and distal septal, distal anterior and apical akineisi to
dyskinesis. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated. There is moderate global
right ventricular free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 73102**] was admitted under cardiology and underwent cardiac
catheterization which revealed severe three vessel coronary
artery disease(see result section), along with severe pulmonary
hypertension(PA pressure 75/22 with a mean of 41mmHg). Based
upon the above results, cardiac surgery was consulted and
further evaluation was performed. Echocardiogram was notable for
severely depressed left ventricular function(LVEF of 20%) and
moderate mitral regurgitation. There was only trace aortic
insufficiency with 1-2+ tricuspid regurgitation. Workup
confirmed history of chronic renal insufficiency. His admission
creatinine was 2.0, with mild improvement to 1.6 prior to
surgical intervention. He otherwise remained stable on medical
therapy and was cleared for surgery.
On [**7-21**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting along with mitral valve repair. For surgical details,
please see separate dictated operative note. Postoperative
course was complicated by persistent mitral regurgitation and
bleeding which required re-exploration. Following surgical
intervention, he was transferred to the CSRU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated. He slowly weaned from inotropic support and was
eventually transferred to the SDU on postoperative day three. He
He developed hypotension (after receiving a dose of carvedilol)
with atrial fibrillation and was transferred back to the
intensive care unit on [**2200-7-25**] for pressure support. He was
stabilized and had no further episodes of hypotension and was
subsequently transferred back to the step down unit on [**2200-7-26**].He
was started on Toprol XL (which he has tolerated well), and was
gently diuresed towards his preoperative weight. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. He has remained stable and
is ready for discharge.
Medications on Admission:
Albuterol MDI, Alprazolam prn, Aspirin 81 qd, Ambien prn,
Atrovent MDI, Coreg 3.125 [**Hospital1 **], Digitek 125 mcg qd, Diovan 40 qd,
KCL, Lasix 40 qd, Lovastatin 40 qd, Paxil 20 qd, Nitro prn
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
Ischemic Cardiomyopathy, Systolic Congestive Heart Failure,
Coronary Artery Disease, Mitral Regurgitation - s/p CABG, MV
Repair
Postoperative Bleeding - s/p Re-Exploration
PMH: Prior MI [**2198**] complicated by cardiac arrest, Chronic Renal
Insufficiency, COPD, History of Upper GI Bleed secondary to
esophogeal varices - s/p cauterization, History of ETOH abuse
Discharge Condition:
Stable
Discharge Instructions:
Patient should shower daily, no baths. No creams, lotions or
ointments to incisions. No driving for at least one month. No
lifting more than 10 lbs for at least 10 weeks from the date of
surgery. Monitor wounds for signs of infection. Please call
cardiac surgeon if start to experience fevers, sternal drainage
and/or wound erythema.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**4-24**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**2-22**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**2-22**] weeks.
Completed by:[**2200-7-29**]
ICD9 Codes: 4240, 4280, 9971, 496, 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3951
} | Medical Text: Admission Date: [**2125-12-31**] Discharge Date: [**2126-1-10**]
Date of Birth: [**2052-10-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Recurrent chest pain
Major Surgical or Invasive Procedure:
[**2126-1-2**] Single Vessel Coronary Artery Bypass Grafting utilizing
vein graft to right coronary artery, Mitral Valve Repair with 26
millimeter CE ring, and Aortotomy with partial RCA stent
removal.
[**2125-12-31**] Cardiac Catheterization
History of Present Illness:
Mrs. [**Known lastname 19688**] is a 73 year old female who has undergone multiple
percutaneous interventions and stent placement to her right
coronary artery. Her most recent was [**2125-2-22**] at the [**Hospital1 18**]. She
has been relatively chest pain free since that time. She
presented to [**Hospital 1474**] Hospital with recurrent substernal chest
pressure and heaviness with left arm/shoulder discomfort. She
ruled in for a NSTEMI. She was stablized on medical therapy and
transferred back to the [**Hospital1 18**] for further medical management.
Past Medical History:
Congestive Heart Failure, NSTEMI, Coronary Artery Disease - s/p
multiple RCA stents, Mitral Regurgitation, Diabetes Mellitus -
on Insulin Therapy, Hypercholesterolemia, Cerebrovascular
Disease - s/p CVA, Known Carotid Disease, Right Subclavian
Stenosis, Peripheral Vascular Disease, History of Humeral
Fracture, GERD, Depression, Prior Bladder Surgery
Social History:
Lives with her daughter. Denies tobacco, ETOH and recreational
drugs. Ambulates with a walker.
Family History:
Denies premature coronary disease.
Physical Exam:
Vitals: T 97.5, BP 165/40, HR 53, RR 18, SAT 98% on 2L
General: elderly female in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD, soft right carotid bruit noted
Heart: regular rate, normal s1s2, soft systolic ejection murmur
at LLSB
Lungs: clear bilaterally
Abdomen: obese, soft, nontender, normoactive bowel sounds
Ext: warm, trace edema, no varicosities
Pulses: decreased distally
Neuro: alert and oriented, slight left facial droop, mild left
sided weakness otherwise nonofocal
Pertinent Results:
[**2126-1-8**] 05:30AM BLOOD WBC-10.2 RBC-3.80* Hgb-11.5* Hct-32.7*
MCV-86 MCH-30.3 MCHC-35.2* RDW-14.7 Plt Ct-228
[**2126-1-6**] 01:58AM BLOOD PT-13.8* PTT-23.6 INR(PT)-1.2*
[**2126-1-8**] 05:30AM BLOOD Glucose-81 UreaN-27* Creat-0.8 Na-140
K-4.4 Cl-104 HCO3-32 AnGap-8
RADIOLOGY Final Report
CHEST (PA & LAT) [**2126-1-8**] 9:49 AM
CHEST (PA & LAT)
Reason: r/o inf., eff
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with CAD for CABG
REASON FOR THIS EXAMINATION:
r/o inf., eff
HISTORY: Status post CABG, evaluate for infiltrate or effusion.
FINDINGS: AP chest radiograph compared to [**2126-1-3**].
There has been interval extubation and removal of the
[**Last Name (un) **]-gastric tube. There has been interval removal of the
Swan-Ganz catheter (via the right IJ) as well.
The previously seen retrocardiac density has improved. The
pulmonary edema has resolved. The enlarged postoperative
mediastinum is unchanged.
IMPRESSION: Resolution of pulmonary edema and decreased left
basilar atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: [**First Name8 (NamePattern2) **] [**2126-1-8**] 2:21 PM
Brief Hospital Course:
Mrs. [**Known lastname 19688**] was admitted and underwent cardiac catheterization.
During the procedure, the right coronary artery could not be
engaged as there was a significant amount (approximately 7mm) of
previously placed stent jutting out into the lumen of the aorta.
The right coronary artery appeared to have a severe ostial
stenosis despite the presence of the previously placed multiple
stents. The LMCA, LAD and LCx had no angiographic evidence of
coronary artery disease. Distal aortography was also performed.
This demonstrated a large plaque in the aorta just distal to the
renal arteries. There was mild-moderate arterial disease in the
right and left iliac arteries and mild arterial disease in the
right common femoral artery. Based on the above results, cardiac
surgery was consulted and further evaluation was performed. An
echocardiogram on [**1-1**] was notable for 2+ mitral
regurgitation and depressed left ventricular function with an
ejection fraction of 30%. Preoperative evaluation was otherwise
unremarkable and she was cleared for surgery.
On [**1-2**], Dr. [**Last Name (STitle) **] performed single vessel coronary
artery bypass grafting along with a mitral valve repair. He also
removed the stent from the right coronary ostium via aortotomy.
The operation was otherwise uneventful and she transferred to
the CSRU for invasive monitoring. Within 24 hours, she awoke
neurologically intact and was extubated. She maintained stable
hemodynamics as she weaned from inotropic support. She
intermittently required intravenous Nitroglycerin for
hypertension. Given her cerebrovascular and peripheral vascular
disease, her SBP was maintained between 120-140 mmHg. She
remained mostly in a normal sinus rhythm. Very briefs episodes
of paroxysmal atrial fibrillation were noted on telemetry, most
likely in the setting of hypokalemia. K and Mg levles were
monitored closely and repleted per protocol. Most of her
preoperative medications were resumed. She made steady progress
and transferred to the SDU on postoperative five. Her blood
sugars remained well controlled. Beta blockade was slowly
advanced as tolerated. She remained in a normal sinus rhythm
without further episodes of atrial fibrillation. Over several
days, she continued to make clinical improvements with diuresis
and made steady progress with physical therapy. She was cleared
for discharge to rehab on postoperative day seven. At discharge,
her chest x-ray showed resolution of pulmonary edema with
decreased left basilar atelectasis. Her BP ranged from the
104-114/50-60's with a heart rate in the 70-80's. Her room air
saturations were 95%. All surgical wounds were clean, dry and
intact without evidence of infection. She had adequate pain
control with Tramadol and Motrin. She was discharged to rehab in
stable condition on POD#8.
Medications on Admission:
Aspirin 325 qd, Plavix 75 qd, Lasix 40 qd, Protonix 40 qd,
Atenolol 25 qd, Lipitor 40 qd, Lisinopril 5 qd, Imdur 60 qd,
Humulin Insulin 70/30 - 35 units qam and 20 units qpm, Advair
MDI, Atrovent MDI, Eye gtts
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks: please decrease to 20 meq QD when Lasix drops to Qd -
titrate accordingly.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks: then decrease to 40 mg QD - titrate accordingly.
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
12. Insulin NPH-Regular Human Rec 70-30 unit/mL Suspension Sig:
15 units units Subcutaneous twice a day: increase to home dose
of 35 units qam and 20 units qpm as tollerated.
13. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per
attached sliding scale Subcutaneous four times a day.
14. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
15. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
Life Care of [**Location (un) 1475**]
Discharge Diagnosis:
Congestive Heart Failure, NSTEMI, Coronary Artery Disease - s/p
multiple RCA stents, Mitral Regurgitation, Diabetes Mellitus,
Hypercholesterolemia, Cerebrovascular Disease - s/p CVA, Known
Carotid Disease, Right Subclavian Stenosis, Peripheral Vascular
Disease, Brief Postoperative Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**3-13**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6700**] in [**1-11**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**1-11**] weeks.
Completed by:[**2126-1-10**]
ICD9 Codes: 4240, 9971, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3952
} | Medical Text: Admission Date: [**2141-11-9**] Discharge Date: [**2142-2-16**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This was a 45 year old man found
on a road by [**Location (un) 86**] Police. He appeared to be ambulating but
had become unresponsive while the police were attempting to
deal with him. His [**Location (un) 2611**] Coma Score on arrival to the
Emergency Room was 3. He was intubated prior to arriving at
the Emergency Room. He was involved in some type of head
trauma; mechanism was unknown. He had a right pupillary
dilation which progressed bilaterally and a third nerve palsy
during the trauma work-up. Head CT scan showed a right
subdural hematoma with other small foci of intracranial
hemorrhage and also a subdural hematoma on the left.
Vital signs were blood pressure of 119/68; pulse of 68; 100%.
The patient was intubated and had not received any sedation.
His right pupil was fixed and nonreactive. His left was five
and nonreactive. No doll's. Positive corneal reflex.
Positive gag and cough. GET manipulation. He had extensor
posturing in his upper extremities and no withdrawal of his
lower extremities. A hard collar was in place and he had an
abrasion on his head but no laceration.
PAST MEDICAL HISTORY: Unknown.
MEDICATIONS: Unknown.
ALLERGIES: Unknown.
LABORATORY: White blood cell count 16.7, hematocrit 43.5,
platelets 299. His PT was 13.9, 27.8 PTT and 1.3 for his
INR. BUN was 11, creatinine was 0.6. Toxicology screen was
negative. Gas was 7.49, 36 and 270.
A CT scan of his head showed a 1.5 cm acute right
frontoparietal subdural hematoma and a small amount of
subarachnoid hemorrhage and a 1 to 2 mm left frontal subdural
hematoma.
HOSPITAL COURSE: The patient went to the Operating Room
emergently on [**2141-11-9**], where he had a right frontoparietal
craniotomy and an evacuation of a subdural hematoma. Post
procedure he was not responding to movement; his pupils had
decreased. His left was 2 to 1.5 and brisk. His right was
2.5 to 2.0, and slightly sluggish. He withdrew to pain in
his upper extremities, left greater than right, and localized
on the left. He withdrew to pain briskly in his lower
extremities bilaterally and then localized. His
postoperative hematocrit was 36.6. He had a repeat CT scan
later on the 18th which showed a tiny amount of residual
subdural fluid and a large amount of subdural air, mostly in
the front location consistent with a recent procedure and a
very small amount of a residual subarachnoid hemorrhage
within the sulci towards the vertex. The grey-white matter
was preserved. There was no shift of the normally midline
structure; the ventricles were normal. There is no evidence
of hydrocephalus. The basal cisterns are free.
The patient also had a chest CT scan on [**11-10**] with indication
because of trauma. There was some minimal dependent
atelectasis shown; no evidence of intrathoracic trauma. He
had a thoracic spine x-ray which was also normal. It did
show some moderate narrowing of his L5-S1 disc space
posteriorly.
The patient was monitored in the Intensive Care Unit where
his blood pressure was kept between less than 140, pCO2 was
kept 35 to 40.
Social Services was involved on his first day due to his
status as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] initially and a missing persons report
was filed with the [**Location (un) 86**] Police. Homeless shelter officials
came to see if they could identify Mr. [**Name13 (STitle) **] and he was not
identifiable at that time.
On [**11-11**] his vent wean was attempted which he did not
tolerate. He had a pressure support of five which caused him
to be tachypneic. His pressure support was increased
overnight. Neurologically, he localized on the left and his
right upper extremity. He had a right gaze deviation. His
pupils were 3 to 2.5 and his toes were downgoing. He
withdrew his lower extremities.
He had a repeat head CT scan on the 20th. The head CT scan
showed good subdural evacuation; no new stroke; generalized
cerebral edema.
The patient did develop a fever up to 102.0 F., and was pan
cultured at that point and he did have a question of a right
middle lobe atelectasis. He was started on Levofloxacin for
that. He was started on tube feedings via an NG tube. He
grew one out of four Gram positive cocci in pairs and
clusters out of his blood cultures.
On the [**12-14**], he was found to spontaneously flex
his right leg. His pupils were on the right 4.5 to 4.0 and
on the left 4.0 to 3.5. He had a slight dysconjugate gaze
localized bilaterally in his upper extremities, withdrew left
greater than right. His blood pressures kept less than 150s.
He was on Dilantin and efforts were made to continue to find
family members for this patient.
The [**Location (un) 86**] Police Department was also involved in the
investigation to try to find the identity of Mr. [**Last Name (Titles) **]. On
the 22nd, two out of eight bottles showed positive
Staphylococcus in his blood and three plus oral flora out of
his sputum. In addition to Levofloxacin he was started on
Kefzol for coverage. On the 22nd, a CT scan showed a right
PCA infarction, otherwise, no evidence of increased ICP. We
would only like the blood pressure treated if it was greater
than 180 and we asked that he continued to be intubated for
the next one to two days.
On the 23rd, he was found to be briskly localizing on the
right and on the left
DICTATION ENDS
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 23588**]
MEDQUIST36
D: [**2142-2-15**] 11:53
T: [**2142-2-15**] 15:27
JOB#: [**Job Number 54140**]
ICD9 Codes: 5070, 2760, 5990, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3953
} | Medical Text: Admission Date: [**2169-8-16**] Discharge Date: [**2169-10-11**]
Date of Birth: [**2117-5-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Initially admitted for:
Fever and neutropenia
Transferred to [**Hospital Unit Name 153**] for:
A fib and hypotension
Major Surgical or Invasive Procedure:
A-line
thoracentesis
bronchoscopy
bone marrow biopsy
mediastinoscopy with LN biopsy
History of Present Illness:
Mr. [**Known lastname 63305**] is a 52 year old Cuban-American man who has resided
in the US for 25 years. For the past year he has experienced
aches and pains, especially worse in the past six months on
stairs. He was working and feeling genrally well until the
beginning of [**Month (only) **] when he developed daily fevers to 102. These
were associated with chills and body aches but no rigors or
nightsweats. He went to his [**Hospital 6435**] clinic and had a CXR which
was negative but was put on antibiotics and analgesics. He
remained well for a few weeks but then suffered 2 syncopal
attacks on [**8-8**] and was admitted to [**Hospital3 **] Hosputal
that day. At LGH, the patient was found to be neutropenic with
72% lymphocytes and a WBC of 0.5. He was also anemic with a HCT
of 17 and was transfused 2 units of PRBCs. Further lab tests
upon admission included a leukemia/lymphoma eval which yielded
abundant myeloblasts with a probable diagnosis of AML. In
addition, >100,000 colonies of E.coli were found in his urine
resistent to Bactrim. ID put him on Zosyn, Vancomycin and
Diflucan by [**8-15**].
At LGH, he had a negative CT scan of the head done for
dizziness. CT of the chest and abdomen was performed as part of
the lymphoma workup with the following key findings: 1) R
paratracheal mass (3.2cm)with BL pleural effusions. 2) Multiple
small liver and splenic lesions of intermediate nature. 3)
Small pancreatic lesion (1.6cm) 4) BL inguinal hernias.
Thoracic surgery was consulted and recommended a mediastinoscopy
under general anesthesia when the patient was feeling better.
He was subsequently transferred to [**Hospital1 18**] on [**8-16**] for further
workup at the request of his wife.
Past Medical History:
Wisdom teeth extracted. Hypertension treated with Toprol XL
100mg daily at home for some time. No other medical issues or
surgeries.
Social History:
Born and raised in [**Country 5976**]. Came to US 25 years ago. Lives with
his wife and 3 children (14, 13, 11). Works as a machinist.
Family History:
Mother died age 53 of a heart attack.
Father died in late 60's of unknown cause.
4 siblings, all living and all well.
Physical Exam:
Vitals: T 99.2 HR 120-130 RR 25 BP 90-100/70-80 100% O2 RA
Gen: diaphoretic
HEENT: PERRLA, No discharge from eyes, ears, nose. EOMI.
Anicteric. Normal conjunctiva.
Neck: No LAD, No JVD, Midline trachea. Normal sized thyroid
with no palpable nodules.
Chest: decreased breath sounds bilaterally
CV: irregular, irregular, II/VI SM
Abd: BS normoactive, nontender, nondistended, increased
adiposity of gut.
Ext: No C/C/E nontender calves
Neuro: CN II-XII intact, A and O x 3.
Skin: No visible lesions. No tender nodules.
Pertinent Results:
At [**Hospital6 3105**]:
CT of the chest and abdomen was performed as part of the
lymphoma workup with the following key findings: 1) R
paratracheal mass (3.2cm)with BL pleural effusions. 2) Multiple
small liver and splenic lesions of intermediate nature. 3)
Small pancreatic lesion (1.6cm) 4) BL inguinal hernias.
CT head was normal
Admission labs at LGH ) WBC 0.5, 8%N, 72%L, 6%B ALT 69, AST 39
Alb 2.7 Alk Phos 159 T Bili 0.7 D Bili 0.22
HIV Neg
Parvovirus Neg
>100,000 E. coli in urine
Discharge labs ([**8-15**]) WBC 0.8, 4%N, 72%L, 17%M, 5%B, 1.3% Eo
RBC 3.13, Platelets 183.
Labs
lactate 2.5
Na 141 K 3.1 cl 105 Hco 21 BUN 22 Creat 1.2 gluc 110
Ca 8.1 Mg 1.6 P 2.4
ALT 37 AP 288 T bili 0.5 AST 53 LDH 461
WBC 11 (neutro 65%, 8% lymph 21 % mono) Hct 34 Plt 264
PT 16.4 PTT 28.7 INR 1.8
FIbrinogen 912
uric acid 7.8
U/A Tr bld
[**2169-10-11**] 12:40PM BLOOD WBC-5.3# RBC-2.91* Hgb-9.1* Hct-26.9*
MCV-92 MCH-31.2 MCHC-33.7 RDW-18.9* Plt Ct-83*
[**2169-10-11**] 12:40PM BLOOD Gran Ct-4770
[**2169-10-11**] 12:40PM BLOOD Glucose-117* UreaN-23* Creat-0.8 Na-133
K-3.6 Cl-102 HCO3-18* AnGap-17
[**2169-10-11**] 12:40PM BLOOD ALT-29 AST-30 AlkPhos-186* TotBili-0.2
[**2169-10-11**] 12:40PM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.1 Mg-1.8
UricAcd-5.4
[**2169-8-19**] 08:49PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE IgM HAV-NEGATIVE
[**2169-9-13**] 04:14AM BLOOD HIV Ab-NEGATIVE
[**2169-9-27**] 05:03PM PLEURAL WBC-750* RBC-[**Numeric Identifier **]* Polys-49*
Lymphs-40* Monos-11*
[**2169-9-27**] 05:03PM PLEURAL TotProt-3.6 Glucose-97 Creat-1.0
LD(LDH)-271 Amylase-77 Albumin-1.8
Brief Hospital Course:
1.) AML: Leukemia/Lymphoma evaluation at outside hospital
yielded probable AML. [**8-18**] BMT done at [**Hospital1 18**] confirmed leukemia
(AML) and pt decided to undergo 7+3 induction treatment here.
DAY 1 was [**2169-8-18**], BM bx completed three times, with the latest
report from [**10-2**] showing no evidence of leukemic cells. Patient
will need maintenance chemo, but was awaiting stabilization of
ID status prior to starting further chemo.
.
2.) Fever and neutropenia/ID:
High fevers persisted, pt had multiple imaging studies including
a CT Chest, Abd Pelvis that revealed multiple splenic and liver
nodules and mediastinal LAD. Pt was seen by ID and pulm (for
RLL effusion and mediastinal LAD seen on CT scan). ID thinks
probably infectious source of liver, spleen nodules and
mediastinal LAD. They asked for several cultures including acid
fast bacilli, legionella, etc. Pulm completed bronch on [**8-22**],
negative for malignant cells. Patient developed some diarrhea,
C.diff sent, which was negative on multiple occasions. Stool
also tested for cryptosporidium/O and P/campylobacter- all of
which were negative. Patient underwent thoracentesis on [**8-30**],
which showed exudative fluid that grew afb in cultures, although
the afb smear was negative. All other cultures negative.
Repeat thoracentesis failed to show further afb growth in
culture, was also negative for CMV. CT chest on [**9-5**] revealed
stable nodules but new pericardial effusion. Patient started on
4 drug anti-tuberculosis regimen on [**9-8**]. AFB in blood was sent
to state lab and pending. Repeat AFB smears were neg x 3 and
patient was taken off precautions. The patient was transferred
to ICU [**Date range (1) 64418**]. When patient returned to BMT, he was placed on
Rifabutin, Ethambutol, Pyridoxine, Clarithromycin for MAC
coverage, as TB+ blood cxs likely MAC vs. TB, anti-TB meds
d/ced, other atypical mycobacteria was also a consideration.
Patient was started on Vanc empirically on [**9-17**] as blood cultures
from [**9-15**] returned [**2-14**] gram + cocci=coag neg staph and those from
[**9-17**]. On [**9-21**], patient underwent a TEE, which was negative for
endocarditis, and a mediastinal LN biopsy, which was positive
for afb on smear and culture. Patient placed back in
respiratory isolation. In addition, pleural fluid from [**9-12**]
returned TB PCR positive, therefore patient's abx regimen
changed back to 4 drug anti-tuberculosis coverage. Vanc was
discontinued as the +blood cultures were thought to be likely
contaminates. [**9-26**], [**9-27**], [**9-29**] AFB smear neg x 3. Remains in
isolation room as w/ likely disseminated TB w/ pulm nodules.
Patient underwent repeat thorax CT, which showed enlarging
abdominal LN and an increasing number of splenic and liver
lesions. Amikacin was added to help potentiated anti-TB drug
effects, however this was later discontinued, along with the
clarithromycin, so that patient was only on anti-TB coverage.
Patient underwent a repeat echo and chest x-ray which showed a
small to moderate pleural effusion and a small decrease in the
mediastinal LAD. The patient was placed on an 11 week steroid
taper (beginning with 60mg prednisone daily) per ID recs to help
lessen risk of constrictive pericarditis. Patient was arranged
with follow-up in the [**Hospital **] clinic in [**Month (only) 359**], and will be followed
by the state center for tuberculosis as well for medication
administration.
.
3.) Cardiology:
Patient developed AFib w/ rapid response to 180's, and unstable
BP (SBP=90's) - therefore was transferred to the ICU on [**9-11**]
where he underwent unsuccessful attempts at cardioversion x3.
The pt became more tachypneic and went into hypoxic respiratory
failure. He was intubated and brought to the [**Hospital Unit Name 153**]. He was found
to be hypotensive, probably due to the decreased preload in the
setting of intubation and the use of Propofol for intubation. BP
improved when he was switched over to Fentanyl for sedation. He
was put on AC, 600, 18, 40% and was tolerating the ventilation
well. An CXR showed an increased interstitial and alveolar
infiltrate especially on the R side with positive air
bronchograms on the R side. He was started on Levofloxacin,
Flagyl and Vancomycin for tx of an suspected pneumonia. An
emergent ECHO showed no signs of cardiac tamponade. A
therapeutic thoracentesis was done the next day and respiratory
state improved significantly. Pt was extubated and supported it
well. Abxs were stopped as repeat CXR did not show any signs of
infection and WBC was back to normal. Acute respiratory failure
was thought to have happened in the setting of intravascular
fluid depletion with decreased preload leading to tachycardia
and tachypnea, worsening the preload even more. In addition a
pulmonary edema and an increasing pleural effusion pressing on
the lund might have contributed. The ARF resolved within a day
and was attributed to intravascular fluid depletion. Pt was then
started and maintained on admiodarone, metoprolol, captopril per
cards recs. Diagnosis per cards was MFAT w/ initial rate >200.
Cardiology also recommended continued diuresis for pleural and
pericardial effusions. Patient was decreased to 200mg of daily
amiodarone on [**10-2**], with monitoring of LFTs and TSH, which were
normal. Echo on [**10-3**] ECHO w/ EF=30%, global LV hypokinesis, and
repeat on [**10-9**] shows small-moderate pleural effusion.
.
4.) Splenic/Liver Lesions
Initially thought to be mets, lymph nodes, or other primary
cancer contributing to recent development of changes in blood
glucose levels. Pt also experienced chronic RUQ abd pain during
his hospitalization. CT abd [**8-19**] showed 1. Necrotic lymph nodes
in the superior mediastinum and in the periportal region. 2.
Multiple tiny areas of low attenuation in liver and spleen.
Although non-specific, these could represent microabscesses from
hematogenous spread of infection, including tuberculosis or
fungal infections. MRI on [**8-25**] confirmed CT findings and showed
potential renal involvement. Given AFB + in blood from [**8-16**],
thought to be possibly disseminated TB. Follow-up CT on [**10-2**]
showed an increased number of lesions in both liver and spleen
(all < 1cm), still thought to be dissemintated TB.
.
5.) Pulmonary nodules: Observed on first CT (approx 3mm in
size) - thought related to other CT findings at the time
(necrotic LNs in mediastinum, liver pancreas and spleen
lesions). A repeat chest CT [**9-18**] showed increased size of pulm
nodules 3mm->5mm. Read as likely infectious in nature, and
assumed to be related to disseminated TB per mediastinal LN
washings (see above). A repeat CT on [**10-2**] showed no change.
.
6.) Elevated Blood Glucose
Despite no prior history of DM, this patient has consistently
had elevated glucoses on FS in the past week. Patient was
monitored by glucose FS TID and covered with RISS and Lantus.
On [**8-20**] pt seen by [**Last Name (un) **] team and recs for BG control changed,
scale adjusted and FS levels improved. [**Last Name (un) **] followed patient
throughout hospitalization and upon discharge, patient was given
diabetic education by nurse [**First Name (Titles) **] [**Last Name (Titles) **] monitoring and insulin
administration. As it was a concern that his sugars would be
difficult to control give his long term steroid use and change
in food intake (from TPN to normal diet), the patient's blood
glucose levels will be monitored closely when he returns for
oncology follow-up. An appointment was made at [**Last Name (un) **] in
[**Month (only) 1096**] (which was the first available).
.
7.) SOB:
On [**9-27**] pt experienced acute episode of SOB. CXR demonstrated
pulmonary congestion, which was likely due to receiving a couple
units of blood on the day prior. Given his increasing O2
requirements and increased work of breathing, he was intubated
in the ICU. Stayed in ICU w/ an uncomplicated hospital course,
and was successfully extubated and transferred back to the floor
on [**10-1**] where his oxygen saturation remained 98% on room air
throughout the remainder of his hospitalization.
.
8.) FEN
The patient was initially eating a normal diet, but on [**9-25**] he
had lost 10lbs in the last 2 weeks due to inadequate food
intake. A PICC was therefore placed and pt was started on TPN
w/ boost supplementation and liberal po intake as tolerated. A
calorie count on [**10-9**] per nutrition showed that patient was
eating 1450 calories per day, and TPN was discontinued on [**10-10**].
.
9.) Coagulopathy: Pt w/ persistently elevated INR, PT. Given
Vit K w/ minimal/no decrease in INR. As such, on [**9-22**] a mixing
study was sent (elevated PT), vit K given - mixing study
negative. Still unknown etiology of coagulopathy, but remained
stable.
Medications on Admission:
RISS
Temazepam 30mg QHS PO
Glargine 10U Daily SC
Zosyn 3.375g IV Q6
Robitussin AC [**6-20**] PRN
Loperamide 2mg [**Hospital1 **] PO PRN
Ibuprofen 600mg PO Q4
Discharge Medications:
1. Ethambutol 400 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*148 Tablet(s)* Refills:*0*
2. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*37 Tablet(s)* Refills:*0*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Pyrazinamide 500 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*111 Tablet(s)* Refills:*0*
5. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
Disp:*74 Capsule(s)* Refills:*0*
6. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*74 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
9. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*0*
10. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Twenty Five
(25) units Subcutaneous twice a day.
Disp:*qs units* Refills:*2*
12. glucometer
glucometer: dispense 1
refills : 0
13. One Touch II Test Strip Sig: One (1) strip Miscell.
twice a day.
Disp:*100 strips* Refills:*2*
14. Lancets,Thin Misc Sig: One (1) lancet Miscell. twice a
day.
Disp:*100 lancet* Refills:*2*
15. Syringe Syringe Sig: One (1) syringe Miscell. twice a
day: Insulin syringes .
Disp:*100 syringe* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Health Services VNA
Discharge Diagnosis:
AML
TB
a-fib
HTN
Discharge Condition:
Good
Discharge Instructions:
We have prescribed you a number of new medications. Please take
these and all of your medications as directed.
You have a number of follow-up appointments scheduled. Please
maintain all of these appointments. Please return to the [**Location (un) **] of [**Hospital Ward Name 1826**] building on the [**Hospital Ward Name 516**] tomorrow at noon.
Please call your doctor or return to the hospital if you develop
fever/chills/nausea or vomiting. Please make sure to check your
blood sugar and administer insulin as instructed.
Followup Instructions:
Provider: [**Name Initial (NameIs) **]/ONC,INPT HEMATOLOGY/ONCOLOGY-7F Where:
HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2169-10-12**] 12:30
Provider: [**Name10 (NameIs) 5373**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CC-5 Where: [**Hospital 273**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2169-10-13**]
10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16881**], MD Where: LM [**Hospital Unit Name 4341**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2169-11-13**] 9:00
You have been scheduled for a follow-up appointment with the
[**Last Name (un) **] clinc for your diabetes on [**2170-1-25**] at 8:30 am.
However, you may call [**Telephone/Fax (1) 2384**] to try and arrange an earlier
appointment.
Please call [**Telephone/Fax (1) 62**] to schedule an appointment with a
cardiologist at the earliest time available.
Please follow up as instructed with the state center for
tuberculosis.
ICD9 Codes: 4254, 5119, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3954
} | Medical Text: Admission Date: [**2127-8-16**] Discharge Date: [**2127-8-27**]
Date of Birth: [**2067-5-30**] Sex: M
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
male who was transferred from [**Hospital6 33**] with an
incarcerated umbilical hernia. The patient reports that his
abdominal pain began at 10 A.M. on the day prior to
admission, was constant, and was unable to be reduced. The
patient experienced vomiting prior to admission. There were
no fevers or chills. The patient presented to the outside
hospital, was evaluated, and was subsequently transferred to
[**Hospital1 69**] for operative
management.
PAST MEDICAL HISTORY: Significant for alcohol use and
ascites.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: No family history of hernia.
SOCIAL HISTORY: The patient reports a past history of
tobacco use. Past and current history of alcohol use, up to
two pints per day.
PHYSICAL EXAMINATION: On examination, the temperature was
99.6, heart rate was 100, blood pressure was 130/60. In
general, the patient was a morbidly obese male. Examination
of the head revealed pupils that were equal, round and
reactive to light, extraocular movements were intact. The
oral mucosa was dry. The neck was supple. Pulmonary
examination revealed lungs clear to auscultation bilaterally.
Cardiac examination revealed a regular rate and rhythm. On
examination of the abdomen, the abdomen was found to be
obese, tender, and firm at the umbilicus, with the hernia
unable to be reduced. There was no costovertebral angle
tenderness. Extremities were unremarkable for cyanosis,
clubbing or edema. There was no rash on the skin.
LABORATORY DATA: On admission, white blood cell count was
8.3, hematocrit was 42.9, platelet count was 216. PT was
12.4, PTT was 22.3, INR was 1.1. Glucose was 164, BUN was
21, creatinine 0.6, sodium 139, potassium 3.6, chloride 95,
bicarbonate 29.
HOSPITAL COURSE: The patient was admitted and taken to the
operating room, where a reduction of the incarcerated ventral
hernia and a segmental small bowel resection were performed,
along with a partial omentectomy and primary repair of the
ventral hernia. Please see the operative note for details.
Following the procedure, the patient was transferred to the
recovery room with subsequent transfer to the Surgical
Intensive Care Unit. On postoperative day one, the patient
was on CPAP ventilation and was kept sedated. He was placed
on an insulin drip for glycemic control. Perioperative
antibiotics included Zosyn, levofloxacin and Flagyl.
On postoperative day four, the patient continued on CPAP
ventilation. The patient was febrile to 101.1. On
postoperative day four, antibiotics were switched to
Cephazolin. The patient continued to be on mechanical
ventilation, still with elevated temperature.
On postoperative day six, the patient was found to be still
febrile the night before, but was found to be more awake and
following commands. The patient was continued on Kefzol.
Total parenteral nutrition was started in the unit for
nutrition. On postoperative day six, antibiotics were
changed, and ceftriaxone and oxacillin were started. The
patient was extubated and was found to be doing well. The
patient was still febrile, with a white count of 12.5.
By postoperative day eight, the nasogastric tube had been
discontinued. A sitter was assigned to the patient for
safety. The patient had been found sitting on the floor, out
of bed. The patient was subsequently transferred to the
floor.
On postoperative day nine, the patient continued on
ceftriaxone and oxacillin. The patient was found to be doing
well, running a low-grade temperature of 100.0, but
tolerating a regular diet. Ceftriaxone was discontinued.
The patient was screened for rehabilitation, and discharge
planning was arranged for transfer to a rehabilitation
facility on [**8-27**].
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg by mouth once daily
2. Nicotine patch 21 mg transdermally once daily
3. Metoprolol 12.5 mg by mouth twice a day
4. Oxacillin 2 grams intravenously every six hours
5. Silver sulfadiazine one application to skin on back three
times a day
6. Dilaudid 2 to 6 mg intravenously every one to two hours
as needed for pain
7. Heparin 5000 units subcutaneously every eight hours
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: Discharged to rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Incarcerated ventral hernia
2. Infarcted omentum and small bowel
3. Status post reduction of incarcerated ventral hernia with
segmental small bowel resection, partial omentectomy, and
primary repair of ventral hernia
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 44338**]
MEDQUIST36
D: [**2127-8-27**] 03:18
T: [**2127-8-27**] 03:55
JOB#: [**Job Number 24702**]
ICD9 Codes: 2762, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3955
} | Medical Text: Admission Date: [**2202-7-30**] Discharge Date: [**2202-8-12**]
Date of Birth: [**2117-12-10**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nitrate Analogues
Attending:[**First Name3 (LF) 2071**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 109788**] is a pleasant 84yo, Spanish-speaking female with a
history of coronary artery disease (s/p RCA stent [**2191**]), severe
TR, pulmonary hypertension, atrial fibrillation, diastolic heart
failure, chronic kidney disease, DM2, HTN who presents with
acute on chronic dyspnea. She has had significant dyspnea on
exertion, orthopnea, and PND for the past two months, but it has
acutely worsened over the past 10-20 days. She occasionally gets
pain in the sternal and lower neck area over that same time
period, but it is unclear if she is interpreting that symptom as
shortness of breath. She struggles to sleep, and needs to be
upright to do so. She has worsening edema of the lower legs as
well, with a departure from her dry weight of 200 to 210. She
has been taking all meds and diuretics. She denies salt loading.
She denies exertional chest pain or pressure. She was instructed
to present to the ED by her PCP after her [**Name9 (PRE) 269**] found her sats to
be 88% on RA this afternoon.
In the ED, initial vs were 98.2 60 120/62 28 98% 8L Mask. She
was in Afib with a rate of 60. Labs notable for elevated BNP to
2654, and Ddimer>1000. She did not get CTA due to renal failure,
which is chronic. CXR showed pulmonary vascular congestion,
which is chronic.
On arrival to the floor, initial vitals were T98.1 BP106/62 HR71
RR22 100/2L. She is resting. She has minimal shortness of breath
right now, and no chest pain or pressure. She complains of
general weakness and malaise.
Notably, she was admitted to [**Hospital1 18**] [**6-/2202**] with toe pain due to
ingrown nail, and had a course complicated by hypoxia and
hypoxic respiratory failure necessitating MICU transfer. She
improved with a multifocal regimen of diuretics, antibitoics,
and steroids and was eventually liberated from oxygen. She has
had multiple admissions for CHF according to her cardiologist.
Efforts to reduce lower extremity edema and mild dyspnea with
exertion are thwarted by worsening renal performance, and she is
allowed to remain modestly overloaded at baseline. Most recent
dry weight appears to be around 200lb.
REVIEW OF SYSTEMS: Positive otherwise for constipation.
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, abdominal pain,
nausea, vomiting, diarrhea, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
1. Diabetes mellitus, type 2, poorly controlled, last HbA1c 9.0
[**1-15**]
2. Atrial fibrillation, on coumadin
3. Coronary artery disease s/p stent to the RCA 09/[**2191**].
4. Congestive heart failure, EF 70% [**12/2198**]
5. Hypertension.
6. Hypercholesterolemia.
7. Seizures
8. Parkinson's disease
9. Hx. PUD and gastritis
10. Hx. abnormal pap smears
11. Status post bilateral total knee replacement.
12. Low back pain
13. Chronic kidney disease with baseline creatinine 1.3-1.9
diastolic CHF
Social History:
Patient lives with her husband in [**Location (un) 686**], daughter lives
nearby. Patient is a former smoker, but none in recent years. No
alcohol. She walks with the aid of a cane. She was born in
[**Male First Name (un) 1056**]. She is spanish speaking only. Grandson, [**Name (NI) **], is
primary communicator for the family.
Family History:
Brother with DM. No CAD or COPD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T98.1 BP106/62 HR71 RR22 100/2L.
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, oral thrush noted
NECK JVD to the tragus
PULM crackles halfway up back bialterally
CV irregularly irregular, varibable intensity S1 S2, 3/6 SEM at
the right lower sternal border
ABD soft NT ND normoactive bowel sounds, no r/g
EXT 2+ edema extending to the mid thigh bilaterally
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
[**2202-7-30**] 08:59PM K+-4.5
[**2202-7-30**] 07:36PM PT-51.5* PTT-45.9* INR(PT)-5.1*
[**2202-7-30**] 06:40PM GLUCOSE-61* UREA N-29* CREAT-1.8* SODIUM-143
POTASSIUM-6.0* CHLORIDE-102 TOTAL CO2-37* ANION GAP-10
[**2202-7-30**] 06:40PM estGFR-Using this
[**2202-7-30**] 06:40PM cTropnT-<0.01
[**2202-7-30**] 06:40PM D-DIMER-1432*
[**2202-7-30**] 06:40PM proBNP-2654*
[**2202-7-30**] 06:40PM WBC-8.4 RBC-3.82* HGB-9.0* HCT-31.8* MCV-83
MCH-23.5* MCHC-28.2* RDW-18.2*
[**2202-7-30**] 06:40PM NEUTS-71.1* LYMPHS-18.9 MONOS-6.9 EOS-2.1
BASOS-0.9
[**2202-7-30**] 06:40PM PLT COUNT-162
BLOOD GAS:
[**2202-7-31**] 07:29PM BLOOD Type-ART Temp-37.4 pO2-72* pCO2-89*
pH-7.23* calTCO2-39* Base XS-6 Intubat-NOT INTUBA
[**2202-7-31**] 10:45PM BLOOD Type-ART Rates-/20 PEEP-5 FiO2-50 pO2-91
pCO2-81* pH-7.27* calTCO2-39* Base XS-7 Vent-SPONTANEOU
[**2202-8-2**] 02:31PM BLOOD Type-[**Last Name (un) **] pO2-82* pCO2-79* pH-7.36
calTCO2-46* Base XS-14 Comment-GREEN TOP
[**2202-8-3**] 07:03PM BLOOD Type-[**Last Name (un) **] Temp-36.9 pO2-52* pCO2-85*
pH-7.40 calTCO2-55* Base XS-22
[**2202-8-4**] 02:59AM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-86* pH-7.41
calTCO2-56* Base XS-24
[**2202-8-4**] 10:58AM BLOOD Type-ART pO2-74* pCO2-79* pH-7.43
calTCO2-54* Base XS-22 Intubat-NOT INTUBA
CXR [**2202-7-30**]
Pulmonary vascular congestion without frank edema, not likely
changed given lower inspiratory effort on the current exam.
CXR [**2202-7-31**]
There are low lung volumes. Moderate-to-severe cardiomegaly and
tortuous aorta are unchanged. Mild pulmonary edema is increased
from prior. There is no pneumothorax. If any, there are small
bilateral pleural effusions. There is no evidence of lobar
pneumonia.
[**2202-8-7**] CT chest IMPRESSION:
1. No effusion or consolidation.
2. Scattered pulmonary nodules and ground glass opacities
requiring follow-up chest CT in 6 months.
3. Mild lower lobe bronchial wall thickening could reflect a
chronic small airways disease.
4. Mild-to-moderate cardiomegaly with prominent coronary artery
calcifications.
DISCHARGE LABS
[**2202-8-11**] 06:50AM BLOOD WBC-11.0 RBC-3.90* Hgb-9.5* Hct-32.3*
MCV-83 MCH-24.3* MCHC-29.3* RDW-19.7* Plt Ct-243
[**2202-8-12**] 05:43AM BLOOD PT-15.7* INR(PT)-1.5*
[**2202-8-12**] 05:43AM BLOOD Glucose-281* UreaN-53* Creat-2.0* Na-133
K-4.7 Cl-91* HCO3-33* AnGap-14
[**2202-8-11**] 06:50AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.3
Brief Hospital Course:
Ms. [**Known lastname 109788**] is a 84yoF with [**Hospital 7133**] medical problems including
diastolic heart failure (EF 70%), DM2, CKD, TR here with
shortness of breath likely caused by decompensation of CHF.
.
# RESPIRATORY DISTRESS: likely related to obesity
hypoventilation and sleep apnea complicated by decompensated
heart failure. Seen by Pulm and Sleep who recommend BiPAP at
night and at day as needed. Improved with BiPAP qHS and
diuresis. Pt continued nebulizer treatments and inhaled steroids
throughout admission. She did not receive systemic steroids.
Pt's respiratory status improved with diuresis approximately 9L,
BiPAP at night, and was successfully weaned off oxygen. She is
set up for outpatient follow-up for pulmonary function tests,
sleep study, and urgent care pulm clinic.
.
# [**Hospital1 **]-VENTRICULAR HEART FAILURE: Pt presented with worsening
dyspnea over several days. ACS ruled out: troponins negative
x2, EKG unchanged from prior, and symptom onset was insidious,
and the patient says her chest pain is close to baseline. Likely
SOB [**1-7**] acute diastolic heart failure, with superimposed COPD
component. The patient was clinically volume overloaded on
admission with worsening lower extremity edema, desaturations,
and increased weight. Lasix drip and fluid restriction was
started on the floor. The patient was placed on supplemental O2
on the floor. Albuterol nebs were given. The patient had a
persistently altered mental status on the floor, with increased
sleepiness and confusion from baseline accoringing to
discussions with her family. Blood gas was obtained, which
showed the patient to be in hypercapnic respirtaroy failure, and
the patient was tranfered to CCU for BIPAP. In the CCU, pt
continued diuresis with lasix drip (approximately 9L) and was
intermittently on Bipap. Lasix gtt was stopped and she was
transitioned back to PO torsemide on the cardiology service, and
maintained at approximately ins = output. PO torsemide was
decreased from 80mg to 60mg daily as she developed acute kidney
injury and hypotension. Dry weight is 84.3kg.
.
# ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE: Pt had elevated
cr to 2.7 from baseline of 1.5. Cr downtrended with diuresis.
Most likely secondary to venous congestion. Creatinine rose
again in the setting of aggressive diuresis and hypotension, but
improved upon discharge after gentle bolus (500cc) of IVF.
.
# ATRIAL FIBRILLATION: On admission, pt had supratheraputic INR
to 6.2 and coumadin was held. She was given 1mg vitamin K to
reverse INR so that patient could go on to right heart
catheterization, she did not end up getting procedure, INR
normalized and coumadin was restarted. Pt's carvedilol was held
for hypotension in CCU and uptitrated to home dose as BP
tolerated, then changed to metoprolol to minimize bronchospastic
component.
.
# CORONARY ARTERY DISEASE: Admission EKG at her baseline. Cont
simvastatin. Lisinopril held in setting of hypotension and
elevated cr, restarted at 20mg, but ultimately discontinued
because she became hypotensive to as low as 80/palp.
Carvedilol changed to metoprolol.
.
# HTN: Continued home meds (clonidine,carvedilol) as BP
tolerated.
Lisinopril initally held, restarted at 20mg on [**8-10**], discontinued
because she became hypotensive.
# BLOOD PRESSURE: Normotensive with SBP in 110-120s on
discharge.
HYPERTENSION:
- Continued clonidine at reduced dose
- Changed carvedilol to metoprolol for redued bronchospasm in
the setting of reactive airway disease
- Torsemide dose decreased
- Lisinopril held on admission, attempted to restart on [**8-10**] at
20mg (half of home dose), but pt developed symptomatic
hypotension, so it was discontinued indefinitely
HYPOTENSION: Normotensive on discharge. Developed hypotension
[**2202-8-10**] in setting of restarting [**12-7**] of home lisinopril 20mg and
increasing torsemide to 80mg. Gave gentle fluid bolus 500cc
IVF, with appropriate improvement in BP and orthostasis.
- No evidence of infection to suggest septic shock - developed
mild transient leukocytosis to 12.1, which resolved the
follwowing day.
# FEVER of 100.5: The patient had a low grade fever on the floor
initially. Has had some urinary symptoms, and was post void
bladder scan showed 400 ccs of urine, so Foley was placed. The
patient also says she has had some cough recently but none has
been noted yet by staff on the floor. No consolidation visible
on CXR. UCx on admission showed no growth. [**2202-7-31**] urine cx
showed 10,000-100,000 Enterococcus. Bcx showed no growth and
WBC downtrended.
CHRONIC ISSUES
# DM2: Continued NPH, QACHS Humalog SS.
.
# PARKINSONS: Continued Sinemet.
.
# THRUSH: Likely from fluticasone. Encouraged rinsing mouth
after administration.
Given nystatin SS. Fluticasone discontinued (replaced with
spiriva and advair)
.
# GERD: Continued omeprazole.
.
# Seizure disorder: Continued Keppra.
.
# Sleep: Continued trazadone.
TRANSITIONAL ISSUES
- Follow-up chest CT in 6 months - pulmonary nodules and
ground-glass opacities
- Outpatient pulmonary function tests
- Outpatient sleep study
- DRY WEIGHT: 84.3kg
- [**Month (only) 116**] consider tapering off clonidine as tolerated
MEDICATION CHANGES
- STOP fluticasone inhaler, being replaced with Spiriva and
Advair inhalers
- START spiriva 1 inhalation twice a day
- START advair inhaler
- DECREASED clonidine from 0.3 to 0.1mg twice a day
- DECREASED torsemide from 80mg daily to 60mg daily
- STOP carvedilol, being replaced with metoprolol
- START metoprolol succinate 200mg DAILY
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. albuterol sulfate *NF* 1-2 puffs Inhalation q4-6hr SOB,
cough, wheezing
2. Carbidopa-Levodopa (25-100) 1 TAB PO TID
3. Carvedilol 50 mg PO BID
4. CloniDINE 0.3 mg PO TID
5. Clotrimazole Cream 1 Appl TP [**Hospital1 **]
6. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
7. LeVETiracetam 500 mg PO BID
8. Lisinopril 40 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Simvastatin 40 mg PO DAILY
11. Torsemide 80 mg PO DAILY
12. TraMADOL (Ultram) 50 mg PO BID pain
13. Warfarin 5 mg PO DAILY16
7.5mg on Fridays
14. Docusate Sodium 100 mg PO BID
15. HumuLIN 70/30 *NF* (insulin NPH & regular human) 32 units in
the AM, 20 units at dinner Subcutaneous twice a day
16. Milk of Magnesia 15-30 mL PO DAILY constipation
17. Psyllium 1 PKT PO Frequency is Unknown
Discharge Medications:
1. Carbidopa-Levodopa (25-100) 1 TAB PO TID
2. Clotrimazole Cream 1 Appl TP [**Hospital1 **]
3. Docusate Sodium 100 mg PO BID
4. LeVETiracetam 500 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. Psyllium 1 PKT PO TID
7. Metoprolol Succinate XL 200 mg PO DAILY
hold for sbp < 90, hr < 55
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth DAILY Disp
#*30 Tablet Refills:*3
8. CloniDINE 0.1 mg PO BID
hold for SBP<100
RX *clonidine 0.1 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*3
9. Simvastatin 40 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
11. Warfarin 5 mg PO DAILY16
7.5mg on Fridays
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
INH twice a day Disp #*1 Inhaler Refills:*0
13. HumuLIN 70/30 *NF* (insulin NPH & regular human) 32 units in
the AM, 20 units at dinner Subcutaneous twice a day
14. albuterol sulfate *NF* 1-2 puffs Inhalation q4-6hr SOB,
cough, wheezing
15. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 IH
DAILY Disp #*30 Capsule Refills:*3
16. Milk of Magnesia 15-30 mL PO DAILY constipation
17. Outpatient Lab Work
Please check Chem7 by [**2202-8-17**].
Discharge Cr: 2.0
Send results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4026**], MD. Fax: [**Telephone/Fax (1) 3382**].
18. Torsemide 60 mg PO DAILY
Start [**2202-8-12**]
RX *torsemide 20 mg 3 tablet(s) by mouth DAILY Disp #*90 Tablet
Refills:*3
19. BiPAP
Home BiPAP 10/5 with heated humidification
Indication/Diagnosis: Hypoventilation leading to hypercarbia
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
PRIMARY: Hypercarbic respiratory failure, acute on chronic
biventricular heart failure (hypertensive cardiomyopathy,
tricuspid regurgitation, pulmonary hypertension)
SECONDARY: Obstructive sleep apnea, obesity-hypoventilation
disease, reactive airway disease, coronary artery disease,
atrial fibrillation, acute on chronic kidney disease, diabetes
mellitus, Parkinson's disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname 109788**],
It was a pleasure caring for your during your hospitalization
for shortness of breath. You were cared for by lung and heart
specialists as your shortness of breath is likely due to a
combination of heart failure, lung disease, and sleep apnea.
Your breathing improved with diuretic medications to remove
fluid from your lungs, nebulizers, and BiPAP machine at night.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
You should continue getting your INR checked and warfarin dose
adjusted at the [**Hospital3 **] Anticoagulation [**Hospital 9085**]
clinic as before.
MED CHANGES:
- STOP fluticasone inhaler, being replaced with Spiriva and
Advair inhalers
- START spiriva 1 inhalation twice a day
- START advair inhaler
- DECREASED clonidine from 0.3 to 0.1mg twice a day
- DECREASED torsemide from 80mg daily to 60mg daily
- STOP carvedilol, being replaced with metoprolol
- START metoprolol succinate 200mg DAILY
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2202-8-13**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6310**], NP [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We are working on a follow up appointment for your
hospitalization in Cardiology with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] or NP [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. It is recommended you be seen within 2 weeks of
discharge the office will contact you at home with the
appointment information. If you have not heard within 2 business
days please call the office at [**Telephone/Fax (1) 62**].
We are working on a follow up appointment for your
hospitalization in Pulmonary. It is recommended you be seen
within 1 week of discharge the office will contact you at home
with the appointment information. If you have not heard within 2
business days please call the office at [**Telephone/Fax (1) 612**].
We are working on a follow up appointment for your
hospitalization in Sleep Medicine. It is recommended you be seen
within 2 weeks of discharge the office will contact you at home
with the appointment information. If you have not heard within 2
business days please call the office at [**Telephone/Fax (1) 612**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]
Completed by:[**2202-8-15**]
ICD9 Codes: 5849, 4280, 496, 5859, 4168, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3956
} | Medical Text: Admission Date: [**2193-3-6**] Discharge Date: [**2193-3-14**]
Date of Birth: [**2107-5-10**] Sex: F
Service: MEDICINE
Allergies:
Avelox / Omeprazole
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Thoracentesis on [**2193-3-11**]
History of Present Illness:
Ms. [**Known lastname 28272**] is an 85 F with a history of COPD on 3 L O2 at home
and a history of recurrent exudative bilateral pleural effusions
of unknown etiology with pleural fluid drainage from her Pleurex
catheter Monday, Wednesday, Friday who came to the ED for chest
pain, SOB, and increased pleural drainage.
Of note the patient's pleural effusions were diagnosed at
[**Hospital 882**] Hospital in [**2192-12-10**], per the last D/C summary in
OMR she was found to have an "undiagnosed lymphocytic, exudative
effusion with negative cytology, AFB, bacterial and fungal
cultures." She was hospitalized late [**Month (only) **] at [**Hospital1 18**] in the
ICU for an exacerbation of her COPD and CT thorax and echo
failed to clearly delineate the cause of the effusions.
Thoracentesis was exudative. It was felt that she was not
healthy enough from a pulmonary point of view to tolerate a
thoracoscopy to further investigate the causes of the pleural
effusions and she opted for a palliative right tunnelled
catheter for symptomatic relief. Hospice was consulted and she
decided that she wanted to return home with services, not
hospice, but would remain DNR/DNI. PT was discharged to [**Hospital 100**]
Rehab and has since returned home for the last two months with
three times weekly drainage of her pleurex.
Last night she noted increased right chest pain. She has a
chronic intermittant cough over the past 6 months and states it
has increased over the past 2 days. This morning her CP
persisted so she had her son come home from work and drain her
pleurex catheter. He noted increased pleural fluid from the
catheter (400 cc vs 150 cc normal), that appeared darker in
color. She continued to have chest pain and was brought to the
ED.
In the ED the patient looked uncomfortable with RR in high 20s.
Portable CXR showed a large left sided pleural effusion. EKG
showed NSR, 87 bpm, old ST dep in V3-V4 and TWI in V1-3. WBC
elevated from baseline at 10. Her K+ was initially elevated but
was repeated and normal. She was given morphine 4 mg x 2 for
pain which helped. Vital signs at transfer were VS: HR 80,
97/52, 20 94% on 4L nc.
On the floor, pt was breathing comfortably on 3 L nc. She
complained of pleuritic chest pain and denied fever, chills, URI
symptoms, dysuria, rash, calf pain, recent weight loss. ROS was
otherwise + for decreased appetite and arthritis in her neck
that occasionally causes headaches.
Past Medical History:
COPD on home O2
Recent exudative pleural effusions as above
Chronic sinusitis with secondary nasal drip and chronic cough.
Hypothyroidism
Chronic cough
OA
Glaucoma
Cataracts
Social History:
Pt is home bound on 3 L O2 24 hrs a day, living with son,
[**Name (NI) **], has services at home. Daughter [**Name (NI) **], however is the
health care proxy. Recently been residing at [**Hospital 100**] Rehab.
Former smoker, quit 22 years ago. Former secretary
Family History:
Father died @ 57 of MI, was smoker with emphysema
Mother died 92 old age
Brother died ? MI
Other brother and sister well
5 children well
Physical Exam:
On Admission:
GEN: pleasant, comfortable with intermittant sharp pain in her
right chest
HEENT: PERRL, EOMI, anicteric, slightly dry MM, op without
lesions, no supraclavicular or cervical lymphadenopathy, no jvd
RESP: decreased breath sounds in the lower left base, mild
expiratory wheeze, increased pain with inspiration localized to
right epigastric area
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nontender to palpation
EXT: no calf tenderness, erythema, or edema
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. Moving all extremities
Pertinent Results:
ADMISSION LABS:
- [**2193-3-6**] 02:50PM GLUCOSE-114* UREA N-21* CREAT-1.0
SODIUM-136 POTASSIUM-5.3* CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
LIPASE-22 ALT(SGPT)-14 AST(SGOT)-42* LD(LDH)-402* CK(CPK)-43 ALK
PHOS-83 TOT BILI-0.5 LACTATE-1.5 K+-5.4*
- [**2193-3-6**] 02:50PM WBC-10.0# (NEUTS-84.3* LYMPHS-9.4*
MONOS-4.2 EOS-1.9 BASOS-0.2) RBC-4.62 HGB-14.1 HCT-41.3 MCV-90
MCH-30.5 MCHC-34.1 RDW-13.8 PLT COUNT-317
- [**2193-3-6**] 02:50PM PT-10.7 PTT-21.7* INR(PT)-0.9
[**2193-3-6**] 05:42PM K+-4.2
DISCHARGE LABS:
- [**3-13**] INR: 1.3
- [**3-14**] INR: 1.6
- [**3-14**] HCT: 29.9
[**2193-3-6**] CTA: INDICATION: Acute onset chest pain and hypoxia.
Evaluate PleurX catheter. CTA CHEST: MDCT imaging was performed
from the thoracic inlet to the upper abdomen without IV
contrast. Subsequently, after the uneventful intravenous
administration of 100 cc of Optiray, MDCT imaging was again
performed from the thoracic inlet to the upper abdomen.
Sagittal, coronal, and oblique reformats were performed. The
patient's IV infiltrated during the saline bolus measuring
approximately 30 cc. A cold compress was applied. Dr. [**Last Name (STitle) 4026**] ICU
resident was made aware.
COMPARISON: CT chest [**2192-12-17**]. FINDINGS: There are
partially occlusive filling defects involving segmental vessels
to the right middle and right lower lobe (3:61, 3:67). No
left-sided pulmonary arterial filling defects are present. The
main pulmonary artery is top normal measuring 2.9 cm. The
thoracic aorta is in its ascending portion is slightly enlarged
measuring 4 cm in AP dimension at the level of the right main
pulmonary artery. Similar to the previous examination is mural
thrombus seen along the right lateral border of the descending
thoracic aorta, which is unchanged. There is calcification at
the aortic arch.
There are severe emphysematous disease, most pronounced at the
lung apices, but similar to the previous study. There is a small
left pleural effusion with basilar atelectasis. The Pleurex
catheter is present in the right chest along the contour of the
right hemidiaphragm. Increased since the prior examination is a
moderate-sized left pleural effusion with adjacent atelectasis.
No pericardial fluid is present. There are coronary artery
vascular calcifications. There are no signs of heart strain.
BONE WINDOWS: There are mild degenerative changes of the
thoracic spine. No suspicious sclerotic or lytic lesions are
present.
IMPRESSION:
1. Pulmonary arterial filling defects in segmental and
subsegmental branches
of the right middle and right lower lobes. No evidence for heart
strain.
2. Moderate left effusion. Small right effusion. Bibasilar
atelectasis.
Satisfactory position of PleurX catheter along the right contour
of the right
hemidiaphragm.
3. Severe emphysema. No pneumothorax.
4. Top normal size main pulmonary artery. Top normal size
ascending aorta
with stable thrombus in the descending thoracic aorta.
Brief Hospital Course:
Ms. [**Known lastname 28272**] is a 85 F with a PMH of COPD and recurrent pleural
effusions of unknown etiology who was originally admitted to the
ICU with worsening hypoxia. CTA of the chest revealed RML/RLL
segmental and subsegmental pulmonary emboli. She was also noted
to have a large left pleural effusion. Ultimately her symptoms
were thought to be from the effusions and exacerbated by the
pulmonary emboli.
She was started on anticoagulation and observed in the ICU and
then called out to the floor. She had a slight drop in her
hematocrit but was guaiac negative on multiple occasions and her
hematocrit stabilized without intervention by discharge.
On arrival to the floor Ms. [**Known lastname 28272**] was quite clear that she was
suffering with her advanced COPD and recurrent effusions and she
wanted to pursue hospice care. Multiple family discussions were
held and collectively it was decided that she would have a
therapeutic thoracentesis of the left-sided effusion. She would
also continue her right-sided pleural fluid drainage on Monday,
Wednesday, and Friday and continue on Lovenox/warfarin for her
pulmonary emboli. However, she would also begin to utilize
Ativan and oral morphine to treat anxiety and her chronic
dyspnea.
She underwent therapeutic thoracentesis on [**2193-3-11**] and 1 liter
was removed. Given her goals of care this was not sent for
pleural fluid analysis. Multiple changes were made to her
medications:
- she was started on a bowel regimen
- pain regimen was changed from Percocet to morphine
- discharged on Lovenox and warfarin as above (last 3 doses of
warfarin were all 2.5mg daily and INRs are listed under results
section)
- stopped alendronate and Advair
- started Robitussin for your cough
There were no tests pending at discharge. She will continue to
follow with her hospice group and Dr. [**First Name (STitle) **] as necessary.
Medications on Admission:
ALBUTEROL SULFATE nebulizaiton QID PRN
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler -ALENDRONATE - 70
mg Tablet - 1 Tablet(s) by mouth weekly
BRIMONIDINE - Dosage uncertain
BUDESONIDE-FORMOTEROL - 160 mcg-4.5 mcg/INH 2 puffs [**Hospital1 **]
FLUTICASONE - 50 mcg Spray, IN [**Hospital1 **]
FLUTICASONE-SALMETEROL - 250 mcg-50 mcg/Dose [**Hospital1 **]
LATANOPROST - 0.005 %
LEVOTHYROXINE - 75 mcg Tablet Q day
LORAZEPAM - 0.5 mg Tablet QID for anxiety
MIRTAZAPINE - 30 mg QHS
MORPHINE - 15 mg Tablet qd prn for pain
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet tid prn For severe
neck pain
TIOTROPIUM BROMIDE - 18 mcg Capsule Q day
.
Allergies: NKDA
Discharge Medications:
1. morphine concentrate 20 mg/mL Solution Sig: 5-20 mg PO every
four (4) hours as needed for pain or shortness of breath.
Disp:*30 mL* Refills:*0*
2. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
3. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*10 syringes* Refills:*2*
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed for wheeze, SOB.
5. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-10**]
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
6. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
7. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day.
9. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
12. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Robitussin DM Max 10-200 mg/5 mL Liquid Sig: Five (5) cc PO
every six (6) hours as needed for cough.
17. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Pulmonary embolus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Breathing comfortably at rest on 3L by nasal cannula (satting
98% on 3LNC).
Discharge Instructions:
Dear Ms. [**Known lastname 28272**],
You were admitted with shortness of breath and found to have an
increased effusion and pulmonary emboli (blood clots in your
lungs). Your breathing improved with drainage of the fluid and
treatment for the blood clots in your lungs.
We have made the following changes to your medications:
- started colace and Senna to prevent constipaion (these are
both over-the-counter laxatives)
- started Lovenox and warfarin to treat your pulmonary embolus
(use the Lovenox to keep your blood thin until your coumadin
levels/INR is between [**3-14**] for 24 hours). You will need to have
your next INR checked on [**2193-3-15**].
- changed your morphine to liquid morphine
- stopped alendronate
- stopped your Percocet given that you are taking morphine
- at admission your medication list suggested you are taking
both Advair and Symbicort; these are essentially the same
medication and you only need to take one of them. It appears
your insurance pays for Symbicort and I stopped the Advair
- started Robitussin for your cough
You will be going home with hospice and can continue to follow
with Dr. [**First Name (STitle) **] as you need.
Followup Instructions:
Your hospice team will meet you at home today. You can also
discuss problems with Dr. [**First Name (STitle) **] (phone [**Telephone/Fax (1) 250**]).
ICD9 Codes: 5119, 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3957
} | Medical Text: Admission Date: [**2115-4-9**] Discharge Date: [**2115-4-13**]
Date of Birth: [**2044-10-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Plavix / Levaquin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
coronary artery bypass grafting x 4 (LIMA-LAD, SVG-0M, SVG-Dx,
SVG-RCA) [**2115-4-9**]
History of Present Illness:
70 year old male with a cardiac history which includes PCI of
the
RCA in [**2096**] at [**Hospital1 2177**]. Cardiac cath [**2098**] showed patent RCA stent
but occlusion of distal circumflex coronary. He has been
medically managed since then. Over the years he has had
intermittent chest pain. More recently, he describes increasing
substernal chest tightness and dyspnea with walking and climbing
2 flights of stairs. Despite negative stress test [**Month (only) 404**] of
[**2115**]
patient is referred for surgical revascularization after failing
medical management and continuation of symptoms.
Past Medical History:
coronary artery disease
PMH:
Rt carotid occlusion
abdominal aortic aneurysm s/p [**Hospital1 **]-iliac stent graft
hypertension
hyperlipidemia
Chronic VEA
retinal vein occlusion of left eye
coronary artery disease-s/p percutaneous coronary intervention
of right coronary artery [**2096**]
Appendectomy
gastroesophageal reflux disease
Social History:
Lives with: wife. 2 children live locally
Occupation: retired design engineer
Tobacco:denies
ETOH:denies
Family History:
father died of sudden death at age 68, mother
died of cardiomyopathy age 84
Physical Exam:
67" 192lbs BSA 2.0m2
BP (R) 141/110 (L) 140/90
HR 70 SR Resp 20 Sat 99% RA
GEN: WDWN in NAD
SKIN: Warm, dry [**Year (4 digits) 5235**], No C/C/E. Multiple skin tags.
HEENT: NCAT, PERRLA, Sclera anicteric, OP benign, teeth in fair
repair.
HEART: RRR, NlS1-S2, No M/R/G
LUNGS: CTA
ABD: Soft, NT, ND, NABS.
EXT: Warm, well perfused. Small superficial spider varicosities
noted but GSV appears suitable on standing. Pulses 2+
throughout.
CAROTIDS: Faint left bruit.
Pertinent Results:
Echo [**2115-4-9**]
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular chamber size and free wall motion are normal.
The ascending [**Month/Day/Year 5236**] is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic [**Month/Day/Year 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-CPB:
Preserved biventricular systolic fxn.
No AI. Trace MR.
[**First Name (Titles) **] [**Last Name (Titles) 5235**]. Other parameters as pre-bypass.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2115-4-9**] where the patient underwent coronary
artery bypass x 4. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Cefazolin was
used for surgical prophylaxis. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. The
patient was neurologically [**Date Range 5235**] and hemodynamically stable on
no inotropic or vasopressor support. Chest tubes and pacing
wires were discontinued without complication. The patient was
transferred to the telemetry floor for further recovery. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. Albuterol inhaler was initiated to aid in weaning
oxygen. By POD 4, the patient was ambulating freely, the wound
was healing and pain was controlled with oral analgesics. The
patient was discharged home in good condition with appropriate
follow up instructions.
Medications on Admission:
Norvasc 10mg daily
Atenelol 100mg in am , 50mg in pm
Lipitor 40mg daily
Ativan 0.5mg three times a day
Losartan 100mg daily
NTG 0.4mg SL as needed
Omperazole 20mg daily
ASA 325mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain, fever.
6. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
Disp:*qs * Refills:*0*
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
1 weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
coronary artery disease
PMH:
Rt carotid occlusion
abdominal aortic aneurysm s/p [**Hospital1 **]-iliac stent graft
hypertension
hyperlipidemia
Chronic VEA
retinal vein occlusion of left eye
coronary artery disease-s/p percutaneous coronary intervention
of right coronary artery [**2096**]
Appendectomy
gastroesophageal reflux disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 8431**] in [**2-9**] weeks
Cardiologist Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 62**] in [**2-9**] weeks
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-6-17**] 1:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2115-6-17**]
1:45
Provider: [**Known firstname 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2115-6-17**] 2:20
Completed by:[**2115-4-13**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3958
} | Medical Text: Admission Date: [**2129-6-9**] Discharge Date: [**2129-6-14**]
Date of Birth: [**2061-7-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Mold Extracts
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Gait Difficulties
Major Surgical or Invasive Procedure:
T8 - T10 LAMINECTOMY TUMOR RESECTION
History of Present Illness:
Ms. [**Known lastname 86154**] was seen by Dr. [**Last Name (STitle) 548**] in the spine center for
neurosurgical consultation. She is a 67-year-old woman with mild
cognitive issues. She presented with a complaint of progressive
reliance on a walker since [**Month (only) 404**] and incontinence that has
been more prominent since [**Month (only) 956**]. She has had increasing
difficulty with ambulation.
Past Medical History:
dev delay, ht murmer,osteoporosis, r atrophic kidney, SOB on
exertion/COPD
Social History:
No tobacco, no alcohol
Family History:
NC
Physical Exam:
[**Hospital 4452**] clinic examination [**5-17**]: Her motor strength was 4+/5 in
the right
iliopsoas. The left was [**6-1**]. The remainder of her lower
extremity exam was normal. There was clonus bilaterally.Babinski
was upgoing on the right and equivocal on the left. Her sensory
examination was intact with respect to modality of light touch.
An attempt to identify sensory level was unsuccessful.
Upon Discharge:as above, at baseline, wound clean dry intact
with staples
Pertinent Results:
CXR [**2129-6-9**]:
pt more kyphotic. ETT tip 1.6 cm above carina. OGT in stomach.
increased
bibasilar ill-defined opacities, possible aspiration and/or
atelectasis in
setting bronchiectasis. surgical skin staples in place.
An MRI of the thoracic spine was available for review. That
study demonstrates a homogeneously enhancing dorsal lesion that
is intradural approximately T8-T9. It imparts significant
compression of the spinal cord and occupies approximately 80% of
the canal.
Brief Hospital Course:
Ms [**Known lastname 86154**] was admitted to the neurosurgery service on [**6-9**] and
underwent a T8 - T10 laminectomies for tumor resection. She was
kept intubated and was traNSfered to the ICU post-operatively.
She was extubated on [**6-10**], diet and activity advanced. Wound
was clean and dry with staples.She was transferred to the floor.
She was evaluated by PT who felt her suitable for rehab which
was arranged. Foley was attempted to be removed but required
replacement for retention. She will need bladder training at
rehab.
Medications on Admission:
Acetaminophen, Albuterol, Colace, Fosamax, Lasix, Lescol, Ativan
and Resperdal
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever,pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
6. Risperidone 0.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
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. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
Evanswood Center for Older Adults - [**Location (un) 8072**]
Discharge Diagnosis:
T9 meningioma
urinary retention
Discharge Condition:
AT BASELINE
Discharge Instructions:
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up / begin daily showers [**6-14**]
?????? 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 a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
Followup Instructions:
PLEASE HAVE YOUR STAPLES REMOVED [**6-20**] AT REHAB OR CALL DR [**Doctor Last Name **] OFFICE FOR APPT FOR REMOVAL OF YOUR STAPLES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NOT NEED XRAYS PRIOR TO YOUR APPOINTMENT
Completed by:[**2129-6-14**]
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3959
} | Medical Text: Admission Date: [**2117-7-12**] Discharge Date: [**2117-7-14**]
Date of Birth: [**2087-7-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 25936**]
Chief Complaint:
syncope and chest pain
Major Surgical or Invasive Procedure:
[**2117-7-13**] Pericardiocentesis
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: 29 yo M without cardiac history
presents with retrosternal chest pain and syncope - 2 episodes
in the last 5 days. First time pain occurred after dinner and
pt describes this as a dull soreness extending from throat to
mid chest, no radiation to arms, jaw, or back. Non exertional.
Lasted about an hour though took advil. Current episode started
10 min after dinner consisting of steak, potatoes, fries and
ginger ale - lasted all night despite taking Advil per pt, was
worse when he was laying down flat and somewhat relieved when
sitting up. No recent cough, diarrhea, fevers, vomiting, no
viral symptoms. Also no history of arthritis or autoimmune
disorders.
Also had a syncopal event 3x in the past day. Each time he
feels nauseous "out of the blue", and then passes out. Once was
observed, in our ED and there were no tonic/clonic jerks, he did
hit his right head. He regained consciousness as soon as he hit
the ground, was pale and clammy with vitals of pulse 80 regular,
BP 80/50. He was able to sit up and walked 8 paces to an exam
table. He always returns to consciousness without biting
tounge, B/B incontinence, or confusion. No headache or changes
in vision.
Seen at BIDN where EKG showed difuse STE, and formal echo showed
moderate-sized pericardial effusion with some evidence of RV
collapse by report. Initial vitals on transfer to [**Hospital1 18**] ED
were: 99.5 101 110/64 18 98% RA. In our ED, he received IV
fluids x 5 L, 2 x 325 mg ASA, oxygen 2L NC, maalox with decrease
in chest discomfort (decreased with maalox and before ASA). His
repeat BP was 120/60, pulse 78/min, stable, alert and oriented.
.
On arrival to the floor, patient is feeling well. He no longer
has chest pain nor nausea/lightheadedness. He did go to the
bathroom without lightheadedness also. No compliants.
.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, pulmonary embolism, bleeding, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. he denies recent fevers,
chills or rigors. he denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
epididymitis
opiate abuse (oxycodone)
Social History:
Works in construction. Lives with wife.
-Tobacco history: 1 ppd x 11 years
-ETOH: social, about 3x/week
-Illicit drugs: was addicted to intranasal oxycodone, now on
naltrexone maintenance and has been clean x 6 weeks
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 99.0, BP 120s/80s, HR 90s, RR 10, O2 sat > 96% RA
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: Right temple with 4x4 cm hematoma, tender, no skin break.
Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of [**9-2**] cm.
CARDIAC: RR, normal S1, split S2. No m/r/g. + 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.
EXTREMITIES: no c/c/e
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: pulsus of 12
Right: radial 2+ PT 2+
Left: radial 2+ PT 2+
.
DISCHARGE PHYSICAL EXAM
VS afebrile, BP 120s/80s, HR 80s, saturations 100% RA
exam unchanged except:
JVD cannot be visualized at 45 degrees
normal S1, S2 and no spliting of S2, S4 remains
Pertinent Results:
ADMISSION LABS:
[**2117-7-12**] 03:40PM BLOOD WBC-17.1* RBC-5.02 Hgb-15.3 Hct-45.7
MCV-91 MCH-30.5 MCHC-33.6 RDW-12.7 Plt Ct-211
[**2117-7-12**] 03:40PM BLOOD Neuts-88.0* Lymphs-7.4* Monos-2.4 Eos-1.9
Baso-0.3
[**2117-7-12**] 03:40PM BLOOD PT-10.1 PTT-25.5 INR(PT)-0.9
[**2117-7-12**] 03:40PM BLOOD ESR-0
[**2117-7-12**] 03:40PM BLOOD Glucose-116* UreaN-16 Creat-0.9 Na-135
K-4.7 Cl-104 HCO3-23 AnGap-13
[**2117-7-12**] 03:40PM BLOOD cTropnT-<0.01
[**2117-7-13**] 05:28AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.2
[**2117-7-13**] 05:28AM BLOOD TSH-2.6
[**2117-7-12**] 03:40PM BLOOD CRP-13.4*
[**2117-7-12**] 03:44PM BLOOD Lactate-1.6
[**2117-7-13**] 06:37AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2117-7-13**] 06:37AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2117-7-13**] 06:37AM URINE RBC-0 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
.
Discharge Labs:
[**2117-7-14**] 05:35AM BLOOD WBC-10.2 RBC-5.05 Hgb-15.5 Hct-44.0
MCV-87 MCH-30.8 MCHC-35.3* RDW-12.5 Plt Ct-199
[**2117-7-14**] 05:35AM BLOOD Glucose-88 UreaN-16 Creat-1.0 Na-140
K-3.6 Cl-106 HCO3-26 AnGap-12
[**2117-7-14**] 05:35AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.0
PERICARDIAL FLUID:
[**2117-7-13**] 05:44PM OTHER BODY FLUID WBC-4778* RBC-2889* Polys-1*
Lymphs-23* Monos-0 Eos-57* Macro-19*
[**2117-7-13**] 05:44PM OTHER BODY FLUID TotProt-4.8 Glucose-81
LD(LDH)-320 Amylase-30 Albumin-3.6
.
MICRO:
[**2117-7-13**] 5:44 pm FLUID,OTHER PERICARDIAL FLUID.
GRAM STAIN (Final [**2117-7-13**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2117-7-14**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
BLOOD CULTURE [**2117-7-12**] NO GROWTH TO DATE
PERICARDIAL FLUID CULTURE [**2117-7-13**] NO GROWTH TO DATE
PERICARDIAL FLUID CYTOLOGY [**2117-7-13**] PENDING
[**2117-7-12**] ECHO:
LEFT VENTRICLE: Overall normal LVEF (>55%).
PERICARDIUM: Small to moderate pericardial effusion. Brief RA
diastolic collapse. Significant, accentuated respiratory
variation in mitral/tricuspid valve inflows, c/w impaired
ventricular filling.
GENERAL COMMENTS: Emergency study performed by the cardiology
fellow on call. Results were reviewed with the Cardiology Fellow
involved with the patient's care.
Conclusions
Overall left ventricular systolic function is normal (LVEF>55%).
There is a small to moderate sized pericardial effusion. Focal
right ventricular diastolic compression is seen in the subcostal
view but is not present in the apical and parasternal views
(this may represent focal/early tamponade). There is brief right
atrial diastolic collapse. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling.
[**2117-7-13**] ECHO: LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. No 2D or
Doppler evidence of distal arch coarctation.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal
mitral valve supporting structures. [**Male First Name (un) **] of the mitral chordae
(normal variant). No resting LVOT gradient. No MS. Trivial MR.
TRICUSPID VALVE: TVP. Normal tricuspid valve supporting
structures. No TS. Physiologic TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: Moderate pericardial effusion. Effusion
circumferential. No RA or RV diastolic collapse. Significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, c/w impaired ventricular filling.
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF 60%). 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 stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. Tricuspid valve
prolapse is present. The estimated pulmonary artery systolic
pressure is normal. There is a moderate sized pericardial
effusion. The effusion appears circumferential. No right atrial
or right ventricular diastolic collapse is seen. There is
significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling, although frank cardiac tamponade is not
present.
Compared with the findings of the prior study (images reviewed)
of [**2117-7-12**], the findings are similar
[**2117-7-14**] ECHO:
This study was compared to the prior study of [**2117-7-13**].
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Normal aortic valve leaflets (3).
TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal PA
systolic pressure.
PERICARDIUM: No pericardial effusion.
Conclusions
FOCUSED STUDY POST-PERICARDIOCENTESIS: Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of [**2117-7-13**],
left ventricular function appears more vigorous.
CXR [**2117-7-14**]: previous images. There is no evidence of
post-procedure
pneumothorax. Cardiac silhouette is at the upper limits of
normal or mildly enlarged. No definite vascular congestion or
acute pneumonia.
Brief Hospital Course:
29 yo M w/ no significant PMH presented with pleuritic chest
pain and syncope (likely vasovagal) and was found to have a
pericardial effusion with a Pulsus of 12 and early tamponade
physiology on TTE who underwent successful pericardiocentesis
with improved chest pressure.
#Pericardial effusion- etiology is unclear. Cytology is still
pending. Given that the most common cause is pericarditis, he
was started on colchicine and ibuprofen in house and will
continue these as an outpatient. He has multiple labs on the
pericardial fluid still pending at the time of discharge. As he
had a significant effusion it was decided to drain it rather
than monitor with serial TTE. He will require f/u with TTE with
Dr. [**First Name (STitle) **] on [**8-2**]. He will continue on colchicine and
ibuprofen until then, and will be directed by Dr. [**First Name (STitle) **] when to
stop the colchicine. He was instructed what to look out for in
terms of signs of tamponade or worsening effusion.
-discharged on colchicine and ibuprofen
-will f/u with Dr. [**First Name (STitle) **] of cardiology to determine course of
treatment
-Multiple pericarld fluid studies are still pending
#Syncope- patient had syncope on admission and it was in teh
setting of pain, and therefore likely due to a vasovagal event
as opposed to his pericardial effusion.
Follow-up needed for:
1.Pericardial fluid studies- to be followed up by Dr. [**First Name (STitle) **]
2. TTE will need to be performed to evaluate for resolution of
the effusion
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Naloxone Dose is Unknown mg IM QMONTH
Discharge Medications:
1. Ibuprofen 600 mg PO Q8H
Take for 5 days, then take 200mg PO TID for 7 days
RX *ibuprofen 600 mg TID and then [**Hospital1 **] Disp #*30 Tablet
Refills:*0
2. Colchicine 0.6 mg PO DAILY
RX *Colcrys 0.6 mg daily Disp #*30 Tablet Refills:*0
3. Naloxone 0 mg IM QMONTH
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial Effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 63724**],
You were admitted to the hospital after you had passed out, and
you were found to have a pericardial effusion (fluid within the
sac surrounding your heart). You were monitored in the Cardiac
intensive care unit and had this fluid drained. The exact cause
of the increase in fluid is still not clear but likely was due
to inflammation in the sac called the pericardium. We started
you on two medications that you will need to continue as an
outpatient to treat your pericarditis.
Transitional Issues:
Pending labs: Pericardial Fluid studies from [**2117-7-13**], including
cytology
Medications started:
1. Colchicine 0.6mg by mouth once a day to help with
inflammation around the heart. You should continue this until
your follow-up appointment with Dr. [**First Name (STitle) **] (cardiology)
2. Ibuprofen to help with inflammation around your heart. You
should take 600 mg three times a day for 5 more days, then 200
mg three times a day for 1 week, and then you can stop.
Medications changed/Stopped: None
Follow-up needed for:
1. You should see a cardiologist as per below and will need a
repeat echocardiogram (ultrasound of your heart). You should
bring your medications to each appointment so your doctors [**Name5 (PTitle) **]
update their records and adjust the doses as needed.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Name:[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],MD
Specialty: Primary Care
Location: [**Hospital **] MEDICAL ASSOC- [**Location (un) **]
Address: [**Location (un) 11898**], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 8506**]
When: A message was left on the office voicemail that you need
an appointment in the next week. You should be called at home
with an appoinment. If you have not heard, please call above
number for status.
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 83560**], MD
Specialty: Cardiology
Location: [**Hospital1 641**]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 38275**]
When: [**8-3**] at 10:40am
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3960
} | Medical Text: Admission Date: [**2185-4-5**] Discharge Date: [**2185-4-14**]
Date of Birth: [**2106-10-23**] Sex: F
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 78 year-old
woman with a dilated aorta to 7 cm found on routine chest
x-ray. A CT scan also showed a dilated aorta. The patient
was admitted for presumed ascending aortic aneurysm repair.
PAST MEDICAL HISTORY:
1. Peptic ulcer disease.
2. Hypertension.
3. Bilateral cataracts.
4. Renal calculi.
5. Obesity.
MEDICATIONS PRIOR TO ADMISSION:
1. Hydrochlorothiazide 25 mg q.d.
2. Protonix 40 mg q.d.
3. Multivitamin.
4. Atenolol 25 mg q.d.
ALLERGIES: Non-steroidal anti-inflammatory drugs and
aspirins both of which cause gastric upset and gastritis.
Also intravenous contrast, which causes chills and shaking.
SOCIAL HISTORY: Positive tobacco use, three to five
cigarettes per day. No alcohol use.
Carotid ultra sounds done in [**Month (only) 956**] of this year showed no
significant disease and a Myoview done also in [**Month (only) 956**]
showed decreased uptake at the apex without wall motion
abnormalities and an EF of 70%.
PHYSICAL EXAMINATION: Heart rate of 80 sinus, blood pressure
132/88 on the right and 122/88 on the left. Height is 5'3".
Weight is 160 pounds. General, no acute distress. Skin no
obvious lesions. HEENT pupils are equal, round and reactive
to light. Extraocular movements intact. Neck si supple with
no JVD or bruits. Chest is clear to auscultation
bilaterally. Cardiac is regular rate and rhythm. S1 and S2
with no murmur. Abdomen is soft, nontender, nondistended.
No hepatosplenomegaly. No costovertebral angle tenderness.
Extremities are warm and well perfuse with no clubbing,
cyanosis or edema. No varicosities noted. Neurological
cranial nerves II through XII intact. Nonfocal examination.
Excellent strength in all four extremities. Pulses femoral
2+ bilaterally. Dorsalis pedis pulse 2+ bilaterally.
Posterior tibial pulse 1+ bilaterally. Radial 2+
bilaterally.
LABORATORY DATA: White blood cell count 10.3, hematocrit 42,
platelets 314, PT 13, PTT 26, INR 1.1. Sodium 135, potassium
3.1, chloride 101, CO2 25, BUN 27, creatinine 1.2. Glucose
195, ALT 8, AST 12, alkaline phosphatase 94, albumin 3.7,
amylase 27. Urinalysis is negative. Chest x-ray shows
ascending aortic aneurysm at the mid arch.
HOSPITAL COURSE: The patient was a direct admission to the
Operating Room for presumed ________. However, a
transesophageal echocardiogram done prior to preinitiation of
the surgery revealed that the distal ascending arch was only
4 cm with no aortic insufficiency and an intraluminal
hematoma in the distal ascending aorta with a descending
aorta that had severe atheromatous disease and calcifications
throughout. The decision was made at that time to cancel the
surgical procedure. Following which the patient was
transferred to the Cardiothoracic Intensive Care Unit for
recovery from anesthesia. Once in the Cardiothoracic
Intensive Care Unit the patient's anesthesia was reversed.
She was successfully weaned from the ventilator and
extubated. Following extubation the patient complained of
nausea and had several episodes of hematemesis with clots.
An nasogastric tube was placed with a return of frank blood
that we were unable to lavage to clear. Gastrointestinal was
called at that time following which they did an endoscopy,
which showed no varices and no bleeding sites with blood in
the fundus and stomach body, but no areas of active bleeding
seen. Following that General Surgery was also consulted and
the patient underwent celiac angiography, which showed no
evidence of active extravasation. It did, however, show an
abnormal collection of air present adjacent to the left
curvature of the stomach. CT of the abdomen was done also,
which showed extraluminal air medial to the esophagus at the
gastroesophageal junction as well as near the lesser
curvature of the stomach.
The patient was brought back to the Intensive Care Unit and
followed over the next several days with serial hematocrits.
She had no further episodes of hematemesis. On the following
day she had a gastrograph and swallow, which was also
negative and therefore a decision was made to treat the
patient conservatively keeping her NPO and treating her with
triple antibiotics while maintaining her in the hospital for
one week on total parenteral nutrition. The patient did well
during that period of time and had no further episodes of
hematemesis and no melena. Her hematocrit remained stable.
Her diet was advanced slowly, starting on post TEE day four
from clear liquids to full liquids to soft solids to a
regular diet and on hospital day ten it was decided that the
patient was stable and ready to be discharged to home.
At the time the patient's physical examination is as follows,
temperature 98, heart rate 76 sinus rhythm, blood pressure
138/80, respiratory rate 14, O2 sat 97% on room air. Weight
prehospital was 86 kilograms, at discharge is 74 kilograms.
Laboratory data on the day of discharge white blood cell
count 10, hematocrit 31, platelets 354, sodium 140, potassium
4.4, chloride 100, CO2 24, BUN 25, creatinine 0.9, glucose
120. Physical examination neurological alert and oriented
times three, moves all extremities, follows commands.
Respiratory clear to auscultation bilaterally. Cardiac
regular rate and rhythm. S1 and S2. No murmur. Abdomen
soft, nontender, nondistended with normoactive bowel sounds.
Extremities are warm and well perfuse with no clubbing,
cyanosis or edema.
DISCHARGE MEDICATIONS:
1. Atenolol 25 mg q.d.
2. Prilosec 40 mg q.d.
3. Levofloxacin 250 mg q.d. times seven days.
4. Flagyl 500 mg t.i.d. times seven days.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Hypertension.
2. Peptic ulcer disease.
3. Bilateral cataract.
4. Renal calculi.
5. Ascending abdominal aortic by MRI.
Sh[**Last Name (STitle) 14388**]o be discharged to home. She is to have follow up
with Dr. [**First Name (STitle) **] her primary care physician in three to four
weeks and follow up with Dr. [**Last Name (Prefixes) **] in his office also
in three to four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2185-4-14**] 12:12
T: [**2185-4-14**] 12:20
JOB#: [**Job Number 14389**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3961
} | Medical Text: Admission Date: [**2151-6-29**] Discharge Date: [**2151-7-7**]
Date of Birth: Sex:
Service: Thoracic Surgery
CHIEF COMPLAINT: Mr. [**Known lastname **] is a 66-year-old gentleman,
status post multiple lung resections for tumor. On [**2151-6-29**], the patient underwent a mediastinoscopy and therapeutic
bronchoscopy and was found to have this large right upper
lobe mass abutting the mediastinum and right main pulmonary
artery. Biopsy proved this to be a mixed tumor, mostly small
lung cell cancer, however, some features of small cell lung
cancer. He had had a failed attempt with chemotherapy and
radiotherapy and had decided to proceed with a resection.
PRIOR MEDICAL HISTORY:
1. Known coronary artery disease.
2. Known lung cancer.
3. Peptic ulcer disease.
4. Home oxygen requirement.
MEDICATIONS AT HOME:
1. Advair.
2. Combivent.
3. Ativan.
4. Prevacid.
5. Effexor.
6. Ambien.
BRIEF HOSPITAL COURSE: On [**2151-6-29**], the patient
underwent a purportedly uneventful right upper and middle
lobectomy without complication. He was kept intubated
overnight in the PACU and sedated, planned for extubation in
the morning.
By the afternoon of postoperative day #1, the patient had
been extubated, however, had a persistent inotrope support
requirement. He was changed to ICU status and transferred to
the intensive care unit.
By postoperative day #3, the patient was comfortable,
however, remained extremely disoriented. There was some
question of whether his disorientation was secondary to
alcoholic withdrawal or was secondary to his respiratory
distress.
Through postoperative day #4 and postoperative day #5, the
patient's agitation continued to worsen. On the morning of
[**2151-7-4**], the patient was found to have increased work of
breathing and deterioration in his mental status. Again, it
was unclear if this was secondary to his respiratory failure
or advanced signs of delirium tremens.
Per family wishes, and after consultation with Dr. [**Last Name (STitle) 952**] on
the morning of postoperative day #5, the patient was
successfully intubated. Several attempts were made at weaning
sedation and vent management, but the patient became
increasingly agitated and had difficulty breathing during
each of these events.
On [**2151-7-6**], the patient became hypotensive and dyspneic.
A Swan-Ganz catheter was placed, showing a high output
picture consistent with sepsis. The patient was started on
vancomycin, Zosyn, and Xigris. This septic picture continued
to evolve throughout the course of the day with final blood
gas of 7.15, 64, 24, -7. At that time, the patient's family
had become increasingly vocal regarding their wishes to
withdraw the patient's care. After several discussions,
including the patient's wife, 2 daughters, and a grandson,
decision was made to withdraw and make the patient comfort
measures only.
At approximately 2:30 in the morning on [**2151-7-8**], the
patient's drips, including Xigris, vasopressin and Levophed
were all discontinued. The ventilator, likewise, was stopped.
The patient expired shortly thereafter.
The medical examiner declined the case. The family likewise
declined autopsy.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern1) 9178**]
MEDQUIST36
D: [**2151-10-7**] 14:54:21
T: [**2151-10-8**] 07:11:47
Job#: [**Job Number 59298**]
ICD9 Codes: 5185, 0389, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3962
} | Medical Text: Admission Date: [**2177-10-20**] Discharge Date: [**2177-11-3**]
Date of Birth: [**2177-10-20**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby girl [**Name2 (NI) **] [**Known lastname 1661**] is the
1.67-kg product of a 33-3/7 week twin gestation, born to a
35-year-old gravida 1, para 0 (to 2) mother.
Prenatal screens were notable for maternal blood type O
positive, antibody negative, hepatitis B surface antigen
negative, rapid plasma reagin nonreactive, Rubella immune,
group B strep unknown.
These were spontaneous dichorionic-diamniotic twins. The
pregnancy was uncomplicated. The mother had preterm labor.
This child was born by cesarean section. He received some
blow by oxygen and was given Apgar scores of 8 and 8.
HOSPITAL COURSE BY SYSTEM:
1. PULMONARY SYSTEM: The child was initiated on some CPAP,
but she rapidly weaned to room air and did well. She was
noted to have a few episodes of apnea of bradycardia over the
course of the hospitalization. This improved. At the time
of discharge, she had no apnea of bradycardia for over five
days.
2. CARDIOVASCULAR SYSTEM: Cardiovascularly, she was stable
with no intervention required.
3. FLUIDS/ELECTROLYTES/NUTRITION: Intravenous fluids were
initiated. Enteral feedings were advanced. She was advanced
to a 24-calorie formula ad lib.
4. INFECTIOUS DISEASE: She received ampicillin and
gentamicin for 48 hours. Her cultures remained negative.
She was off therapy after 48 hours.
PHYSICAL EXAMINATION ON DISCHARGE: She was well-appearing
without any signs of distress. A nondysmorphic child with
clear breath sounds. No murmur. The abdomen was soft and
benign. No rashes. Her weight was 1.755 kg.
CONDITION AT DISCHARGE: Her condition on discharge was good.
DISCHARGE DISPOSITION: Discharge disposition was to home.
PRIMARY PEDIATRICIAN: The name of the primary pediatrician
was Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 44797**].
CARE RECOMMENDATIONS:
1. Continue feeding at 24-calorie formula ad lib.
2. Follow up with pediatrician.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Apnea of prematurity.
3. Rule out sepsis.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Name8 (MD) 44795**]
MEDQUIST36
D: [**2177-11-4**] 18:15
T: [**2177-11-4**] 18:51
JOB#: [**Job Number **]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3963
} | Medical Text: Admission Date: [**2133-1-27**] Discharge Date: [**2133-1-31**]
Date of Birth: [**2061-8-12**] Sex: F
Service: MEDICINE
Allergies:
Cortisone / Codeine
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
admission for total knee replacement
Major Surgical or Invasive Procedure:
total knee replacement
tracheal intubation
mechanical ventilation
cardiopulmonary resuscitation
History of Present Illness:
71yo woman with HTN, GERD and hemochromotosis treated with
periodic phlebotomy who underwent an elective right total knee
replacement for osteoarthritis on [**2132-1-28**]. The patient
was transferred from the PACU at 17:30PM. The nursing acceptance
note documents the patient was alert and oriented with stable
vital signs, and that she was given juice and jello at 2100.
During the course of the day a dilaudid epidural was placed by
anesthesia for continuing post-operative pain (T11-12 epidural
14skin/9space APS20@[**6-27**] Hydromorphone 20 mcg/ml + Bupivacaine
0.1% 1 mg/ml infused at 6-10 ml/hr). The pt was well until at
least midnight, the time of the last nursing check.
.
At 01:43, a code blue was called. On arrival to the scene, the
patient was cyanotic and cold. CPR was initiated with good
peripheral pulses appreciated. The cardiac monitor demonstrated
asystole. The patient was given two rounds of epinephrine and
atropine. A brief wide complex rhythm was obtained but was not
sustained. Another round of epinephrine and atropine was given
with establishment of an unclear wide complex rhythm without
pulse. A pulseless electrical activity code was initiated, but
she subsequently was able to establish a narrow complex
tachycardia with palpable radial pulses without any further
medications administered. BP at the time was 190/110 with heart
rate in the 120s. The length of time the patient was
unresponsive was unclear, however a perfusing pulse via CPR was
established within several minutes and a native beat was
established within 15 minutes of initiating the code. During
this time, anesthesia attempted intubation with endotracheal
tube, but was met with difficulty. There was moderate amounts of
brown aspiration material appreciated with bagging, and
difficulty with the wall suction prevented rapid intubation.
After copious suctioning, the patient was subsequently intubated
with good breath sounds bilaterally. Additional access via
femoral line was obtained. Initially the right femoral was
cannulated and dilated but a catheter was unable to be threaded;
subsequently the left femoral was accessed and a triple-lumen
catheter was placed. The patient was transported to the [**Hospital Unit Name 153**] by
02:30.
Past Medical History:
PAST MEDICAL HISTORY:
1. hypertension
2. hemochromatosis
3. gastroesophageal reflux disease
4. osteoporosis
PAST SURGICAL HISTORY:
1. status post cholecystectomy
2. status post vein ligation
3. status post total abdominal hysterectomy
4. status post open left knee lateral meniscectomy in [**2092**]
5. status post left knee arthroscopy in [**2128**]
Social History:
Tobacco: none
Alcohol: none
Illicit drugs: none
Family History:
Significant cardiac history in extended family
Physical Exam:
VS: BP: 70/palp, HR: 140, RR: 12 - bagged with ET tube.
GEN: obese caucasian female intubated with ET tube
HEENT: pupils dilated and fixed, no extra ocular movements
Chest: good air movement with ventilated breath sounds
CV: tachycardia of seeming regularity, no murmurs, rubs, gallops
Abd: obese, soft, nontender, nondistended, no bowel sounds
appreciated after one minute of auscultation bilaterally
Ext: cool, dry
Neuro: Fixed dilated pupils, no extraocular movements, unable to
assess other cranial nerves. No dolls eyes reflex, no grasp
reflex, Babinski negative. No tone. No spontaneous movements.
Pertinent Results:
Labs at time of code:
CBC: WBC-10.6 RBC-3.34*# Hgb-10.9*# Hct-32.3* Plt Ct-150
Coags: PT-14.9* PTT-33.4 INR(PT)-1.5
Chem 10: Glucose-408* UreaN-19 Creat-1.0 Na-140 K-4.3 Cl-105
HCO3-16* Calcium-7.5* Phos-7.6* Mg-2.0 freeCa-1.17
Enzs: ALT-172* AST-228* LD(LDH)-498* AlkPhos-90 TotBili-0.4
Cardiac enzymes:
CK: 02:21AM 46, 4am 69, 11am 80, 10pm 116
CKMB: 2am 2, 4am 3, 11am not done, 10pm 5
Trop: 2am <0.01, 4am <0.01, 11am 0.02, 10pm 0.03
ABG: 7.03/65/234/18 -> 7.31/35/285/18
Lactate: 8.2
CXR [**1-28**]: Endotracheal tube is seen in good position.
Improvement of previously described central pulmonary vessel
prominence was likely positional.
LLE u/s: No evidence of left lower extremity DVT.
CTA: CT OF THE CHEST WITH IV CONTRAST: In the most superior
aspects of the visualized field, there is an enlarged right
thyroid. Within the lungs, there are bilateral infiltrates seen
within the posterior lower lobes, along with small patchy
infiltrate seen in the posterior right upper lobe. These
infiltrates along with pulsation artifact slightly obscure the
evaluation of the subsegmental pulmonary vasculature. However,
within the subsegmental and segmental pulmonary arterial
vasculature in the right lower lobe there are filling defects
consistent with pulmonary emboli. No pleural effusions or
pneumothoraces are seen. There is no evidence of pathologic
lymphadenopathy seen within the mediastinum, hilum, or axilla.
The heart and remaining great vessels are otherwise
unremarkable. This patient is status post intubation and gastric
tube placement.
Within the liver, there are two areas of low attenuation, the
first along the border of the right and left lobes measuring
approximately 30 x 21 mm and the second in the left lobe,
measuring 19 x 18 mm. Both demonstrate fluid attenuation that
probably represent liver cysts.
BONE WINDOWS: There is no evidence of lytic or sclerotic lesions
seen within the chest.
IMPRESSION:
1. Pulmonary emboli seen within the segmental and subsegmental
pulmonary arteries of the right lower lobe.
2. Bilateral lung infiltrates seen within the lower lobes and
posterior aspect of the right upper lobe.
3. Two areas of low attenuation seen within the liver that
likely represent liver cysts.
ECHO:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. LV
inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: There is an anterior space which most likely
represents a fat
pad, though a loculated anterior pericardial effusion cannot be
excluded.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
The left atrium is normal in size. 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%). Right
ventricular chamber size and free wall motion are normal. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is borderline pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a fat pad, though a loculated anterior
pericardial effusion cannot be excluded.
MRI: FINDINGS: Both the diffusion and FLAIR images show high
signal throughout the cortex of both cerebral hemispheres. High
signal is also seen within the hippocampus, more evident on the
FLAIR than the diffusion-weighted sequence. There is also
possible slightly elevated signal seen within the dorsal pons on
both sequences. Taken together, these findings are consistent
with a global hypoxic/ischemic injury. There are no areas of
abnormal susceptibility seen. The principal vascular flow
patterns are identified. There is an air-fluid level within the
sphenoid sinus, presumably a result of intubation, as are
air-fluid levels in the maxillary sinuses bilaterally, as well
as moderate mucosal thickening within the left frontal air cell
and ethmoid sinuses bilaterally. Finally, fluid and mucosal
thickening are noted within both mastoid sinuses.
CONCLUSION: Findings consistent with global anoxic injury of the
cerebral hemispheres and possibly a portion of the brainstem.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], neurology resident caring for this patient,
was informed of these findings by telephone today.
Right knee x-ray: 1. No hardware fracture or malalignment status
post right knee TKR.
CXR [**1-29**]: Lungs are now clear. Heart is normal size. Tip of the
ET tube approximately 5.4 cm above the carina is in standard
placement. No pleural abnormality or evidence of central
vascular dilatation. Nasogastric tube passes into the stomach
and out of view.
EKG [**1-29**]: Sinus tachycardia. Ventricular premature complex. Poor
R wave progression - probable normal variant. Since previous
tracing of [**2133-1-28**], the rate is slower.
Brief Hospital Course:
Assessment - 70yo woman with HTN, hemochromatosis, s/p elective
TKR for osteoarthritis admitted to the [**Hospital Unit Name 153**] s/p asystolic arrest
and resuscitation, noted to have global anoxic ischemic brain
injury, died after withdrawal of life support.
Hospital course is reviewed below by problem:
1. Asystolic arrest - As detailed in the HPI, the patient had an
arrest on the med/[**Doctor First Name **] floor,of unclear etiology. The possible
etiologies included aspiration of gastric contents (airway
obstruction), pulmonary thromboembolic disease, hypoxemia due to
hypopnea/apnea, or primary cardiac dysrhythmia. A primary
cardiac event was less likely as the resussitation was
successful without significant rhythm disturbances. The patient
had emesis at the time of attempted intubation, but not clear
whether prior aspiration was experienced by the patient leading
to hypoxemia. The possibility of hypopnea/apnea secondary to
sedation was considered, although an appropriate sensory level
was previously documented well below T4. Also considered the
possiblity of a primary neurologic event such as actue stroke
syndrome. Although the RLL segmental and subsegmental pulmonary
emboli may have contributed to the hypoxemia, in the absence of
central embolism (main PA trunck or main right or left PA)
whether these emboli represented the etiology for the arrest was
not apparent. The radiologists [**Location (un) 1131**] the CT agreed with this
assessment. She was mechanically ventilated, monitored on
telemetry in the MICU, and given iv heparin. With the poor
prognosis associated with non-traumatic coma, and based on the
findings of the head MRI, the family members (including the
patients' husband) expressed desire to withdraw mechanican
ventilation on MICU day #5 and focus care on comfort. The
patient expired on MICU day #5.
2. Mental status - On arrival to the ICU, the patient had no gag
reflex, corneal reflex, or dolls eye reflex, and was not
initiating breaths. Throughout her stay, she was initiating
breaths but still had no other reflexes. An MRI and CT showed
diffuse global anoxic injury. The neurology service was called.
They recommended giving mannitol and allowing the patient to be
slightly hypocarbic. WIth non-traumatic coma, the Neurology
service reported that the patient's prognosis was grim, with a
>99% chance that the patient would remain in a persitent
vegetative state. The patient remained in coma during the
entire time in the MICU. After waiting 24-48 hours to ensure
the prognosis was accurate, consistent with the patient's
previously expressed wishes, the family members agreed to
withdrew all life-sustaining measures and changed the goals of
care to comfort measures only.
3. Acid/base status - On MICU admission, the patient had a mixed
metabolic and respiratory acidotic picture. The metabolic
acidosis was likely secondary to lactate acidosis from ischemia,
the respiratory acidosis from apnea. This corrected very well
with increased respiratory rate. Afterwards, the patient had a
respiratory alkalosis, overbreathing the ventilator.
4. Hematocrit drop - She was noted to have a hematocrit drop
thought secondary to a GI bleed, as it coincided with the start
of heparin and was associated with coffee ground emesis. She had
no bruits or hematomas to suggest bleed into groin.
5. Hypertension - Intially, after the code, the patient was
hypotensive, requiring vasopressors. However, this lasted
shortly and she became hypertensive and required
antihypertensives for a goal MAP>80.
6. Fevers - The patient was noted to have fevers, most likely
secondary to aspiration pneumonitis vs pneumonia, pulmonary
emboli, or status post surgery. Her triple lumen catheter placed
during the code was replaced, and she was treated for a
pneumonia with levofloxacin until this was withdrawn per family
request.
7. Polyuria - The patient had significant urine output after
arriving in the MICU with what appeared to be very dilute watery
urine. This was thought to be secondary to IV fluid
admministration. She did not have evidence for a urinary tract
infection.
8. Hyperglycemia - The patient initially had hyperglycemia with
an elevated glucose of 408, most likely secondary to a stress
reaction from the arrest. She was maintained on an insulin
sliding scale until her goals of care were changed to comfort
measures only.
9. status post total knee replacement - The patient underwent a
total knee replacement.
10. Hemochromotosis - Not an active issue.
Medications on Admission:
1. HCTZ
2. Tiazac
3. Diovan
4. Prilosec
5. Naprosyn PRN
6. Zantac
7. Oxycodone PRN
8. Tylenol
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest
Global anoxic brain injury
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 9971, 4275, 5070, 2762, 5185, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3964
} | Medical Text: Admission Date: [**2102-7-8**] Discharge Date: [**2102-7-14**]
Service: MEDICINE
CHIEF COMPLAINT: The patient fell, with bleeding.
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old
white female with hypothyroidism, who presented to the [**Hospital1 1444**] for evaluation after the
patient was found in her bed this morning with bruises and
bleeding. Reportedly, the patient was in her usual state of
health on the day prior to admission. She recalled having
had dinner and not feeling great and went to bed.
The patient did not remember falling, but did remember
crawling into bed, which was on the [**Location (un) 1773**] and required
the patient to ascend three steps. She reported feeling
wetness on her sheets and not feeling well. She called her
neighbor, who came over and found her to have numerous
bruises with blood on her sheets. The patient denied any
preceding events such as chest pain, headache, visual
changes, convulsions or lightheadedness. She denied recent
orthopnea or paroxysmal nocturnal dyspnea. She had baseline
shortness of breath that had been ongoing for two years. She
noted occasional pain in the left part of her sternum, but
cannot recall when it happened last.
PAST MEDICAL HISTORY:
1. Hypothyroidism.
2. History of peptic ulcer disease.
3. Status post total abdominal hysterectomy.
ALLERGIES: There were no known drug allergies.
MEDICATIONS ON ADMISSION: Medications included Levoxyl and
aspirin.
SOCIAL HISTORY: The patient had been a widow for eight years
and lived alone, but had neighbors who looked in on her
routinely. She worked as a laboratory technician and
[**Hospital6 1129**] and at [**Hospital1 190**] in the past. She reported a smoking history,
but quit six to seven years ago.
PHYSICAL EXAMINATION: Vital signs revealed a temperature of
98.9??????F, a heart rate of 92, a blood pressure of 153/56, a
respiratory rate of 20 and an oxygen saturation of 94% on
room air. In general, the patient was alert and oriented, in
no acute distress and very talkative. On head and neck
examination, the patient had a right periorbital hematoma but
the eye was anicteric and not injected. She had a left
surgical pupil, but her right pupil was reactive. There was
a right lateral tongue hematoma. There was no jugular venous
distention.
The pulmonary examination showed decreased breath sounds with
no wheezes. The cardiovascular examination revealed distant
heart sounds with a I/VI systolic murmur in the left upper
sternal border. There were no rubs or gallops. The abdomen
had positive bowel sounds and was nontender and nondistended
with no hepatosplenomegaly appreciated. On examination of
the extremities, there was a large left arm hematoma with
left third and fourth toe hematomas as well. There were 1+
pulses bilaterally. On neurological examination, the patient
was alert and oriented times three with intact language and
comprehension. Cranial nerves II through XII were grossly
intact. Gait was not tested.
LABORATORY: The patient had a hematocrit of 34.4, white
blood cell count of 16,100, hemoglobin of 11.9 and platelet
count of 218,000. There was a sodium of 132, potassium of
4.2, chloride of 95, bicarbonate of 121, BUN of 23,
creatinine of 1.3 and glucose of 201. Prothrombin time was
13.6 and partial thromboplastin time was 26.6. CK was 786
with an MB of 6.
RADIOLOGY: The left elbow was without fracture. However,
the right distal radius had a fracture with dorsal
displacement of the fracture, but no loss of joint space. A
head CT scan revealed a right subdural hematoma from the
parietal to the occipital lobe; this was 6 to 7 mm at its
widest diameter. The chest x-ray revealed no pneumothorax
and no infiltrate at the time.
HOSPITAL COURSE: The patient was admitted to the medical
intensive care unit for further workup. The neurosurgery
service was consulted. However, given her age and frail
status, no surgical intervention was offered at that time.
[**Hospital 17552**] medical management was begun. With regard to
her right radial fracture, the orthopedic service was
consulted. During her hospital stay, the fracture was
reduced and a cast was placed. Further laboratory workup
revealed in line changes consistent with an acute myocardial
infarction. CPKs were 914, 736, 459 and 337 sequentially
with a troponin elevation of 16.5, 11.2 and 8.9 sequentially.
The CK MB initially were 25, 15, 14 and 8 with indices of 3,
2 and 3.
Because of the patient's fall and subdural hematoma, the
decision was made not to anticoagulate her with heparin or
aspirin. She was stabilized in the medical intensive care
unit and transferred to the floor for further workup. She
underwent an echocardiogram, which revealed a left
ventricular systolic ejection fraction of greater than 55%,
but with a moderate resting left ventricular outflow tract
obstruction. These findings were consistent with a
hypertrophic obstructive cardiomyopathy.
During the hospitalization, the patient experienced an acute
respiratory exacerbation with oxygen saturations decreasing
to the low 70s. She was started on 100% nonrebreather with
adequate desaturation. Subsequently, she was weaned to a 40%
scoop mask with oxygen saturations in the mid to high 90s.
The rapidity of her respiratory decline was worrisome for a
pulmonary embolism or possibly congestive heart failure.
However, the patient had no evidence of left ventricular
systolic dysfunction. Lower extremity Doppler studies were
done to evaluate for deep vein thrombosis, which were
negative.
Because of the patient's bleeding tendency, a decision was
made not to further evaluate her for a pulmonary embolism
after a discussion with her primary attending physician and
with the patient. A chest x-ray during this time was
suggestive of a pulmonary infiltrate and the patient was
started on empiric antibiotic treatment. She remained
afebrile during this time. She was given scheduled Atrovent
and albuterol nebulizer treatments to decrease wheezing and
poor air movement, with good result. The patient was begun
on a regimen of Lopressor to treat her idiopathic
hypertrophic subaortic stenosis and to obtain rate control
kept between the 60s and 70s.
The patient had a questionable history of falls in the past.
However, after a discussion with her primary physician, [**Name10 (NameIs) 1023**]
had cared for her for 40 years, we were reassured that she
had not fallen before this episode which resulted in
hospitalization. At this time, the cardiology service did
not feel it necessary to consider placement of a
defibrillator. However, with the patient's idiopathic
hypertrophic subaortic stenosis, this may be a consideration
if her signs and symptoms of syncope increase.
At the time of discharge, the patient was ambulating with the
assistance of physical therapy without problems.
CONDITION ON DISCHARGE: Improved.
DISCHARGE STATUS: The patient was discharged to the [**Hospital **]
rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Hypothyroidism.
2. Status post fall with subdural hematoma.
3. Status post non-ST elevation myocardial infarction.
4. Idiopathic hypertrophic subaortic stenosis or
hypertrophic obstructive cardiomyopathy.
5. Likely pneumonia.
DISCHARGE MEDICATIONS:
1. Levoxyl 75 mcg p.o. q.d.
2. Protonix 40 mg p.o. q.d.
3. Lopressor 75 mg p.o. b.i.d.
4. Levofloxacin 500 mg p.o. q.d. for 11 more days.
5. Boost nutritional supplement p.o. t.i.d.
FOLLOW UP: The patient is to follow up with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in two weeks' time. She is also to
follow up with Dr. [**Last Name (STitle) **] in two weeks' time at
[**Telephone/Fax (1) 5499**] at the [**Hospital Ward Name 23**] Center of [**Hospital1 190**].
[**Doctor First Name 21527**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 21528**], M.D. [**MD Number(1) 21529**]
Dictated By:[**Last Name (NamePattern1) 47096**]
MEDQUIST36
rp08/17/[**2101**]
D: [**2102-7-14**] 10:14
T: [**2102-7-14**] 12:14
JOB#: [**Job Number 60125**]
ICD9 Codes: 486, 2765, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3965
} | Medical Text: Admission Date: [**2123-6-25**] Discharge Date: [**2123-7-2**]
Date of Birth: [**2043-12-20**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Central venous line placement
Esophagogastroduodenoscopy (EGD)
History of Present Illness:
79-year-old woman who is being admitted for abdominal pain and
hypotension. She was noted in the ED to have temperature to 104.
Cultures were taken, pressures dropped to SBP 80s. Femoral line
was placed and patient was started on norepinephrine. CXR was
reportedly clear (?retrocardiac opacity). UA was negative. Labs
remarkable for white count of 13.3 and creatinine of 1.5, up
from baseline 1.0. Patient was given 1g vancomycin (?hand
cellulitis) and meropenem. Vitals at time of transfer were T
99.8, HR 102, BP 140/54, 99% on 4L, RR 18.
Of note, patient was recently admitted to the general medicine
service ([**Date range (1) 21715**]) for neck pain. She was treated
conservatively with ibuprofen and tylenol prn, with negative
head CT and negative CT c-spine. She was also treated for
urinary tract infection during that admission with a Levaquin. A
foley catheter was left in place due to concern of urinary
retention.
Past Medical History:
- Churg-[**Doctor Last Name 3532**] vasculitis, Positive p-ANCA
- Vascular dementia
- Chronic leg edema
- Osteoporosis
- Asthma
- History of GI bleed
- Right hip replacement due to AVN ([**2121-7-13**])
- Hypertension
- Chronic renal insufficiency (baseline Cr 1.0-1.5)
- Recent hospitalization for multiple left-side rib fractures
- Cholelithiasis s/p CCY
- GERD
- CAD (unclear details)
- Anemia (Hct in [**6-20**] 33.7)
- G3P3, all vaginal deliveries
- Recent ?zoster infection in left lateral chest wall
- Per patient, h/o heart murmur
Social History:
She currently lives at [**Location (un) 5481**] for short term rehab. She's
a widow. She was prior living independently at [**Hospital1 **] Village a
few weeks ago. She has good family support [**First Name8 (NamePattern2) **] [**Hospital1 **] dc
summary. Has 3 sons and 7 grandchildren (only 1 grandchild is a
girl). No tobacco, alcohol, or illicit drug use. Denies smoking,
occasional alcohol, none recently.
Family History:
Had niece with some type of cancer ("maybe lung cancer but also
in stomach" per son). Unclear how parents died.
Physical Exam:
Admission Exam
General: sleeping but rousable.
HEENT: non-icteric sclera, pupils equal and reactive
Heart: RRR, normal s1/s2
[**Last Name (un) **]: soft, non-distended, mild diffuse tenderness without
rebound or guarding
Extremities: warm and well-perfused
Pertinent Results:
On admission:
[**2123-6-24**] 07:20PM BLOOD WBC-13.3* RBC-3.69* Hgb-10.2* Hct-30.9*
MCV-84 MCH-27.5 MCHC-32.9 RDW-16.9* Plt Ct-232
[**2123-6-24**] 07:20PM BLOOD Neuts-80* Bands-0 Lymphs-16* Monos-2
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2123-6-24**] 07:20PM BLOOD Plt Smr-NORMAL Plt Ct-232
[**2123-6-24**] 07:20PM BLOOD Glucose-108* UreaN-13 Creat-1.5* Na-141
K-3.9 Cl-102 HCO3-26 AnGap-17
[**2123-6-24**] 07:20PM BLOOD ALT-13 AST-23 AlkPhos-76 TotBili-0.9
[**2123-6-24**] 07:20PM BLOOD Albumin-3.3*
[**2123-6-25**] 05:49AM BLOOD Albumin-2.9* Calcium-7.4* Phos-3.1
Mg-0.9*
[**2123-6-25**] 05:49AM BLOOD TSH-3.1
[**2123-6-25**] 05:49AM BLOOD Cortsol-6.1
[**2123-6-26**] 05:38PM BLOOD ANCA-NEGATIVE B
[**2123-6-26**] 05:38PM BLOOD CRP-168.9*
.
On discharge:
[**2123-7-1**] 07:50AM BLOOD WBC-10.2 RBC-4.15* Hgb-11.2* Hct-35.3*
MCV-85 MCH-27.0 MCHC-31.8 RDW-16.7* Plt Ct-378
[**2123-7-1**] 07:50AM BLOOD Plt Ct-378
[**2123-7-1**] 07:50AM BLOOD PT-12.5 PTT-22.4 INR(PT)-1.1
[**2123-7-1**] 07:50AM BLOOD Glucose-97 UreaN-5* Creat-0.8 Na-141
K-3.6 Cl-101 HCO3-32 AnGap-12
[**2123-6-26**] 03:59AM BLOOD ALT-12 AST-20 LD(LDH)-184 CK(CPK)-49
AlkPhos-72 TotBili-0.4
[**2123-6-26**] 03:59AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2123-6-26**] 03:59AM BLOOD Lipase-51
[**2123-7-1**] 07:50AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.6
.
LUE ultrasound:
IMPRESSION: No DVT in the left upper extremity.
Brief Hospital Course:
Ms. [**Known lastname **] is a very pleasant 79 yo woman who presented to the
[**Hospital1 18**] ED with initial symptom of abdominal pain, and was
admitted to the ICU with fevers and hypotension without obvious
source. She was called out to the general medicine service on
[**2123-6-27**], and was discharged from the hospital on [**2123-7-1**] in good
condition, ambulatory, with stable vital signs. Her brief
hospital course was notable for:
.
# Fever/Hypotension: At the time of admission septic shock was
the largest concern. There was no obvious infection despite
broad infectious work-up. Only clear source of infection was
left hand cellulitis which rapidly improved on Vancomycin. TSH
and cortisol both normal, ruling out endocrine sources of
hypotension. During admission she did have evidence of melena
with a GI hemorrhage, but had minimal drop in Hct. She was
treated with Vancomycin for 7-day course for possible hand
cellulitis (Day 1 = [**6-24**]). Was also treated with Flagyl
empirically for C. Diff. This was stopped with culture came
back negative. By the time the Pt was called out to the floor
fevers and hypotension resolved and the Pt remained afebrile and
normotensive or hypertensive while on the floor. The Pt
completed a 7 day course of vancomycin for presumed L hand
cellulitis. The exact cause of the patient's fever and
hypotension remains unclear. She has had recent admissions to
outside hospitals for fevers which have reportedly been
unrevealing. This will require further outpatient workup, but at
the time of discharge the Pt did not have active medical issues
to prohibit her discharge.
.
# Melena: Hematocrit downtrended slowly. Received one unit
PRBCs on [**6-27**]. H.pylori serology negative. GI was consulted and
recommended EGD. EGD was performed on [**2123-6-29**] which demonstrated
gastritis and esophagitis, but no active bleeding. Two biopsies
were obtained. Pt was started on sucralfate 1 mg QID and given
prescription to continue this as outpatient. Pt's dose of
pantoprozole was increased from 40 mg qD to 40 mg [**Hospital1 **]. Diet
recommendations were made including avoiding caffeine, onions,
alcohol, chocolate, and peppermint. Pt's aspirin 81 mg daily was
stopped. Pt did not have any further episodes of melena or Hct
drop while in the hospital.
.
# Vasculitis. Initially started on IV steroids given concern
for possible adrenal insufficiency as source of hypotension.
Cortisol was normal. She was then rapidly tapered to on day to
Prednisone 5 mg [**Hospital1 **]. Home prednisone dosing was confirmed and
she was transitioned to 5 mg prednisone daily. At the time of
discharge she was maintained on her admission dose of 2.5 mg qD
and 5 mg qHS.
.
# Hypoxic episodes: Patient intermittently with oxygen
saturation below 90%. This was in the setting of Ativan and
associated somnolence. Also appeared to have a positional, OSA
component. At the time of discharge the Pt had been maintaining
O2 sats over 90% on RA for over 24 hours. Should have
outpatient sleep evaluation.
.
# Dementia: Patient was continued on Namenda.
.
# GERD: Patient was continued on Protonix. This was increased
to [**Hospital1 **] once she developed guaiac positive stools.
.
# Neck pain: Contined on lidocaine patch.
.
# Depression: Continued on Citalopram.
.
# Hypertension: Pt was noted to be hypertensive to 180s systolic
on the day prior to discharge. Her Metoprolol dose was increased
on the day of discharge from 12.5 mg [**Hospital1 **] to 25 mg [**Hospital1 **].
Optimization of her outpatient medication should be done as an
outpatient, including addition of a thiazide diuretic and/or ACE
inhibitor.
.
# Left hand swelling: Pt had left hand swelling and was treated
with a 7 day course of Vancomycin for cellulitis. After the
treatment, on two different days the Pt experienced left hand
swelling, without pain, erythema, warmth vascular compromise, or
limitation in range of motion, which resolved spontaneously. The
etiology of this swelling is unclear. The Pt had negative
ultrasound studies of the upper extremity to rule out DVT.
.
All other chronic medical issues for this patient were stable.
She was discharged to rehab in good condition, ambulatory, with
stable vital signs, and appropriate outpatient follow-up
arranged. No further changes were made to her outpatient
medication regimen other than those described above.
Medications on Admission:
(per most recent discharge summary [**6-6**])
- aspirin 81 mg daily- multivitamin
- namenda 10 mg daily
- prednisone 2.5 mg daily, 5 mg qhs
- simvastatin 20 mg daily
- protonix 40 mg daily
- calcium carbonate 500 mg tid
- cholecalciferol 800 u daily
- citalopram 20 mg daily
- senna
- docusate 100 mg [**Hospital1 **]
- lidocaine patch
- magnesium hydroxide 400 q8h
- acetaminophen
- metoprolol 12.5 mg daily
- ibuprofen 400 mg q8h
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Memantine 5 mg Tablet Sig: One (1) Tablet PO bid ().
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Place
on for 12 hours then off for 12 hours daily.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: One (1) dose
PO three times a day.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary: cellulitis, sepsis
Secondary: Chrug-[**Doctor Last Name 3532**] vasculitis, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital1 69**] on
[**2123-6-26**] after you experienced fevers and hypotension. You
were initially treated and monitored in the medical intensive
care unit. Your condition improved and you were treated and
monitored on a general inpatient medicine floor. Your condition
has improved and you are now being discharged to a
rehabilitation facility in good condition, with stable vital
signs.
.
We have made the following changes to your outpatient medication
regimen:
- CHANGED Metoprolol tartrate 12.5 mg [**Hospital1 **] to Metoprolol tartrate
25 mg [**Hospital1 **]
- CHANGED Pantoprozole 40 mg PO qD to Pantoprozole 40 mg PO BID
- STARTED: Sucralfate 1mg QID (four times daily) for esophagitis
and gastritis
- STOPPED: Aspirin 81 mg qD
.
Please continue to take all other outpatient medications as you
had been prior to this hospitalization.
Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2123-7-27**] at 1 PM
With: EMG LABORATORY [**Telephone/Fax (1) 2846**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RHEUMATOLOGY
When: THURSDAY [**2123-9-2**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 0389, 311, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3966
} | Medical Text: Admission Date: [**2140-6-9**] Discharge Date: [**2140-6-9**]
Date of Birth: [**2067-7-11**] Sex: F
Service: [**Last Name (un) 18171**] ICU
HISTORY OF PRESENT ILLNESS: This is a 73 year-old female
with a history of systemic lupus erythematosus and atrial
fibrillation who complains of a five day history of a cough
productive of white sputum. She reports that yesterday she
developed increasing shortness of breath (gradual) along with
subjective fevers with chills and sweats. The patient
therefore called EMS.
She states that she returned from a vacation in the Catskills
approximately one week prior to admission and had a sore
throat that subsequently resolved.
REVIEW OF SYSTEMS: Negative for chest pain, shortness of
breath, emesis, diarrhea, bright red blood per rectum or
melena. She reports recent nausea with dry heaves. She has
had chronic leg pain and edema (secondary to venostasis and
peripheral neuropathy), but denies increase above baseline.
The patient denies orthopnea or paroxysmal nocturnal dyspnea.
She does report some palpitations and racing heart. EMS gave
the patient a Lasix dose times one and sublingual
nitroglycerin times three and brought the patient to the [**Hospital1 1444**] Emergency Department.
In the Emergency Department her temperature was 100.0. Heart
rate 100 to 117. Blood pressure 160/110. Her oxygen
saturation was 85% on room air, which increased to 95% on a
100% nonrebreather. The patient's electrocardiogram showed
minimal lateral nonspecific ST changes. Her chest x-ray
(after the Lasix dose) showed no congestive heart failure,
pneumothorax or pneumonia. An arterial blood gas done on
100% nonrebreather was 7.49, PCO2 of 37, and PO2 of 75.
Significant examination findings in the Emergency Department
included bibasilar crackles, jugulovenous distention and
peripheral edema. With the patient's history of deep venous
thrombosis and PE there was a concern for pulmonary embolus.
The CT angiogram was performed, which was negative for
pulmonary emboli or for any pulmonary parenchymal process.
The patient was then transferred to the MICU due to her
elevated oxygen requirement.
On arrival to the MICU the patient reported feeling much
better. Her oxygen saturations were in the mid 90s on 6
liters nasal cannula.
PAST MEDICAL HISTORY: Systemic lupus erythematosus, atrial
fibrillation, osteoarthritis, status post bilateral total
knee replacements, peripheral neuropathy, status post venous
stripping, status post hiatal hernia repair, status post
cataract surgery, question of coronary artery disease (this
is according to a discharge summary, the patient denies
history of heart disease). History of deep venous thrombosis
(occurred postop from the total knee replacement).
Osteoporosis.
HOME MEDICATIONS: Lasix 40 mg po every other day, Digoxin
0.125 mg p q day, Protonix, Coumadin 7.5 mg q Monday through
Saturday and 10 mg q Sunday, Prednisone 10 mg po q day,
Neurontin 600 mg q.i.d., Fosamax 70 mg q week, Duragesic
patch 75 micrograms q 72 hours, Miacalcin nasal spray one
spray q.d., Cardizem 80 mg q day.
ALLERGIES: The patient has allergies recorded to aspirin,
sulfa, Penicillin, percocet and Codeine.
LABORATORIES ON ADMISSION: White blood cell count of 11.2
with 73% neutrophils and 15% lymphocytes, hematocrit 43.9 and
platelets of 273, PT 17.0, PTT 41.1, INR 2.0. chem 7 sodium
1356, potassium 3.7, chloride 95, bicarb 29, BUN 12,
creatinine 0.9, glucose 101, calcium 9.2, magnesium 1.7, phos
3.3. Urinalysis showed small blood, negative nitrite or
leukocyte, 0 to 2 red blood cell and 0 to 2 white blood cell,
occasional bacteria and no epithelial cells. A Digoxin level
was subtherapeutic at 0.3.
Electrocardiogram showed atrial fibrillation at a rate of 100
with normal axis, normal intervals, 1.[**Street Address(2) 1755**] depression in
V4 through V5 compared with prior in 5 of [**2135**] (the prior
also showed normal sinus rhythm). CT angiogram was negative
for pulmonary embolus. It showed no consolidation and only
minimal bibasilar atelectasis.
HOSPITAL COURSE: The patient was admitted to the MICU at
3:00 a.m. on [**2140-6-9**]. This patient usually receives her
care at [**Hospital6 2910**]. Later that morning
contact was made with her primary physicians and the
arrangements were made for transfer to that institution.
Pulmonary: The patient reported subjective improvement in
her shortness of breath after her diuresis. The patient's
oxygen requirement at the time of this dictation is 5 liters
nasal cannula to maintain oxygen saturations in the mid 90s.
Cardiovascular: 1. Ischemia, the patient's records record a
history of coronary artery disease, which is not further
documented. The patient's electrocardiogram on admission
showed nonspecific ST changes, which were resolved by repeat
electrocardiogram this morning. The patient denies any
history of chest pain associated with this shortness of
breath. Serial enzymes are being obtained to rule out
myocardial infarction. At the time of this dictation the
first two sets are negative and the patient was maintained on
telemetry and a low dose beta blocker was started during the
rule out protocol. No aspirin was started as the patient
reports an aspirin allergy.
2. Pump, the patient has no history of congestive heart
failure and her ejection fraction is unknown. Her
presentation examination was consistent with congestive heart
failure and she did have subjective improvement with
diuresis.
3. Rate/rhythm, the patient has chronic atrial fibrillation
and is currently reasonably rate controlled on her home dose
of Cardizem (heart rates have been in the 90s). The patient
is on anticoagulation with Coumadin.
Infectious disease: The patient presented with a low grade
temperature. She had a mildly increased white blood cell
count with a left shift. It was felt that this patient
likely has tracheobronchitis. She did receive one dose of
Levofloxacin in the Emergency Department. Sputum cultures
were obtained.
Endocrine: 1. The patient has a history of chronic
Prednisone use. The patient received one dose of
Hydrocortisone as stress dosed steroids in the Emergency
Department. In the Intensive Care Unit the patient was
mildly hypertensive. It was therefore felt the stress dose
steroids were not necessary. She was continued on her home
dose of Prednisone.
2. Osteoporosis the patient is treated with Miacalcin spray
and Fosamax.
Rheumatology: History of systemic lupus erythematosus. The
patient will be continued on her usual Prednisone dose.
Neurology: The patient has a history of peripheral
neuropathy and is treated with Neurontin. The patient has a
history of chronic pain and is treated with a Fentanyl patch.
DISCHARGE STATUS: The patient is medically stable for
[**Hospital 18172**] transfer to the [**Hospital6 2910**].
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Tracheobronchitis.
DISCHARGE MEDICATIONS: Protonix 40 mg po q day, Coumadin 7.5
mg po q day on Monday through Saturday and 10 mg on Sunday.
Neurontin 600 mg po q.i.d., Prednisone 10 mg po q day,
Fosamax 70 mg po q week, Duragesic patch 75 micrograms q 72
hours, Miacalcin one spray q.d., Cardizem 180 mg po q day,
Lopressor 12.5 mg po b.i.d., Lasix 40 mg intravenous q.d.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 15468**]
MEDQUIST36
D: [**2140-6-9**] 12:44
T: [**2140-6-9**] 12:54
JOB#: [**Job Number 18173**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3967
} | Medical Text: Admission Date: [**2175-6-27**] Discharge Date: [**2175-7-7**]
Date of Birth: [**2120-1-16**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 55-year-old
woman with the past medical history of schizoaffective
disease, atypical Parkinsonism, most likely secondary to
antipsychotic medications, hypothyroidism, lung nodule,
chronic obstructive pulmonary disease, torticollis and
urinary retention. She presented to the ED from her [**Hospital3 12272**], where she was reported to be confused and short of
breath. In the ED, she was 80% on room air, nonrebreather.
Saturations were 92%. The ABG was 7.28, 59, 80, 29. She had
a temperature of 101.4. The blood pressure was 96/50, pulse
81, respiratory rate 24. She was intubated for hypercarbic
respiratory failure on the 12th. She went to the emergency
department. She had Gram-negative rods greater than 100,000
in her urine. however, it was greater than two-colony
morphologies, possibly representing contamination.
The patient was extubated on the [**10-27**] with good
result. She had a sputum culture, which showed
Staphylococcus aureus Methicillin sensitive and sensitive to
Levaquin in her sputum. The patient was treated initially
with Ampicillin and Levaquin in the Intensive Care Unit. She
had two episodes of low blood pressure in 60s that responded
to IV fluids. She was also given Hydrocort empirically. The
Cortisol level was checked and it was 33. She presented
initially with the anion gap of 20, normal on the second day
of hospital stay.
The patient has had multiple admission to [**Hospital6 2121**], [**9-/2174**], [**2175-1-13**], for failure to
thrive, multiple urinary tract infections. The patient had a
suprapubic catheter placed and had another urinary tract
infection two weeks ago. The patient has improved physically
in the unit. But, according to the family members, the
patient had decreased level of functioning in that she had
been prior to admission.
PAST MEDICAL HISTORY:
1. Atypical Parkinsonism. I spoke to the patient's outside
neurologist, Dr. [**Last Name (STitle) 98503**] at [**Hospital1 2025**], who said that the
patient had atypical features of Parkinsonism, most likely
secondary to neuroleptic medications, that the patient had
received for treatment of her schizoaffective disease. The
patient has right torticollis and contractures.
Dr. [**Last Name (STitle) 98503**] reported that the patient had been tried
on a number of antiParkinsonism medicines with no resolution
of her Parkinsonism or torticollis. She had been tried on
Botox injections with no success. He suggested Ativan and/or
Benadryl for relief of her discomfort and muscular pain, but
suggesting that due to the longstanding nature of the
torticollis for approximately three years, that the vertebra
most likely have been permanently damaged by the torticollis.
2. Chronic obstructive pulmonary disease.
3. Emphysema.
4. Hypothyroidism.
5. Osteoporosis.
6. Failure to thrive.
7. Urinary retention status post suprapubic catheter.
The patient is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], primary care
physician at [**Name9 (PRE) 2025**]. Dr. [**Last Name (STitle) **] had said that the patient had
neurogenic-like bladder and that she was unable to straight
catheterize herself due to her movement disorder and the
decision was between a Foley catheter and a suprapubic
catheter and the suprapubic catheter would be more
comfortable for the patient and less of an infection risk.
MEDICATIONS PRIOR TO ADMISSION:
1. Effexor 32.5 mg q.a.m.
2. Klonopin 0.5 mg q.h.s.
3. Depakote 250/500.
4. Levoxyl 50 q.a.m.
5. Prilosec 20 b.i.d.
6. Tylenol #3 q.d. for pain.
7. Zanaflex 2 mg q.3h.
8. Atrovent MDI.
9. Albuterol MDI.
SOCIAL HISTORY: The patient came from [**Hospital3 **]
[**Hospital3 **]. Her sister, [**Name (NI) 4134**] [**Name (NI) 35914**], was spoken to on many
occasions. Phone #: [**Telephone/Fax (1) 98504**]. PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D.
Phone #: [**Telephone/Fax (1) 64118**] at [**Hospital1 2025**].
PHYSICAL EXAMINATION: Examination at the time of transfer to
the floor revealed the following: Blood pressure 100/60,
pulse 78, oxygen saturation 98% on two liters. GENERAL: The
patient was lying in bed, curled with contractions. HEENT:
The patient had right torticollis using neck accessory
muscles to assist breathing. The patient initially had a
left subclavian line that was pulled two days after being on
the floor. The patient had lung examination clear to
auscultation, bilaterally regular rate and rhythm, no
murmurs, rubs, or gallops. The patient did have some
scattered wheezing, positive bowel sounds, soft, suprapubic
catheter site was clean, dry, and intact on transfer to the
floor. EXTREMITIES: Mild 1+ edema to the ankles.
Peripheral pulses intact. NEUROLOGICAL: The patient was
awake, alert, and in depressed mood. The patient had
shuffling gait, when observed with the walker. The patient
had cogwheel rigidity and right torticollis.
LABORATORY DATA: Labs on admission revealed the following:
White blood cell count 17.8, hemoglobin 12.6, hematocrit
37.2, 249,000 platelet count, INR 1.6, lactate 1.3. Sodium
144, potassium 4.1, chloride 101, bicarbonate 23, BUN 9,
creatinine 0.6, calcium 9.3, magnesium 1.6, phosphorus 3.1,
urinalysis cloudy, 11 to 20 red blood cells, 6 to 7 white
blood cells. Serum toxicology was negative. The patient had
a head CAT scan on admission, which showed no acute
intracranial pathology. The patient had a chest x-ray on
[**6-27**], showing no pneumonia, no CHF, increased
interstitial markings, right middle and lower lobes. As
mentioned before, the patient had Gram-negative rod in the
urine, greater than 100,000 colony-forming units, however,
two different specimen types. The patient had coagulase
positive, Staphylococcus aureus in sputum, sensitive to
Levaquin and oxacillin. Blood cultures: No growth from
final. The patient also had rare amount of Aspergillus
fumitagus on sputum culture, had rare growth. The gram stain
from that culture showed greater than 25 PMNs, 4+
Gram-positive cocci in pairs and clusters, which were the
Staphylococcus aureus and 2+ Gram-negative rods. The patient
had elevated CKs to 475 and 585 with negative troponins and
negative MBs both times.
The patient had a CT scan on the [**7-2**] to evaluate
the possibility of Aspergillosis. This examination showed no
evidence of Aspergillosis or AVPA. There was a 1 cm left
apical nodule, nonspecific apical and right middle lobe
scarring. It was suggested that these studies be followed up
with a CAT scan in two to three months as a new process
cannot be excluded at the present time. The patient had
bilateral pleural effusions, atelectasis, and mild emphysema.
The patient is a 55-year-old woman with the past medical
history of atypical Parkinsonism, schizoaffective disease,
extrapyramidal side effects, torticollis, multiple UTIs,
failure to thrive, suprapubic catheter placed. Chronic
obstructive pulmonary disease, who presented to the ED with
acute respiratory distress. The patient was found to have
gram-negative rod UTI and Staphylococcus positive sputum.
The patient was extubated and now is on the floor doing well.
HOSPITAL COURSE: (by system)
#1. The patient had both the Staphylococcus aureus and
urinary bacteria be covered by Levaquin. The patient was on
Levaquin 500 mg PO q.d, beginning on [**6-28**]. The
patient will finish a two-week course on [**7-12**]. The
patient is doing well, afebrile. White blood cell count has
decreased to 10.5 on the [**7-7**]. The Aspergillosis
was most likely a colonizing organism, discovered on routine
sputum examination and has no pathological significance.
#2. PSYCHIATRY: The patient is being followed by the
Department of Psychiatry. The patient was started on Effexor
75 mg q.d. They suggested adding 1.25 Zyprexa q.h.s. for
sleep and history of psychosis in the past. The patient is
also on Depakote 250 mg PO q.a.m. and 500 mg PO q.a.m.;
Klonopin 0.5 mg PO b.i.d.; Zyprexa 1.25 mg q.h.s. will be
stopped on the 23rd, for fear they may be discontinued even
at such a low dose contributing to the patient's torticollis
that she has been experiencing.
#3. NEUROLOGICAL: Parkinson torticollis rigidity. The
patient is on Zanaflex 2 mg t.i.d. The patient also was
started on Benadryl 25 mg t.i.d. and Ativan 0.5 mg to 1 mg
p.r.n.q.4h. for torticollis muscle rigidity. The patient had
reported some improvement on this regimen.
#4. ENDOCRINE: The patient is on Levoxyl 50 mcg PO q.d. for
hypothyroidism. TSH was checked; it was 0.19. Free T4 was
1.2.
#5. GENITOURINARY: The patient has suprapubic catheter
placed at an outside institution. During her stay here a
[**Hospital1 69**] the catheter became
dislodged and the nursing staff reports that the patient
pulled out the catheter. The patient denies this. The
Department of Urology was contact[**Name (NI) **] and the catheter is to be
replaced on the afternoon of the [**7-7**].
#6. PROPHYLAXIS: The patient was on Protonix 40 mg PO q.d.,
Tylenol, heparin subcutaneously 5000 q. 12. The Department
of Physical Therapy is working with the patient. The patient
is on aspiration precautions, solids are to be chopped.
Medications should be given with applesauce. The patient has
a swallowing study on the [**6-30**], which was not
positive for aspiration, however, it did show that the
patient had quick transition from oropharynx to esophagus and
the recommendations were to chop her solids and to give her
medications in applesauce and to have the patient eat all
liquids and solids in an upright position.
CURRENT PLAN PER DISPOSITION: The patient is being evaluated
for [**Hospital 4820**] rehabilitation skilled nursing facility. This
option was discussed with the patient and the patient's
sister. The patient initially had fears of being locked away
and complained that she did not want to go to a nursing home.
After conversations and explaining to the patient the nature
of skilled care she had received there, including physical
therapy and qualified nursing care, the patient agreed to a
long-term skill nursing facility with the hope that she would
be able to increase her function level to return to [**Hospital3 12272**]. The patient is also being screened by her prior
[**Hospital3 **] institution.
This covers the hospital course up to [**2175-7-7**]. The
rest of the charts should be dictated by the following
physician: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2175-7-7**] 14:28
T: [**2175-7-7**] 14:52
JOB#: [**Job Number 98505**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3968
} | Medical Text: Admission Date: [**2128-8-28**] Discharge Date: [**2128-12-19**]
Date of Birth: [**2128-8-28**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 2643**] is the 656 gram
product of a 25-week twin gestation born to a 35-year-old G2,
P1, now 3 woman.
Maternal history notable for single functioning kidney.
No other details at this time.
Prenatal screens were as follows: B positive, direct Coombs
negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, GBS unknown.
Antenatal history - IUI, dichorionic, diamniotic, twin
gestation. Pregnancy complicated by cervical dilatation,
treated with bed rest at 21 weeks. Betamethasone
complete on [**8-23**]. Fetal survey normal at 18 weeks and
subsequently had normal growth of both twins. Cesarean
section on day of delivery under spinal anesthesia for
progress of cervical dilatation. No intrapartum maternal
fever or other clinical evidence of chorioamnionitis. No
intrapartum antibacterial prophylaxis administered. Membranes
were ruptured at delivery and yielded clear amniotic fluid.
The infant was vigorous at delivery, orally, nasally bulb
suctioned, dried. Bag mask ventilation given for less than 1
minute. Infant intubated uneventfully on an initial attempt
using a 2.5 ET tube. Heart rate was well maintained. Apgars
were 6 and 7 at 1 and 5 minutes respectively.
PHYSICAL EXAMINATION: Birth weight was 656 grams. Anterior
fontanel soft and flat. Nondysmorphic. Eyes fused. Palate
intact. Neck normal. Chest with severe intercostal and
subcostal retractions. Fair breath sounds bilaterally. A few
scattered coarse crackles. CARDIOVASCULAR: Well perfused.
Regular rate and rhythm. Femoral pulses normal. S1 and S2
normal. No murmurs. ABDOMEN: Soft, nondistended. No
organomegaly. No masses. Bowel sounds active. Anus patent. 3-
vessel umbilical cord. GENITOURINARY: Normal preterm female
genitalia. CNS: Active, responsive to stimulation. Tone
appropriate for gestational age. Symmetric. Moves all
extremities. Gag intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: [**Known lastname **] was intubated in labor and delivery and
was admitted to the newborn intensive care unit, received a
total of 2 doses of surfactant for respiratory distress
syndrome. Max ventilator support was 21/5 with a rate of 26.
She remained on the ventilator for a total of 48 days at which
time she transitioned to CPAP. She remained on CPAP for a
total of 7 days at which time she transitioned to nasal
cannula oxygen. She was on nasal cannula until [**2128-12-2**], at which time she transitioned to room air and continues
to be stable on room air. She did receive treatment with
caffeine citrate early in her hospital course which was
discontinued on [**11-11**]. This was initiated for management
of apnea and bradycardia of prematurity. She also received
Diuril for management of chronic lung disease which was
discontinued on [**12-8**]. Pulmonary consult was obtained.
Dr. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 37305**] from [**Hospital3 1810**] was the
pulmonologist who saw her.
CARDIOVASCULAR: [**Known lastname **] received a total of 3 courses of
indomethacin for treatment of PDA. On [**9-20**], the infant
continued to have a large patent ductus arteriosus at which
time she was transferred to [**Hospital3 1810**] for PDA
ligation. Since that time she had an intermittent PPS murmur
which has since resolved.
FLUIDS, ELECTROLYTES AND NUTRITION: Her birth weight was 656
grams. Her discharge weight is 3.3 kg, head circumference 35
cm, length 50.5 cm.
On admission to the newborn intensive care unit, she was
maintained with UAC and UVC with parenteral nutrition of D5W.
A central PICC line was placed at 7 days of age for further
management. Enteral feedings were initially started on day
of life 7 which were later discontinued secondary to her
patent ductus arteriosus. She was restarted on [**9-24**] and
achieved full enteral feedings by [**10-2**]. Her maximum
caloric intake was 140 ml per kg per day of breast milk 32
calories with ProMod. She is currently ad lib feeding
Enfamil 26 calories (use 4 calories by concentration, 2
calories with corn oil). Discharge weight is 3265 grams.
GASTROINTESTINAL/ GENITOURINARY: Peak bilirubin was 4.5/0.3.
She received phototherapy. This issue has since resolved.
HEMATOLOGY: Her blood type is A positive. Coombs negative.
Her initial hematocrit on admission was 39.5. During her
hospital course she received a total of 6 packed red blood
cells transfusions with her most recent being on [**10-20**]. Her most recent hematocrit was on [**11-25**] which was 31
with a reticulocyte count of 3.3. She is currently receiving
ferrous sulfate 0.3 ml PO once daily, concentration is 25 mg
per ml.
INFECTIOUS DISEASE: Initial CBC and blood culture obtained on
admission. CBC was benign and blood culture remained negative
after 48 hours at which time ampicillin and gentamycin were
discontinued. She also received during her hospital course 2
doses of Ancef around her PDA ligation. She received
vancomycin and gentamycin for two separate reasons. One
secondary to redness at the surgical site, blood cultures
remained negative, and vancomycin and gentamycin were
discontinued after 48 hours. Vancomycin and gentamycin were
later started secondary to a pustule on the surgical site.
They were discontinued after 72 hours as the pustule resolved
and the cultures remained negative.
NEUROLOGICAL: She has had 3 normal head ultrasounds; her most
recent being on [**11-10**] which was at 35 weeks corrected
gestational age. She has been appropriate for gestational
age.
SENSORY: Hearing screen was performed with automated auditory
brain stem responses and the infant passed.
OPHTHALMOLOGY: Her most recent examination was on [**12-13**]
revealing stage 1, zone 2 to 3, 4 to 5 clock hours
bilaterally with recommended follow up in 1 week. Dr.[**First Name9 (NamePattern2) **]
[**Name (STitle) **] is the ophthalmologist; telephone number: [**Telephone/Fax (1) 63493**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10817**]. Telephone
No.: [**Telephone/Fax (1) 37814**].
CARE RECOMMENDATIONS:
1. Feeds at discharge - continue ad lib feeding Enfamil 26
calorie.
2. Medications: Ferrous sulfate 0.3 ml PO daily.
3. Car Seat Position Screening was performed and the infant
passed a 90-minute screen.
4. State Newborn Screens have been sent per protocol and
have been within normal limits.
5. Immunizations received: [**Known lastname **] received Hepatitis B
vaccine on [**9-27**]. She received Pediarix on [**10-25**]. She received HIB on [**10-26**]. She received
Prevnar on [**10-26**]. Synagis given [**12-18**].
6. Immunizations recommended:
Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] 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 the
following: daycare during the RSV season, a smoker in
the household, neuromuscular disease, airway
abnormalities, or school age siblings.
3. with chronic lung disease.
Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
Follow up appointments recommended:
Ophthalmology on the week of [**12-20**] with Dr.[**First Name9 (NamePattern2) **]
[**Name (STitle) **]. Telephone No.: [**Telephone/Fax (1) 50314**].
Dr. [**Last Name (STitle) 10817**] a few days after discharge.
VNA
DISCHARGE DIAGNOSES:
1. Premature infant born at 25 weeks
2. Twin #1.
3. Respiratory distress syndrome.
4. Mild chronic lung disease.
5. PDA s/p ligation.
6. Hyperbilirubinemia, treated.
7. Apnea/bradycardia of prematurity, resolved.
8. Anemia of prematurity, resolved.
9. Rule out sepsis with antibiotics.
10. Synagis candidate.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2128-12-18**] 23:52:45
T: [**2128-12-19**] 00:59:43
Job#: [**Job Number 63494**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3969
} | Medical Text: Admission Date: [**2108-12-25**] Discharge Date: [**2109-1-31**]
Date of Birth: [**2041-10-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
fever/hypotension/sepsis/respiratory failure
Major Surgical or Invasive Procedure:
Redo sternotomy, Redo aortic root replacement(19mm homograft),
Mitral valve repair. [**2109-1-3**]
History of Present Illness:
Ms. [**Known lastname **] is a 67year old white female s/p aortic valve
replacement in [**2104**] who presented 3 days ago with fever,
myalgia, arthralgia and sore throat. She started feeling unwell
10 days previously with dyspnea, back pain and intermittent
fevers. She went to her primary care who obtained a CXR (which
was reportedly normal) and sent her to [**Hospital **] Hospital where
she was admitted. There she developed hypotension to the
70's/30s. Vancomycin and Ceftriaxone were started.
She had increasing O2 demand in the setting of an initially
normal CXR, with repeat CXR showing white out. She was
transferred to the ICU and intubated and sedated. Levophed was
started. Her temperature rose to 103F. Blood cultures showed [**3-6**]
gram positive cocci in chains. She was transferred here for
further management. On arrival to the MICU, she was intubated
and sedated.
Cardiac surgery was consulted for surgical correction of
bacterial endocarditis.
Past Medical History:
Hypercholesterolemia
Hypertension
s/p Aortic valve replacement/asc aorta replacement on [**2105-9-23**]
h/o Pancreatitis
cataract
anxiety
depression
s/p C-section
Social History:
unemployed
quit smoking 5 years ago, [**12-5**] ppd x 25 years
occasional ETOH
lives alone
no IVDU
Family History:
noncontributory
Physical Exam:
ADMISSION EXAM
T 102.7, HR 61, BP 129/54, POx 100%
A/C TV 380, PEEP 12, Rate 20, FiO2 60%
General: intubated, sedated
HEENT: Sclera anicteric, MM dry, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, [**3-8**] ejection murmur best heard at RUSB
Lungs: intubated, junky breath sounds in b/l A/L fields
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No evidence of [**Last Name (un) **] lesions, splinter hemorrhages, or
osler nodes.
Neuro: PERRL, not moving extremities sensation
Pertinent Results:
ADMISSION LABS
[**2108-12-25**] 07:28PM BLOOD WBC-14.9*# RBC-3.40* Hgb-10.0* Hct-30.3*
MCV-89 MCH-29.4 MCHC-33.1 RDW-14.3 Plt Ct-274#
[**2108-12-25**] 07:28PM BLOOD Neuts-86.2* Lymphs-9.8* Monos-3.8 Eos-0.2
Baso-0.1
[**2108-12-25**] 07:28PM BLOOD PT-15.5* PTT-28.4 INR(PT)-1.5*
[**2108-12-25**] 07:28PM BLOOD Fibrino-595*
[**2108-12-25**] 07:28PM BLOOD Glucose-148* UreaN-11 Creat-0.5 Na-133
K-4.7 Cl-106 HCO3-21* AnGap-11
[**2108-12-26**] 03:41AM BLOOD ALT-29 AST-17 LD(LDH)-281* AlkPhos-47
TotBili-0.7
[**2108-12-25**] 07:28PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-7957*
[**2108-12-26**] 09:01PM BLOOD CK-MB-3 cTropnT-<0.01
[**2108-12-27**] 03:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2108-12-25**] 07:28PM BLOOD Calcium-7.4* Phos-2.1* Mg-2.5
MICRO DATA
[**2108-12-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2108-12-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2108-12-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2108-12-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2108-12-27**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2108-12-27**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2108-12-26**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2108-12-26**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2108-12-26**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2108-12-26**] URINE URINE CULTURE-FINAL INPATIENT
[**2108-12-25**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2108-12-25**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[[**2108-12-23**] Isolate from [**Hospital **] Hospital for MIC-PRELIMINARY
{STAPHYLOCOCCUS LUGDUNENSIS, STAPHYLOCOCCUS, COAGULASE NEGATIVE}
IMAGING:
CXR [**2108-12-25**]
As compared to the previous radiograph, there is no relevant
change. Right internal jugular vein catheter that shows a normal
course, the tip of the catheter projects over the mid SVC. The
patient has an
endotracheal tube, the tip of the tube projects approximately
2.2 cm above the carina, the tube could be pulled back by
approximately 1-2 cm.
A nasogastric tube has been placed. The course of the tube is
unremarkable, the tip of the tube is not included in the image.
No other monitoring and support devices. Unremarkable alignment
of sternal wires after cardiac surgery.
In unchanged manner, the lung displays extensive bilateral
apical parenchymal opacities of reticular appearance. An
additional alveolar component could also be present, given the
presence of multiple air bronchograms. Extensive retrocardiac
atelectasis, small left pleural effusion. No newly appeared
focal parenchymal opacities. No pneumothorax.
[**2108-12-26**] TEE
Moderately thickened and stenotic prosthetic aortic valve with
probable vegetation. Cannot exclude aortic root abscess. Mild
mitral regurgitation. Hyperdynamic left ventricular systolic
function.
Compared with the prior study dated [**2105-9-23**] (images
reviewed)- The aortic bioprosthesis is now stenotic with a mass
concerning for vegetation. The thickening around the aortic
homograft is similar in size, but the echolucency is new.
[**2108-12-28**] TEE
Aortic prosthesis and mitral (native) valve
vegetations/enodcarditis with aortic root abscess as described
above. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2108-12-26**] a
vegetation is now seen on the mitral valve.
[**2109-1-1**] CT head with con: Enhancing 2 mm focus in the right
frontal lobe may be a prominent vessel, but in this clinical
setting, is concerning for a small septic embolus or septic
aneurysm. Would recommend an MRI with and without contrast for
further evaluation if clinically indicated.
[**2109-1-1**] CT C/A/P with con: No focal fluid collections within the
chest, abdomen or pelvis to suggest focal abscess. Scattered
mediastinal lymph nodes, though none pathologically enlarged. No
mediastinal hematoma or fluid collection. Multiple stable
subcentimeter subpleural pulmonary nodules, unchanged since
prior chest CT from [**2104**]. Given the stability over several
years, no further followup is necessary. Bilateral pleural
effusions and diffuse ground-glass opacities, findings
consistent with diffuse pulmonary edema. An asymmetric opacity
in the right upper lobe may reflect asymmetric edema, though
superimposed infection is also
within the differential. Multiple bilateral renal hypodensities
that are too small to characterize, though most likely represent
simple cysts.
[**2109-1-1**] MRI T spine: Multiple focal areas of high signal
intensity throughout the vertebral bodies, likely consistent
with non-expansile hemangiomas, some of them atypical with
persistent high signal on the STIR sequence. Degenerative
changes are identified at the T8/T9 and T9/T10 levels with no
evidence of neural foraminal narrowing or spinal cord
compression. There is no evidence of abnormal enhancement to
indicate leptomeningeal disease or epidural abscess. There is no
evidence of findings suggesting osteomyelitis.
[**2109-1-1**] MRI L spine: Heterogeneous signal is noted in the bone
marrow with multiple rounded areas of hyperintensity on T2- and
T1-weighted sequences, likely consistent with non-expansile
hemangioma with atypical high signal on the STIR at the level of
L1. If there is any clinical concern related with this findings,
correlation with bone scan is recommended if clinically
warranted. There is no evidence of epidural abscess, fluid
collections or findings suggesting osteomyelitis. Mild disc
degenerative changes at L2-L3, L3/L4 and L4/L5 with no evidence
of neural foraminal narrowing or spinal canal stenosis.
[**2109-1-1**] TTE: Abnormal aortic valve bioprosthesis with thickened
leaflets and high transvalvular gradients. Aortic root abscess.
Moderate mitral regurgitation. Hyperdynamic left ventricular
systolic function. Moderate pulmonary hypertension. No definite
vegetations seen.
[**2109-1-2**] MRI HEAD: A small enhancing focus in the right parietal
lobe. This shows no slow diffusion. This likely represents a
possible subacute embolic infarct. Metastasis is another
differential though is less likely as patient has no known
primary. Few chronic microhemorrhages in bilateral frontal
lobes. A small extra-axial enhancing lesion along the right
frontal convexity which likely represents a meningioma. No
evidence of stenosis, occlusion or aneurysm in arteries of head
Brief Hospital Course:
She was initially covered with vancomycin and Ceftriaxone but
per ID this was changed to Vancomycin and gentamicin when blood
cultures fromNorwood grew coagulase negative staphlococcus.
Speciation showed Staph lugdunensis sensitive to
Nafcillin/Gent/Rifampin so she was switched to these. Aortic
vegetation was noted on echo and repeat TEE showed new mitral
veg as well as aortic root abscess. She was transferred to
the Cardiology Service where she remained hemodynamically stable
and her EKG did not show any conduction abnormalities. She
underwent extensive work up prior to cardiac Ssrgery to rule out
other involvement of the endocarditis. Neurology was consulted
and recommended MRA/MRI and continuing to avoid
anti-coagulation. A MRI was obtained and indicated possible
subacute embolic infarct. Discussion between Infectious
Disease, Cardiac Surgery and Cardiology was done and the
decision was made to pursue surgery sooner rather than later as
benefits outweighed the risks.
She was taken to the Operating Room on [**2109-1-3**] and underwent redo
sternotomy,redo aortic root replacement with a size 19 homograft
and mitral valve repair by Dr.[**First Name (STitle) **]. Cardiopulmonary Bypass
Time= 241 minutes. Cross Clamp Time= 213 minutes. Please refer
to the operative note for further surgical details.
She tolerated the procedure well and was transferred to the
CVICU intubated and sedated requiring pressor support. She awoke
neurologically intact and on POD#1 she weaned to extubation
without incident. ID continued to follow postoperatively for
antibiotic recs regarding her bacterial endocarditis. She weaned
off pressor support and was placed on beta-blocker, aspirin,and
aggressively diuresed. All lines and tubes were discontinued per
protocol.
Post op confusion was evident. Neurology continued to follow
postoperatively due to the subacute embolic infarct seen on MRI
preop. Narcotics were minimized and her mental status improved.
Hemodynamically she remained stable with a transient
postoperative episode of NSVT v. atrial fibrillation with
abberancy. She tolerated beta-blocker well. Pacing wires were
removed per protocol.
On [**2109-1-5**] she complained of right upper quadrant discomfort.
LFTs showed an elevated total bilirubin. Ultrasound was done and
revealed minimally distended gallbladder with sludge. No
gallstones or signs of acute cholecystitis.
Nephrology was consulted for postop renal failure (baseline
creatinine 0.4->3.7). Antibiotics were adjusted and her renal
function closely monitored and slowly stabilized and fell.
She transferred to the step down unit for further monitoring and
recovery. Physical Therapy was consulted for evaluation of
strength and mobility.
On [**1-9**] she acutely decompensated with severe hypotension,
respiratory distress and required intubation, a PA catheter and
pressors. Emergent TEE showed moderate mitral regurgitation,
fasirtly preserved LV function and the CXR demonstrated
pulmonary edema. She was stabliized over several days, diuresed
and her renal function improved. Tube feeding were given and
she awakened. The CXR progressed to one of ARDS, but she
improved, weaned from high PEEP requirements and was eventually
extubated on [**1-24**]. Bilateral chest drainages were performed and
no souce of sepsis located. Nafcillin and Rifampin were
continued.
She was again encephalopathic, but cleared with some
intermittent confusion. Video swallow cleared her for soft
solids and thick liquids. She was below her preop weight,
without evidence of fluid overload so diuresis was stopped, but
may be required in the future.
At discharge wounds were clean and healing, she was beginning to
ambulate with a lot of help and oriented mostly.Follow up
appointments were given as appropriate.
She was transferred to [**Hospital3 105**] Northeast in [**Location (un) 1110**] for
further recovery prior to returning home.
Medications on Admission:
- Diovan 160mg PO BID
- ASA 81mg PO daily
- Fish oil 1200mg PO daily
- furosemide 20mg PO daily
Discharge Medications:
1. bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release
(E.C.) PO DAILY (Daily) as needed for Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. rifampin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8
hours) for 14 days.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**5-10**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
7. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): until fully mobile.
8. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 400mg(two tablets) twice daily for two weeks, then
200mg(one tablets) twice daily for two weeks, then 200mg(one
tablet) daily until instructed otherwise,.
9. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
10. insulin lispro 100 unit/mL Solution Sig: per scale
Subcutaneous ac & hs: 120-160:2units sc ac,none
HS;161-200:4units ac, 2units HS; 201-240:6units ac,4units
HS,241-280:8units ac, 6units HS.
11. olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for fever or pain for 4 weeks.
13. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gms
Intravenous Q4H (every 4 hours) for 14 days.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
2 weeks.
15. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous once a day as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
-s/p Redo sternotomy/ Redo aortic root replacement with a size
19 homograft/Mitral valve repair secondary to bacterial
endocarditis-
Secondary:
HTN, HL, and bicuspid aortic valve with stenosis s/p aortic
valve replacement in [**2104**] who now presents with bacterial
endocarditis with vegetations on her aortic prosthesis, native
mitral valve as well as aortic root abscess. -
Discharge Condition:
Alert and oriented x3 mostly, nonfocal
Ambulating with unsteady gait with assistance
Incisional pain managed with oral analgesics
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2109-2-26**] at 1:15pm
Infectious Disease at [**Hospital1 18**]: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 457**]) on
[**2109-2-11**] at 10am [**Hospital 6752**] medical Office basement
Cardiologist:ask your primary care doctor for a referral
Please call to schedule appointments with:
Primary Care: Dr.[**Last Name (STitle) 79992**] [**Name (STitle) 17385**] ([**Telephone/Fax (1) 41459**]in [**12-3**] 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**
Weekly CBC w/diff,LFTs,BUN/creat. Fax results to [**Numeric Identifier 79993**].
Call ID nurses w/antibiotic questions-[**Telephone/Fax (1) 79994**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2109-1-31**]
ICD9 Codes: 5849, 5119, 2761, 4240, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3970
} | Medical Text: Admission Date: [**2170-12-3**] Discharge Date: [**2170-12-7**]
Date of Birth: [**2108-4-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Vasotec / Iodine; Iodine Containing /
Hydrochlorothiazide / Sulfonamides / Trilafon / Elavil /
Tegaderm / Tegretol / Verapamil / Nitrofurantoin / Fentanyl /
Levofloxacin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
CC: lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Mr. [**Known lastname 1968**] is a 62 yo wheelchair bound male with h/o HIV,
CRI, HTN, CVA with residual L-sided hemiparesis and ? seizure
disorder who presented from a Senior Center with lethargy on
[**2170-12-3**]. Patient does not remember the events prior to his
admission. The last thing he remembers is waiting to get on the
bus prior to going to work yesterday. He doesn't remember
anything from that time until ~3 hours ago today. He recalls
feeling fine the night before and just a little more tired prior
to this event. Per report of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3077**], the co-worker who called
the ambulance yesterday, the patient appeared disoriented when
he arrived at work yesterday. He first rode his wheelchair into
a door and then into a table. He was unable to sit up in his
chair and kept slumping down. He was less responsive than he
normally is and had slow (but not slurred) speech. She stated it
sounded as if he was having "difficulty finding his words". He
was able to understand her when she spoke to him. He did not
voice any complaints to her, except that he "had a bad weekend
and needed something to eat." His face also appeared a little
more flushed to her. He had no episodes of shaking, no loss of
consciousness and no bowel or bladder incontinence. He may have
had one episode of emesis. Ms. [**Name13 (STitle) 3077**] states the patient became
more disoriented and less responsive over the course of 45
minutes. By the time he reached the ambulance he was barely able
to keep his eyes open. Per report he was given narcan in the
field with little effect.
Past Medical History:
Past Medical History:
1. HIV/?AIDS- most recent VL undetectable; CD4 336
2. CKD (baseline Cr 1.9-2.0)
3. Hypertension
4. Gerd
5. h/o RTA
6. CVA [**2161**] with residual L-sided hemiparesis
7.? seizure disorder that resolved per the patient. Patient
describes occasional shaking with his seizures in the past, with
some lethargy and no bowel or bladder incontinence
8. s/p colectomy for C. difficile colitis in [**2153**] with
colostomy.
9. h/o recurrent LLE cellulitis
10. s/p L hip replacement [**2167**]
11. Depression
12. h/o memory loss evaluated by Dr. [**Last Name (STitle) 2340**] in neurology
clinic
Social History:
SH: Denies Tob or Illicit drug use. H/o heavy EtOH use in the
past. Last drink 3 days ago (3 vodka tonics). Works at [**Company 27162**] for united people with disability. Lives in his own
apartment at a Senior Home. Has a home aide and nurses that help
him 3 times per week.
Family History:
father d. CVA, mother d. MI, ages unknown
Physical Exam:
Gen: awake and alert, NAD
HENNT: MMM, anicteric, PERRL, EOMI
Neck: right IJ line, no significant JVP
CV: RRR, nl S1S2, No M/R/G
Lungs: CTA B
Abd: soft, NT/ND, +BS, ostomy intact with soft green stool in
bag
Ext: LLE trace edema compared to right, Left LE with ulcer on
lateral aspect of leg with no purulent drainage. Granulation
tissue around medial malleoulus with erythema, but does not feel
significantly more hot than right side.
Neuro: A&Ox3, CN2-12 intact
Right UE/LE muscle strength 5/5, Left UE/LE strength decreased
Pertinent Results:
[**2170-12-3**] 12:33PM BLOOD WBC-5.2 RBC-4.15* Hgb-12.3* Hct-37.6*
MCV-91# MCH-29.6 MCHC-32.6 RDW-17.9* Plt Ct-227
[**2170-12-5**] 06:40AM BLOOD WBC-5.2 RBC-4.01* Hgb-11.7* Hct-35.5*
MCV-88 MCH-29.2 MCHC-33.0 RDW-17.5* Plt Ct-214
[**2170-12-6**] 07:00AM BLOOD WBC-4.6 RBC-4.03* Hgb-12.3* Hct-36.1*
MCV-90 MCH-30.6 MCHC-34.1 RDW-18.8* Plt Ct-216
[**2170-12-7**] 07:00AM BLOOD WBC-5.3 RBC-4.60 Hgb-13.4* Hct-40.7
MCV-88 MCH-29.0 MCHC-32.8 RDW-17.4* Plt Ct-239
[**2170-12-3**] 12:33PM BLOOD Neuts-63.0 Lymphs-27.6 Monos-5.8 Eos-2.8
Baso-0.9
[**2170-12-6**] 07:00AM BLOOD Neuts-55.6 Lymphs-34.1 Monos-5.6 Eos-3.8
Baso-0.8
[**2170-12-3**] 12:33PM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1
[**2170-12-3**] 12:33PM BLOOD Glucose-107* UreaN-16 Creat-1.7* Na-141
K-4.0 Cl-110* HCO3-21* AnGap-14
[**2170-12-7**] 07:00AM BLOOD Glucose-105 UreaN-28* Creat-1.9* Na-137
K-5.1 Cl-104 HCO3-18* AnGap-20
[**2170-12-3**] 12:33PM BLOOD ALT-13 AST-17 CK(CPK)-78 Amylase-106*
TotBili-0.3
[**2170-12-3**] 12:33PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2170-12-3**] 12:33PM BLOOD Albumin-3.5 Calcium-8.6 Phos-4.1 Mg-2.0
[**2170-12-3**] 12:33PM BLOOD VitB12-436 Folate-GREATER TH
[**2170-12-3**] 12:33PM BLOOD Osmolal-289
[**2170-12-6**] 06:50PM BLOOD Vanco-20.9*
[**2170-12-3**] 12:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2170-12-3**] 01:47PM BLOOD Lactate-1.6.
.
[**2170-12-3**] 02:15PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2170-12-3**] 02:15PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2170-12-3**] 02:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
[**2170-12-3**] 1:35 pm BLOOD CULTURE LINE OR SITE NOT NOTED.
AEROBIC BOTTLE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
ANAEROBIC BOTTLE (Final [**2170-12-7**]):
REPORTED BY PHONE TO [**Female First Name (un) 10561**] O. 11R [**2170-12-5**] AT 0915.
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES.
.
URINE CULTURE ([**2170-12-3**]): NO GROWTH.
.
[**2170-12-4**]:
GRAM STAIN (Final [**2170-12-5**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
[**2170-12-5**]: 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).
PROTEUS SPECIES. HEAVY GROWTH.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
GRAM POSITIVE BACTERIA. QUANTITATION NOT AVAILABLE.
? OF TWO COLONIAL MORPHOLOGIES.
BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW.
ANAEROBIC CULTURE (Final [**2170-12-7**]):
UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF SWARMING
PROTEUS SPP..
.
Bcx [**12-5**], [**12-6**], [**12-7**] NGTD
.
CT head [**12-3**]: No intracranial hemorrhage or mass effect.
.
CXR [**12-3**]:Limited study due to marked patient rotation. No gross
evidence of pneumonia. Dedicated PA and lateral chest radiograph
suggested for more complete assessment when the patient's
condition permits.
.
EKG [**12-3**]:Baseline artifact. Sinus bradycardia. Early precordial
QRS transition is non-specific and probably within normal
limits. Since the previous tracing of [**2169-1-2**] sinus bradycardia
is present.
.
CXR [**12-4**]:IMPRESSION: AP chest compared to [**12-3**].
Heart size top normal. Lungs clear.
.
left foot x-ray [**12-5**]: Three views of the left ankle were
obtained. There is diffuse demineralization. There has been
interval removal of the previously identified distal fibula
metallic fixation plate and screws. Defects are noted in the
areas of the prior screws. Two fixation screws are
redemonstrated, extending from the medial malleolus into the
distal tibia. No fractures or destructive changes are present to
suggest osteomyelitis. Soft tissue swelling is noted.
Brief Hospital Course:
* Lethargy: The patient presented with lethargy and slow speech.
Upon arrival to the ED the patient was noted to have SBPs in the
80s. He was given 3 liters of normal saline, Aztreonam, Vanco,
and Decadron. Tox screen was negative. He initially admited to
taking 2 tabs of MS Contin prior to arrival, however, later
denied taking any extra meds. CT in ER showed no acute changes.
.
He was transferred to the [**Hospital Unit Name 153**] where he was A&Ox3 and answering
questions appropriately. He denied CP, SOB, fever, chills, HA,
photophobia, neck stiffness, belly pain, nausea, vomiting,
increased ostomy output. He did report going to a pub two
nights prior to his admission, where he drank 3 vodka tonics. He
had no memory problems the next day. He was a heavy drinker in
the past, however, he denied binge drinking for the past 12 yrs.
He denied other drug abuse or recent changes in medication. He
reported his last seizure was 4-6 months ago. As per OMR notes,
pt had a similar episode of altered mental status thought to be
secondary to EtOH intoxication in [**7-17**]. He was being evaluated
in neurology clinic by Dr. [**Last Name (STitle) 2340**] for memory loss. Of note,
B12, Folate, and TSH were unremarkable in [**6-17**].
.
In the [**Hospital Unit Name 153**] the patient was observed and his mental status
improved. He was then transferred to the floor where he was
A&Ox3. His PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11412**] was [**Name (NI) 653**], as well has his
neurologist Dr. [**Last Name (STitle) 2340**]. Per his PCP, [**Name10 (NameIs) **] patient had several
episodes like this in the past and often this was thought to be
secondary to ETOH intoxication or dehydration after drinking.
Patient's last drink prior to this episode was ~36 hours prior.
It was possible this was secondary to dehydration and this was
the working diagnosis. DDx also included: Sedative effect from
medications including ultram, trazodone and remeron, seizures,
TIA, depression, ETOH abuse with dehydration or infectious
source. Remeron, Trazodone and loratidine were stopped because
of their possible sedating effects. He was ready to be
discharged when blood cultures that were drawn while the patient
was in the ER grew out G+ cocci in pairs and chains in an
anaerobic bottle. Patient had been afebrile with normal WBC
throughout admission. It was possible this could have been a
contaminant, but the patient was kept and started on Vancomycin
until speciation and sensitivities could come back. Plastics and
podiatry were consulted to look at his left foot ulcer, as this
could have been a possible source for bacteremia. Surveillance
blood cultures were drawn and negative at d/c. Several days
later the initial blood cultures were found to be growing
coagulase negative staph and peptostreptococcus. It was thought
these were a contaminant and the patient was discharged without
antibiotics. He was to follow-up with Dr. [**Last Name (STitle) 11412**], who stated
he would take care of the f/u appt and with Dr. [**Last Name (STitle) 2340**].
.
Foot ulcer: Patient stated he had a chronic left lower extremity
ulcer x 7 years. He had numerous surgeries on his foot and had a
skin graft placed over the ulcer at [**Hospital1 756**] by plastics. The
ulcer looked erythematous, but not infected during his stay. He
was seen by plastics and podiatry since the ulcer was thought to
be the possible site for the bacteremia. They did not think the
patient required debridement at this time. Foot x-ray was done
and was negative for osteo. Wound swab was done and grew out
GNR, g+ cocci in pairs and clusters and G+ rods. Final
speciation was pending at discharge. He was not treated for the
GNR because they were not growing in his blood and he had a h/o
anaphylactic reactions to levaquin and PCN. He had wet to dry
dressing changes qd and the wound was packed.
.
* Anion Gap metabolic acidosis with metabolic alkalosis: Patient
had an anion gap metabolic acidosis with metabolic alkalosis.
The acidosis was likely secondary to renal failure with
increased bicarb secondary to bicitra. He was continued on
bicitra for his h/o RTA.
.
* CKD. Baseline Cr was noted to be 1.9-2. Creatinine was
followed and was between 1.5-1.9 during his admission and all
medications were renally dosed.
.
* HTN: BPs were stable and he was continued on Norvasc.
.
*HIV:Last known CD4 was 336 and VL was undetectable. His HAART
regimen was clarified with his pharmacy and he was continued on
Epivir,Levixa and Ziagen.
.
* Depression: He was continued on Celexa. His Trazodone was
used for sleep and this was discontinued to reduce sedating
medications in his regimen. His Remeron was used as an appetite
stimulant but did not work for him, so this was discontinued as
well.
.
* FEN: He was continued on a regular diet and lytes were
repleted PRN.
.
* PPX: For prophylaxis he was on SC heparin, PPI, bowel regimen
and Celexa.
Medications on Admission:
Home Meds:
- Bicitra 15-30 mL TID
- Celexa 40 mg daily
- Depo Testosterone 200 mg/1mL taken every 2 weeks
- quinine 325 daily
- ASA 325 qd
- Ziagen 300 [**Hospital1 **]
- Levixa 700 [**Hospital1 **]
- Norvasc 10 daily
- Ultram 50 mg 1-2 tabs q 6 hours PRN
- Remeron 30 qhs
- Prilosec 20 daily
- Flomax 0.8 qhs
- Trazodone 50 mq qhs
- Epivir 300 mg qhs
- Loratidine 10 mg qd
- Panafil Ointment PRN for leg wound.
Discharge Medications:
1. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
15-30 MLs PO TID (3 times a day).
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Fosamprenavir 700 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
8. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Depo-Testosterone 200 mg/mL Oil Sig: One (1) injection
Intramuscular q 2 weeks.
10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
Physician [**Name9 (PRE) **] [**Name9 (PRE) **]
Discharge Diagnosis:
Primary Diagnosis:
1. Lethargy likely secondary to dehydration
2. Chronic leg ulcer
.
Secondary Diagnosis:
1. HIV
2. Chronic Renal Insufficiency
3. Hypertension
4. GERD
Discharge Condition:
Patient was stable, afebrile with a normal WBC. He was alert and
oriented to person, place and time.
Discharge Instructions:
Please take your medications as prescribed.
.
Please call your primary care doctor or return to the emergency
department if you develop fevers, chills, dizziness, confusion,
increased redness or pain in your left foot or difficulty
breathing.
.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) 11412**], in [**1-14**] weeks. His phone number is [**Telephone/Fax (1) 27157**].
.
Please follow-up with Dr. [**Last Name (STitle) 27163**] in Plastic surgery in [**1-14**]
weeks. If you are not able to get an appointment with him, you
may follow-up with the plastic surgeons at [**Hospital1 **]. The phone number for them is [**Telephone/Fax (1) 6331**].
.
The following appointment has already been made for you:
Provider: [**Name10 (NameIs) 2341**] [**Last Name (NamePattern4) 2342**], M.D. Phone:[**Telephone/Fax (1) 2343**]
Date/Time:[**2170-12-12**] 2:30
ICD9 Codes: 5859, 4019, 311, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3971
} | Medical Text: Admission Date: [**2138-3-13**] Discharge Date: [**2138-3-27**]
Date of Birth: [**2065-10-30**] Sex: F
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 33749**] is a 72 -year-old
woman who was admitted on [**2138-3-13**] to the Medical Intensive
Care Unit and transferred to the Medical floor on [**2138-3-22**].
She was admitted to [**Location (un) **] - [**Hospital 1459**] Hospital on [**2-23**],
for an open reduction and internal fixation procedure on her
ankle after sustaining a fracture after a fall. On [**2-25**],
she had to be intubated for respiratory distress. She had a
negative CT scan angiogram at this time and an echocardiogram
revealed an ejection fraction of 45%.
She was noted to have a decreased hematocrit of 24% and
required transfusions of four units of packed red blood
cells. An upper endoscopy was performed after she was noted
to have an upper gastrointestinal bleed. This endoscopy
revealed a bleeding duodenal ulcer. She was also found to be
serum Helicobacter pylori positive. For the latter, she was
started on a regimen of metronidazole, tetracycline,
Prilosec, and Bismuth.
She was extubated on [**3-1**] and transferred to a
rehabilitation facility. On [**3-11**], the patient again
experienced respiratory distress and was sent back to [**Location (un) **]
- [**Hospital 1459**] Hospital, requiring re-intubation. At this point
she was transferred to the Medical Intensive Care Unit at the
[**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**3-13**]. She was
found to have a urinary tract infection with E coli and was
treated with a course of Bactrim. She was also found to have
a right sided weakness and hemiparesis, with a CT scan of the
head showing a left parietal, non-hemorrhagic,
cerebrovascular accident of undetermined age. On
examination, she was also noted to have a carotid bruit which
after carotid Dopplers, revealed an 80% stenosis of the
carotid artery. The patient was evaluated by the Neurology
service, who felt that after extubation, the patient should
be followed up with an MRI.
She was extubated for the second time on [**2138-3-16**].
However, the following day she began to experience more
respiratory distress. Electrocardiogram at this time showed
changes consistent with ischemia. She underwent coronary
artery angiography on [**2138-3-20**], and had one stent
placed in the right coronary artery and a second in the first
obtuse marginal artery.
In addition, she was also noted to have increased wheezing on
examination and was started on a steroid dose IV which was
eventually changed to po. She was also noted to be
intermittently in mild congestive heart failure for which she
has been diuresed. She has had no recurrence of respiratory
distress since then. For her coronary artery disease, she
was placed on Plavix daily, aspirin, metoprolol, and
Captopril.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Obesity.
3. Congestive heart failure with an ejection fraction of
45%.
4. Status post right ankle fracture and open reduction and
internal fixation on [**2138-2-24**].
5. History of duodenal ulcer and upper gastrointestinal
bleed.
6. Cerebrovascular accident.
7. Status post appendectomy.
ALLERGIES: Include penicillin, castor oil, and Levaquin
causes a rash.
SOCIAL HISTORY: The patient lived at home prior to her ankle
fracture. She has a 30 pack year tobacco history, stopped
approximately fifteen years ago. Her daughter is the [**Male First Name (un) **] at
[**Name (NI) **] Dental School. The patient is a full code.
PHYSICAL EXAMINATION: Vital signs on transfer: temperature
is 100.2 F, heart rate is 74, blood pressure 140/59,
respiratory rate is 22, oxygen saturation is 95% on four
liters via nasal cannula. General: the patient is a pleasant
Caucasian female in no acute distress, lying reclined in bed.
Head, eyes, ears, nose and throat: pupils equal, round, and
reactive to light, mucous membranes were moist, there was no
jugular venous pulse. Neck is supple. Cardiovascular
examination revealed regular rate and rhythm with distant
heart sounds with a II/VI holosystolic murmur at the apex.
Respiratory: diffuse inspiratory and expiratory wheezes, no
crackles, no rhonchi, with decreased breath sounds at the
left base. Abdomen: there are normoactive bowel sounds.
Abdomen is soft without tenderness, guarding, or distention.
Extremities: there is a right ankle splint,
.................... splint deformity. There is a right PICC
line in place. Skin: there are ecchymoses over the abdomen.
Neurologic: the patient is alert and oriented times three,
motor is [**4-26**] except for the right upper extremity which is
[**1-27**] at the fingers and [**2-24**] at the biceps, deltoid, and
triceps, 1+ reflexes throughout.
LABORATORY DATA: On transfer, reveal a white blood cell
count of 15.4 on steroids, hematocrit of 33.5, platelets are
523,000. Serum chemistries reveal a sodium of 139, potassium
is 4.8, chloride is 102, bicarbonate is 24, BUN is 15,
creatinine 1.2, serum glucose is 108.
Carotid ultrasound reveals an 80% stenosis. Catheterization
from [**2138-3-20**] revealed symptomatic stenosis of the right
coronary artery and first obtuse marginal artery with stent
placement. Electrocardiogram on transfer showed normal sinus
rhythm at a rate of 70, normal axis, normal intervals, with
no acute ST-T-wave changes and poor R-wave progressions with
an old Q-wave in lead III.
HOSPITAL COURSE:
1. Pulmonary: The patient with a baseline chronic
obstructive pulmonary disease, complicated by flash pulmonary
edema and probable pneumonia. The patient received a course
of antibiotics for pneumonia while she was in the Intensive
Care Unit. She was started on a course of IV Solu-Medrol
which was changed to po prednisone for her chronic
obstructive pulmonary disease and she was aggressively
diuresed and received intermittent doses of prn Lasix after
transfer to the Medical floor. She was started on an inhaler
regimen, including Combivent and Flovent of four to six puffs
per day. The patient was continued to be followed by the
Pulmonary Consult service after transfer to the Medical floor
outside of the Intensive Care Unit, who felt the patient
should follow-up for outpatient pulmonary function test with
a pulmonologist.
In addition, it was also felt that the patient secondary to
her cerebrovascular accident, was felt to be an aspiration
risk. She was also noted to be possibly aspirating during
her ingestions on daily examination. A Speech and Swallow
consultation was obtained and the patient went for a video
swallow which revealed prominent cricopharyngeus muscle and
aspiration with thin liquids. The patient was changed to a
nectar thick diet and placed bolt upright during feeding to
prevent further aspiration risk. In addition, she was
scheduled for an outpatient Ear, Nose, and Throat follow-up
for further evaluation of her Zenker's diverticulum.
2. Cardiovascular: The patient was status post right
coronary artery and first obtuse marginal artery stent
placement. This procedure was performed by Dr. [**Last Name (STitle) **]
for symptoms of recurrent ischemia. The patient was placed
on an aggressive blood pressure control regimen, including
an ACE inhibitor and a beta blocker which were maximized for
dosage during her hospitalization. In addition, she is to
continue on aspirin and Plavix for one month post stent
placement and she is to receive cardiac rehabilitation after
discharge.
3. Gastrointestinal: The patient is status post upper
gastrointestinal bleed secondary to ulcer which is
Helicobacter pylori positive. She is on triple antibiotic
therapy for a total fourteen day course which is to end on
[**2138-3-27**]. After this time she is to continue Prilosec.
Her hematocrit has remained stable since discharge from the
Unit and although her stools have remained trace guaiac
positive, further work up was not done secondary to known
upper gastrointestinal bleeding source.
4. Neurologic: The patient is aphasic with a right sided
weakness which is likely secondary to her cerebrovascular
accident. She does need an MRI and an MRA as an outpatient.
The patient was followed by Dr. [**Last Name (STitle) **] of the Neurology
Department here at [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **].
However, an MRI was not done during this hospitalization
since the patient was not able to have an MRI / MRA performed
prior to her coronary stent placement. Given the fact that
this stent has likely not epithelialized yet and further
neurologic imaging would not change her management at this
time, it was felt that it would be wise to wait one to two
weeks for her coronary stents to epithelialize prior to
performing the MRI.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 3023**]
Dictated By:[**Name8 (MD) 5469**]
MEDQUIST36
D: [**2138-3-27**] 10:15
T: [**2138-3-27**] 11:19
JOB#: [**Job Number 33750**]
ICD9 Codes: 4280, 486, 496, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3972
} | Medical Text: Unit No: [**Numeric Identifier 68331**]
Admission Date: [**2132-7-24**]
Discharge Date: [**2132-9-5**]
Date of Birth: [**2132-7-24**]
Sex: F
Service: NB
REASONS FOR ADMISSION:
1. Prematurity (32 and 7-weeks gestation).
2. Respiratory distress syndrome.
MATERNAL HISTORY: Baby Girl [**Known lastname 50883**] was [**Known lastname **] to a 29-year-
old G2, P0 mom with prenatal screens: [**Name (NI) **] group O-positive,
antibody negative, RPR NR, rubella immune, hepatitis B
negative, GBS unknown. Her EDC was [**2132-9-30**]. The
pregnancy was complicated by shortened cervix with cerclage
placement and bed rest from 25 weeks. Labor was complicated
by prolapsed cord requiring a STAT C-section. Membranes were
ruptured less than 24 hours prior to delivery. She was not
treated with antibiotics prior to delivery.
DELIVERY: Baby was [**Name2 (NI) **] by STAT C-section for prolapsed
cord. The infant emerged active with Apgar scores of 7 and 8
at 1 and 5 minutes respectively. She was transferred to NICU
in view of prematurity and risk of respiratory stress
syndrome.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.1, heart rate 147, respiratory rate 70, saturations 92 in
room air, [**Name2 (NI) **] pressure 54/41 (mean 46), D-stick 34, weight
1,660 (75-90th percentile), length 43 cm (75th percentile),
head circumference 29.5 (75th percentile). HEENT:
Normocephalic, anterior fontanel open, flat, palate intact,
red reflex present bilaterally. Neck: Supple. Respiratory:
Lungs: Shallow respirations, but clear bilaterally, mild
intercostal retraction. CVS: Regular rate and rhythm, no
murmur, femoral pulses palpable bilaterally. Abdomen: Soft
with active bowel sounds, no masses or distention. GU: Normal
preterm female. Hips: Stable, clavicles intact. Spine:
Midline, no dimples. Skin: Intact. Extremities: Warm, well
perfused with brisk capillary refill. Anus: Patent.
Neurology: Slightly decreased tone, but moving all
extremities equally.
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Baby Girl [**Known lastname 68332**] initial respiratory
course and chest x-ray findings were consistent with
respiratory distress syndrome. She was ventilated soon
after arrival to the NICU. After the 1st dose of
surfactant, she made rapid progress and was extubated to
CPAP on day 1. She continued to require CPAP for the next
4 days and was successfully transitioned to room air on
day of life 6. Since then, she has continued to be in
room air. At the time of discharge, she is comfortably
breathing with no signs of respiratory distress. She also
had initial apnea of prematurity for which she received
caffeine. She has been off the caffeine since day of life
26 and has had no significant spells since then.
2. Cardiac: No complications. No evidenced of PDA.
3. Fluid, electrolytes, and nutrition: She received IV
fluids and intravenous nutrition in the 1st 48 hours.
Breast milk was introduced on day of life 3, and feeds
were gradually advanced to a maximum of 150 mL per
kilogram per day of breast milk 28 calories per ounce by
day of life 15. She showed good weight gain. At the time
of discharge, she is on ad-lib p.o. feeds of breast
milk/Similac 24 calories per ounce and taking
approximately 170-180 mL per kilogram per day over the
last 48 hours. She did demonstrate a period of feeding
immaturity a week back, but has rapidly progressed over
the last 2 days. Weight at discharge 2,980 grams.
4. GI: No complications. She had a maximum bilirubin of
8/0.5 on day of life 4 for which she received
phototherapy.
5. Hematology: Hematocrit at birth was 52. She did not have
problems of anemia of prematurity and did not need any
[**Known lastname **] transfusion.
6. Infectious diseases: She received a 48-hour rule out without
IV antibiotics at the time of admission. However, she
subsequently showed no evidence of proven or suspected
sepsis.
7. Neurology: Her cranial ultrasound scans on [**7-31**]
and [**2132-9-2**] have both been normal.
8. Sensory: 1) Audiology: She has passed her hearing test.
2) Ophthalmology: ROP screening on [**2132-8-18**] had
shown retinal vessels immature in zone III. Followup has
been recommended in 3 weeks from this examination. This
will, therefore, will be due next week. Parents will be
making an appointment with the eye clinic, Dr. [**Last Name (STitle) **],
telephone number [**Telephone/Fax (1) 50314**].
9. Psychosocial: No concerns.
CONDITION AT DISCHARGE: Well.
DISCHARGE DISPOSITION: Home.
NAME OF THE PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **] of
the [**Hospital 10478**] Clinic, telephone number is [**Telephone/Fax (1) 43460**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge is ad-lib p.o. feeds of breast
milk/Similac 24 calories per ounce.
2. Medications are ferrous sulfate 0.45 mL p.o. once daily,
multivitamins 1 mL p.o. once daily.
3. Car seat position screening passed.
4. State newborn screen sent on [**2132-7-27**] and
[**2132-8-6**]. Initial results are normal. Full
report pending.
5. Immunizations received: Hepatitis B vaccine on [**8-15**], [**2131**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 3 criteria: 1) [**Month (only) **] at less than 32 weeks; 2)
[**Month (only) **] between 32-35 weeks with 2 of the following: Daycare
during RSV season, smoker in the household, neuromuscular
disease, airway abnormalities, or school-age siblings; or
3) with chronic lung disease.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age (and for the 1st 24 months of the child's
life), immunization against influenza is recommended for
household contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS SCHEDULED AND RECOMMENDED:
1. Pediatrician, Dr. [**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **] 2-3 days following
discharge, telephone number [**Telephone/Fax (1) 43460**].
2. VNA appointment 1-2 days from discharge.
3. Ophthalmology, Dr. [**Last Name (STitle) **], telephone number [**Telephone/Fax (1) 50314**].
DISCHARGE DIAGNOSES:
1. Prematurity (32 and 7 weeks gestation).
2. Respiratory distress syndrome.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Name8 (MD) 65832**]
MEDQUIST36
D: [**2132-9-5**] 15:34:56
T: [**2132-9-5**] 16:10:59
Job#: [**Job Number 68333**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3973
} | Medical Text: Admission Date: [**2161-10-21**] Discharge Date: [**2161-11-19**]
Date of Birth: [**2161-10-21**] Sex: F
Service: Neonatology
HISTORY: Baby Girl [**Known lastname **] is a former 30-3/7-weeks gestational
age premature infant now 29 days old with corrected
gestational age of 34-4/7 weeks being transferred from [**Hospital1 1444**] to [**Hospital6 204**].
Baby Girl [**Known lastname **] was born to a 35-year-old G5, P0-2-1 mother on
[**2161-10-21**] at gestational age at 30-3/7 weeks. Maternal
prenatal screens as blood type O-positive, antibody positive,
IG warm antibody PEG plus, [**Last Name (un) 101**] minus, hepatitis B negative,
RPR nonreactive, rubella immune, GBS positive. GC/chlamydia
negative. Pregnancy complicated by bilateral choroid plexus
cyst noted on prenatal ultrasound on [**2161-7-21**]. She was
followed with prenatal ultrasounds and complete resolution of
cyst was noted on [**2161-7-31**]. Pregnancy was also
complicated by premature rupture of membranes on [**2161-10-18**]. Mother was beta complete on [**2161-10-20**].
Mother presented to [**Hospital1 69**] with
a preterm labor and maternal fever to 101.3 on [**2161-10-21**]. Intrapartum antibiotics were given more than 4 hours
prior to delivery. Infant was delivered on [**2161-10-21**]
at 8:42 a.m. following rapid progression of labor. Apgars
were 8 and 9. Infant was brought to the neonatal intensive
care unit without complications.
PHYSICAL EXAM ON ADMISSION: Weight 1,425 grams, length 42
cm, head circumference 28.5 cm, temperature 98.2, heart rate
152, blood pressure 52/29 with mean 37, respiratory rate 46,
O2 saturation 98% in room air. General: Comfortable appearing
premature infant. HEENT: Anterior fontanel open and soft.
Mucous membranes: Moist. Palate and clavicles: Intact.
Positive red reflex. Lungs: Coarse breath sounds with good
and equal air entry bilaterally. Mild subcostal retractions.
Cardiovascular: Regular rate and rhythm, normal S1 and S2, no
murmur. Abdomen: Soft, nontender, nondistended, no
hepatosplenomegaly, 3-vessel cord. GU: Normal female external
genitalia. Patent anus. Extremities: Hips intact. Normal
extremities.
HOSPITAL COURSE BY SYSTEMS: Respiratory. Infant remained
stable through hospital course on room air. No respiratory
support was required. She was started on caffeine on day of
life 2 for apnea of prematurity with a good response. She
remained on caffeine until [**2161-11-15**]. Caffeine was
discontinued. She remained with few apneic spells which were
mostly self-resolved.
Cardiovascular. Baby Girl [**Known lastname **] remained through her hospital
stay with normal cardiac exam. No murmur was noticed.
FEN/GI. Baby Girl [**Known lastname **] was made NPO on admission. She was
started on IV fluids with D10W at 80 cc per kilogram. Enteral
feeds with Premature Enfamil 20 were introduced on day of
life 2. She was quickly advanced on enteral feeds and was at
full feeds on day of life 5. Her calories were increased, and
she is currently on Premature Enfamil 26 with ProMod at 150
cc per kilogram per day. She demonstrated an excellent weight
gain on this calorie supplementation, and at the moment of
discharge, her weight is 2,060 grams.
Due to significant spit ups, her feeds were given over 2
hours on the pump. She was followed for hyperbilirubinemia
through her hospital course. Her jaundice peaked on day of
life 2 with bilirubin level at 7.7, and phototherapy was
started. Phototherapy was discontinued on day of life 5.
Rebound bilirubin was 4.2.
Hematology. Her initial CBC was reassuring with 6.7 white
blood cells, 25 polys, and 2 bands. Her hematocrit was 57.2
and platelets 214,000. Her hematocrit was followed through
hospital course and the last was done on [**2161-11-11**] at
day of life 21 and it was 37.8.
Infectious diseases. Due to maternal history and prematurity,
she was started on ampicillin and gentamicin on admission.
Her blood cultures were followed and were negative at 48
hours. Antibiotics were discontinued on day of life 2. She
remained without complications through the rest of her
hospital course.
Neurology. Head ultrasound was done on day of life 7. It
shows normal size and configuration of the lateral
ventricles. The 3rd ventricle appeared mildly distended.
There is a small choroid plexus cyst within the left lateral
ventricle. Follow-up head ultrasound was planned prior to
discharge from the hospital.
Ophthalmology. Baby Girl [**Known lastname **] had an eye exam done on [**2161-11-16**], day of life 26. Ophthalmologic exam showed that
retina is immature zone III. No ROP. Follow-up exam was
recommended in 3 weeks.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged to [**Hospital6 204**]
level II neonatal intensive care unit.
PRIMARY CARE DOCTOR: Is in [**Location (un) 15749**] Pediatric Practice.
FEEDS AT DISCHARGE: Premature Enfamil 26 calories per ounce
with ProMod at 150 cc per kilogram per day. Please run over 2
hours.
CURRENT MEDICATIONS: Ferrous sulfate at 0.2 cc p.o. PG once
a day, vitamin E 5 units p.o. PG once a day.
IMMUNIZATIONS: No immunizations were given over her hospital
course.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1. Born at less than 32
weeks; 2. Born between 32 and 35 weeks with 2 of the
following: Daycare during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings. 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
DISCHARGE DIAGNOSIS LIST:
1. Prematurity.
2. Apnea of prematurity.
3. Feeding immaturity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Name (STitle) 62294**]
MEDQUIST36
D: [**2161-11-19**] 08:55:50
T: [**2161-11-19**] 09:35:07
Job#: [**Job Number 52660**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3974
} | Medical Text: Admission Date: [**2201-12-11**] Discharge Date: [**2202-2-9**]
Date of Birth: [**2148-10-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
continuous bleeding after tooth extraction 1 day PTA
Major Surgical or Invasive Procedure:
bone marrow biopsy [**2201-12-17**]
splenectomy
picc line
exchange of abdominal drain
History of Present Illness:
53 yo M w/ hep C cirrhosis s/p OLT in [**4-/2198**], chronic
thrombocytopenia and recent pan-cytopenia, CRF who presents with
continuous bleeding (oozing) after a dental extraction. In the
[**Name (NI) **] pt. was noted to have a plt count of 11 and was transfused 1
bag of platelets with some improvement in oozing. He was then
admitted for further observation and w/u of his pancytopenia.
This AM he has no specific complaints and his gum bleeding has
further improved. He does report starting on neurontin on
[**2201-11-10**] (by pain clinic) and taking prophylactic abx. (unclear
which one) starting on Wednesday prior to his dental procedure.
.
ROS: no recent f/c, weight loss, SOB. Reports rectal pain and
some blood in stool which is his baseline. Also, c/o of some
urinary discomfort.
Past Medical History:
# ESLD [**1-23**] HCV cirrhosis, s/p OLT on [**2198-5-20**]
- c/b biliary strictures w/ Roux en-Y hepaticogjejunostomy
[**2198-12-24**]
# h/o polysubstance abuse
# h/o L ureteral obstruction s/p stent placement [**2201-6-16**]
- new stent placed [**2201-11-20**] for L hydronephrosis
# anal fissures/fistulae s/p repair [**2198-12-4**], [**2199-4-29**], [**2201-9-30**]
# hypertension
# SVT
# esophagitis
# cognitive disorder
# adjustment disorder
.
PSH: (per initial H&P)
# OLT [**2198-5-20**] c/b biliary strictures w/ Roux en-Y
hepaticojejunostomy
# incision hernia repair [**2196-12-6**]
# s/p hemorrhoid repair
# anal fistulectomy in [**2198-12-4**] + [**2199-4-29**], seton placement
[**2201-9-30**]
# appendectomy
# cholecystectomy
Social History:
Lives with elderly aunt and uncle. Denies tobacco, alcohol or
drug use. Has a sister, a nurse, who is very aware of his health
issues.
Family History:
Non-contributory.
Physical Exam:
Vitals: T:98.7 BP:118/70 HR:60 RR:20 O2Sat:99% on RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: + blood clots over tooth extraction sites, still with
small amounts of oozing, dry mucous membranes, EOMI, PERRL,
sclera anicteric, no epistaxis
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, II/VI early systolic murmur at LUSB and LLSB
non-radiating, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, palpable spleen tip, scar from liver
[**Month/Day/Year **], no rebound or guarding.
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II - XII
grossly intact. No asterixis. moves all 4 extremities. Strength
[**4-26**] in upper and lower extremities. Patellar DTR +1. Plantar
reflex downgoing. No gait disturbance. No cerebellar
dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2201-12-11**] 04:01PM WBC-1.2* RBC-3.11* HGB-9.0* HCT-28.8* MCV-93
MCH-28.9 MCHC-31.2 RDW-17.3*
[**2201-12-11**] 04:01PM PLT COUNT-11*
[**2201-12-11**] 04:01PM GRAN CT-900*
[**2201-12-11**] 04:01PM PT-14.3* PTT-28.8 INR(PT)-1.2*
[**2201-12-11**] 04:01PM GLUCOSE-84 UREA N-46* CREAT-1.4* SODIUM-139
POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-29 ANION GAP-15
[**2201-12-11**] 04:55PM POTASSIUM-4.5
.
[**2202-1-5**] 5:47 pm BLOOD CULTURE Source: Line-R PICC.
**FINAL REPORT [**2202-1-8**]**
Blood Culture, Routine (Final [**2202-1-8**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle [**Month/Day/Year **] Stain (Final [**2202-1-6**]):
[**Month/Day/Year **] NEGATIVE ROD(S).
.
MRI PELVIS W/O & W/CONTRAST [**2202-1-10**] 9:15 PM
MRI PELVIS W/O & W/CONTRAST
Reason: assess for perirectal abscess.
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
53 year old man s/p liver [**Hospital **], rectal fissure surgery,
fever.
REASON FOR THIS EXAMINATION:
assess for perirectal abscess.
CONTRAINDICATIONS for IV CONTRAST: None.
EXAMINATION: MR pelvis.
INDICATION: Status post liver [**Hospital **]. Rectal fissure
surgery, fever. Evaluate for perirectal abscess.
COMPARISON: Comparison is made with the previous MR [**First Name (Titles) 767**] [**2199-4-27**].
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired
on a 1.5 Tesla magnet, including dynamic high-resolution 3D
imaging, obtained prior to, during and after the uneventful
intravenous administration of 0.1 mmol/kg of gadolinium-DTPA. 2D
and 3D reformations and subtraction images were performed on an
independent workstation.
MR [**First Name (Titles) 30339**] [**Last Name (Titles) **]: In the [**2-25**] o'clock position (when viewed
lithotomy position, left-to-left/posterior) of the
intersphincteric space situated approximately 2 cm proximal to
the anus, an area of crescentic high signal intensity is
identified on the T2-weighted imaging (series 6, image 26) that
measures 1.5 cm AP x 7 mm TV x 1.5 cm SI, with a peripherally
enhancing rim, consistent with a tiny abscess too small to
drain. This is at approximately the level of the levator ani
(series 105a, image 14), and might communicate inferiorly with
the rectal canal at the 6:00 location (series 100, image 68),
approximately 4.5 cm superior from the anal verge.
A thin slip of high signal on T2W images (series 6, image 29),
with thin curvilinear enhancement extends from this tiny
collection inferiorly along the intersphincteric space and along
the expected location of the internal sphincter from the
3:00-6:00 location until reaching the anal verge, where there is
thickening of the external sphincter on the left side (series
104a, image 27). It is unclear if this represents a tract, or
may be secondary to previous surgery or granulation tissue. This
lays along the course of the fistula described in [**2199-4-21**]. No
definite fluid is seen along this slip. Susceptibility is seen
along the inferior aspect, similar to images from [**2198**]. The
internal sphincter is hypoenhancing on post- gadolinium images,
and indistinct but slightly hyperintense on T2W images, again
possibly due to prior surgery.
There is nonspecific edema and vascular engorgement within the
perirectal fat.
There are bilateral hydroceles with an inguinal hernia on the
left containing some peritoneal fat and fluid. Left ureteral
catheter is seen with pigtail curling within the bladder.
Bladder is nondistended.
No evidence of any significant lymphadenopathy. The remainder of
the bowel where visualized is unremarkable. The osseous
structures where visualized are normal.
2D and 3D reformations provided multiple perspectives for the
dynamic series.
IMPRESSION:
1. Small intersphincteric abscess from the 3 to 6 o'clock
location (from lithotomoy position) on the left at the level of
the levator ani. This may communicate with rectal lumen
inferiorly, crossing the internal sphincter at the 6 o'clock
position as described above, but is too small to drain.
2. No drainable abscess.
3. Mild hyperintensity on T2W images, mild enhancement, and
thickening of left external sphincter along course of previously
([**2198**] MRI) described intersphincteric tract, which may represent
residual tract, or postoperative or granulation
tissue--correlate with surgical history.
4. Bilateral hydroceles with left inguinal hernia containing fat
and peritoneum.
5. Nonspecific edema and engorgement of vessels in perirectal
fat. This may be due to hepatic disease and collateral portal
blood flow.
6. Left ureteral stent with pigtail in the bladder.
Brief Hospital Course:
This was a 53 yo M s/p liver [**Year (4 digits) **] in [**2197**], pan-cytopenia,
splenomegaly who presented with continuous oozing after tooth
extraction. Hospital course by problem below:
Thrombocytopenia - platelet count of 69 on [**11-25**]. Platelet count
on [**12-10**] was 14. Neurontin (started on [**2201-11-10**]) and
prophylactic antibiotics [**12-10**]. Neurontin was held. DIC labs
were negative for chronic DIC. HIT Ab negative. Parvovirus B19
Ab negative. Bone marrow biopsy showed ITP. Prednisone and
rituxan were not options for therapy given his history of Hep C.
The patient underwent two doses of IVIG at 35g, two days apart.
He experienced only minimal improvement in his platelet counts
each time, from [**10-5**]. He was also transfused platelets on two
occasions, when his platelets decreased below 10. he
experienced only minimal improvement in platelet counts after
transfusion, from [**6-3**]. It was decided that splenectomy would
be the next best option for him. An abd CT was done on [**12-26**] to
evaluate for splenic vein thrombosis. [**Month/Day (1) **] were significant
for non-occlusive thrombus adherent to the wall of the main
portal, splenic, and the tributaries forming the SMV near the
portosplenic confluence.
On [**1-15**] splenectomy and distal pancreatectomy were performed.
Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please see operative note for
further details. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed. Postop, he was sent
to the SICU. Pain management was an issue requiring Acute Pain
service management. He was trasferred out of the SICU to the
med-[**Doctor First Name **] unit where he continued to have high outputs via the JP
(~ 3 liters) for which he received IV fluid replacements and
albumin. Given that he had a distal pancreatectomy, the JP fluid
was sent for amylase. This was initially 191 on [**1-22**], but
increased to 4170 on [**1-25**]. A repeat JP amylase on [**1-27**] was 2769.
JP drainage trended down to 40 by [**2-4**]
Bacteremia: Patient developed fever and leukocytosis on [**1-5**].
He was treated empirically for a neutropenic fever with
cefepime. The following day his fever had resolved. Blood
cultures grew pan sensitive e.coli. His abx were switched to
cipro, and his PICC line was removed. A source of his bacteremia
was thought to be from a perirectal abscess identified on MRI.
He remained afebrile while on cipro. A general surgery consult
was obtained with recommendations for an MRI. A MRI was done
noting small intersphincteric abscess from the 3 to 6 o'clock
location (from lithotomoy position) on the left at the level of
the levator ani. This was non-drainable. Cipro and flagyl were
recommended for 2 weeks. On [**1-24**] CVL was d/c'd for low grade
temps.
On [**1-25**] he was febrile to 101.2. Blood and urine cultures were
negative. JP fluid was negative for growth. An abd CT was done
revealing partially walled-off fluid in the left upper abdomen
with air locules, interval progression of nonocclusive thrombus
in the portal system, to a greater degree in the splenic vein
and left portal vein, moderate left pleural effusion, and left
nephroureteral stent in stable position, with moderate
dilatation of the left renal pelvis, which has progressed from
the prior study. A heparin drip was started. Coumadin was then
started with goal inr achieved and discontinuation of heparin.
He was sent home on a coumadin dose of 0.5mg qd with inr to be
drawn on [**2-10**].
On [**1-30**] he spiked a temp to 101.8. Blood and urine cultures were
again sent with the urine negative and blood cultures negative
to date. Vanco and Zosyn were started on [**1-31**]. A CXR
demonstrated L lung base atelectasis and a small left pleural
effusion. A CT guided exchange of the drain was done for failure
of the JP to drain. Upsizing of left abdominal drain as
described above without immediate complications. Pull back study
through track failed to demonstrate track communucation with the
left thorax or left pleural effusion. The drain was upsized.
Vanco and Zosyn were started on [**1-31**]. After 3 doses, the zosyn
was switched to Levaquin. Flagyl was added on [**2-3**]. He was
discharged home on Vanco, flagyl and Levaquin with indefinate
duration pending resolution of fluid collection. He did complain
of some loose stool which was sent for c.diff x 2. These were
negative.
.
#) Hypertension -diltiazem and atenolol were continued at 25mg
daily. He received his home doses of lasix (40 qam and 20mg
qpm). Lower leg edema persisted.
.
#) Diabetes - Glargine was discontinued due to persistent low
glucoses. Humalog sliding scale continued. [**Last Name (un) **] followed.
Kcals were ordered for poor po intake and supplements were
ordered.
.
#) Liver [**Last Name (un) **] - His tacrolimus, lamivudine (tx. liver from
hep B+ patient), and prednisone were continued. His tacrolimus
levels were monitored and dose adjusted based on levels.
VNA services were arranged for home as he was discharged with
the JP in place. A picc line was also present in his Left arm
for iv vancomycin.
He was ambulatory with stable vital signs tolerating a regular
diet at time of discharge. Labs were to be drawn on [**2-10**] with
results fax'd to the [**Month/Year (2) 1326**] office. Blood cultures from [**2-5**]
finalization were pending (negative to date).
Medications on Admission:
atenolol 50mg PO Q day
calcium carbonate + vit D2 600mg/400u 1 tab PO Q day
diltiazem HCL 180mg PO QD
colace 100mg PO BID
glargine 12u SC QHS
HISS
lamivudine 100mg PO Q day
lidocaine 4% cream TP TID prn
methadone 65mg PO Q day
omeprazole 40mg PO Q day
prednisone 3mg PO Q day
risedronate 35mg PO Q week
sertraline 50mg PO Q day
tacrolimus 1.5mg PO BID
testosterone 100mg TP Q day
white petrolatum TP [**Hospital1 **] prn
Trazodone 150mg qHS
neurontin 100 TID
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Risedronate 35 mg Tablet Sig: One (1) Tablet PO qSunday ().
8. Testosterone 1 %(50 mg/5 [**Hospital1 **]) Gel in Packet Sig: One (1)
Transdermal [**Hospital1 **] ().
9. Methadone 10 mg Tablet Sig: Seven (7) Tablet PO DAILY
(Daily): total of 75mg qd. took [**2-9**].
10. Methadone 5 mg Tablet Sig: One (1) Tablet PO once a day:
total of 75mg qd. took [**2202-2-9**].
11. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): both eyes.
13. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
14. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
17. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous qid per sliding scale.
Disp:*1 bottle* Refills:*0*
18. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for sleep.
Disp:*60 Tablet(s)* Refills:*0*
19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*42 Tablet(s)* Refills:*0*
20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*14 Tablet(s)* Refills:*0*
21. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
22. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Warfarin 1 mg Tablet Sig: half Tablet PO qd (Once).
25. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
26. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection DAILY (Daily) as needed: and after antibiotic.
Disp:*60 ML(s)* Refills:*0*
27. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: following saline
after antibiotic infusion.
Disp:*60 ML(s)* Refills:*0*
28. Vancomycin in Dextrose 1 [**Month/Day/Year **]/200 mL Piggyback Sig: One (1)
[**Month/Day/Year **] Intravenous once a day.
Disp:*14 doses* Refills:*0*
29. Outpatient Lab Work
Labs Wednesday for cbc, chem 10, ast, alt, alk phos, t.[**Month/Day/Year **],
albumin, trough prograf, PT/INR
Then labs every Monday and Thursday for cbc, chem 10, lfts,
PT/INR, trough prograf and trough vanco level
fax to [**Telephone/Fax (1) 697**]
30. Glucometer
Free Syle Lite
31. Lancets
1 box
Refill: 1
32. Test Strips
Free Style Lite
1 box
Refill: 1
33. Insulin
syringes-lo dose for qid sliding scale insulin
1 box
refill: 1
34. Alcohol
pads
1 box
refill: 1
35. Methadone
Received 75mg on [**2202-2-9**] at 6am
36. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
37. LUQ abdominal drain Flushes
Normal saline 0.9% prefilled 10cc syringes for LUQ abdominal
drain tid
Supply: 60
Refill:
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
thrombocytopenia
portal vein thrombus
s/p liver [**Hospital **]
splenomegaly
h/o substance abuse on methadone
HTN
DM
Portal vein thrombus
Discharge Condition:
stable
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] if you have fevers, chills, nausea, vomiting,
abdominal distension, incision redness/bleeding, drainage,
bleeding, easy bruising, chest pain, shortness of breath, bloody
stools, dizziness, or any other concerns.
.
Please take all medications as directed.
No heavy lifting
No driving while taking pain medication.
.
You received methadone 75 mg on the day of discharge.
Followup Instructions:
You should follow-up with Dr. [**Last Name (STitle) 497**] [**Telephone/Fax (1) 673**] in 2 weeks.
Call Dr.[**Name (NI) 10946**] office ([**Telephone/Fax (1) 9011**] to schedule a
follow up appointment in [**12-23**] weeks
Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] to schedule follow
up visit in 1 week.
Call [**Hospital **] clinic to schedule follow up appointment within the
next few weeks
Completed by:[**2202-2-9**]
ICD9 Codes: 5856, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3975
} | Medical Text: Admission Date: [**2196-12-15**] Discharge Date: [**2196-12-20**]
Date of Birth: [**2169-10-4**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Dilaudid
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Ms. [**Known lastname 55537**] is a 27yo woman with h/o HCV, liver transplant x
2 in [**2177**] (rejected first liver), (?Wilson's disease per
records) and 3rd OLT in [**2189**] who was in her USOH until yesterday
afternoon when she began to have RUQ pain that radiated like a
band across her stomach. She had chills and diaphoresis at that
time, and a headache (which she frequently gets per records), N
but no V. Noted that she "just din't feel good" and was sleeping
a lot yesterday. She also noted a few hours later she had some
chest pain, not pleuritic, sharp pain "like needles", no cough,
+SOB along with abd and CP. Yesterday, she presented to [**Hospital 1281**]
Hospital in [**Location (un) **], MA, where she had an abdominal CT scan that
was unremarkable. She was found to have an elevated bilirubin
over 4 (baseline 2.0). She remained there overnight and went
home today, when she went to see Dr. [**Last Name (STitle) 497**]. In his office she
was febrile to >101. He sent her immediately to be admitted to
the hospital.
.
ROS: HA as above (per records complained of this over last few
weeks), facial tingling "all over in a circle." otherwise
unremarkable.
Past Medical History:
liver transplant x 2 in [**2177**] at [**Hospital **] [**Hospital1 11900**](rejected first liver); ?3rd transplant in [**2189**]
- does not recall CMV infections, but did have HSV esophagitis
in 2/87
- possible cholangitis [**2187**]
- recurrent UTIs
- HCV: past interferon treatment suppressed VL from 6mill to
79,000 but had to stop [**3-10**] depression/disorientation. Recently
restarted ribaviron and pegylated interferon on [**11-30**].
- incarcerated hernia repair
- s/p ccy with liver transplantation
.
Meds:
prednisone 10mg po qother day (took today)
cyclosporin 125 mg po qday
ribavirin 400mg po bid
interferon 120mcg (0.3mL) SQ QFri
trazodone 10mg po qhs prn
.
All: bactrim --> hives; dilaudid
Social History:
lives at home with her daughter and her brother's family (his
wife and 4 children). Does not work. Denies tobacco, alcohol, or
other drugs including intravenous drugs.
Family History:
mother with DM, HTN, breast ca.
Physical Exam:
HR 96, BP 95/59 RR 19 O2 98% RA
Gen: sleepy but answers questions with poor concentration
HEENT: NCAT, PERRL, sclerae mildly icteric, OP not injected, MM
dry, no sinus tenderness, no photophobia
Neck: supple, no JVD, no LAD
Cor: RRR, II/VI systolic flow murmur heard throughout precordium
non radiating, s1s2
Pulm: CTAB
Abd: well-healed transverse surgical scar, RUQ tenderness, +
[**Doctor Last Name 515**] sign, + rebound tenderness over upper but not lower
abdomen, + diffuse abdominal tenderness to moderate palpation,
+BS, soft, ND
Ext: no c/c/e, w/w/p, pulses 2+ radial and PT pulses bilat
Neuro: moves all four to command, strength 4/5 bilateral quads,
[**6-10**] bilateral hands and feet at ankles, rest of neuro exam not
performed given sleepiness of pt
Pertinent Results:
CT abd from OSH [**2196-12-14**]: film reviewed by trauma [**Doctor First Name **] here with
radiology and was basically negative (pneumobilia only, with
mild intrahepatic dilation, no free air or abscesses)
.
RUQ U/S:Normal hepatic vessels in this patient post transplant.
No other commentary.
.
CXR: no acute CP process.
CT abd [**2196-12-15**]:
IMPRESSION:
1. Decrease pneumobilia status post hepaticojejunostomy.
2. Splenomegaly.
3. Increasing bibasilar atelectasis compared to same day study
from outside hospital. Possible consolidation cannot be
excluded.
.
MRCP: negative for obstruction
.
CMV/EBV negative
[**12-15**] bld cx + pan-[**Last Name (un) 36**] E coli; + Urine cx from OSH + for E coli
repeat bld cx neg
.
HSV DFA +
.
Lumbar Puncture: 0 rbc, 0 wbc
.
[**2196-12-16**] 04:04AM BLOOD WBC-5.7 RBC-3.16* Hgb-9.7* Hct-27.5*
MCV-87 MCH-30.8 MCHC-35.4* RDW-15.7* Plt Ct-74*
[**2196-12-20**] 04:50AM BLOOD WBC-4.3 RBC-3.66* Hgb-11.6* Hct-31.3*
MCV-86 MCH-31.8 MCHC-37.2* RDW-15.9* Plt Ct-184
[**2196-12-15**] 02:30PM BLOOD Glucose-78 UreaN-12 Creat-0.8 Na-139
K-3.9 Cl-108 HCO3-22 AnGap-13
[**2196-12-15**] 02:30PM BLOOD ALT-29 AST-27 LD(LDH)-244 AlkPhos-145*
Amylase-42 TotBili-4.2* DirBili-0.8* IndBili-3.4
[**2196-12-20**] 04:50AM BLOOD ALT-27 AST-27 TotBili-1.1
[**2196-12-15**] 09:21PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
.
Bld Cx + for E coli
Brief Hospital Course:
Ms [**Known lastname 55537**] is a 27F with h/o liver transplant x 3 (last in
[**2189**]) who presented with fever and abdominal pain and direct
hyperbilirubinemia who was presumed to have cholangitis but was
subsuquently found to have E coli urosepsis.
.
Upon admission to the floor Ms [**Known lastname 55537**] was found to be
tachycardic to the 120s, hypotensive with sbp in the 90s fever
to 104. She was given 3LNS boluses, started on Zosyn and Flagyl
to empirically cover for cholangitis, and was transferred to the
ICU for further management. She received another 2LNS boluses in
the ICU and did not need pressors for BP support. Ms [**Known lastname 55537**]
had a stat CT abdomen and Abdominal ultrasound which did not
reveal any signs of cholangitis. She was subsuquently found to
have E coli bacteremia and urine culture from an outside
hospital revealed E. coli UTI. She was changed to IV
ciprofloxacin when sensitivities returned and was discharged
with a 14 day course of oral cipro. Her fevers gradually
resolved as did her hypotension and her abdominal pain was
completely resolved by discharge. Repeat blood cultures were
negative. UA and urine cultures repeated at [**Hospital1 18**] were negative
and CT-abdomen showed no evidence of pyelonephritis.
.
# Immunosuppression: Ms [**Known lastname 55538**] post transplant
immunosuppressive regimen was cyclosporine 150bid + prednisone
10 QOD. She was admitted with supra-therapeutic cyclosporine
levels above 300. Her CSA doses were adjusted with wide
fluctuation in her level. Her dose was decreased to 100mg po
bid prior to discharged because the concern is her sepsis was
likely induced by her overimmunosuppression. Her CSA level on
the morning of discharge was 344, but this was not reported
until after the patient's discharge. She was contact[**Name (NI) **] via
telephone to have another level drawn the next day.
.
During Ms. [**Known lastname 55538**] stay she developed oral lesions that
were + for herpes virus by direct antigen testing. She had also
been reporting headache and photophobia so a lumbar puncture was
performed that showed no RBC or WBC. She was treated briefly
with IV acyclovir and then transitioned to a 10-day course of
valacyclovir 500mg po bid. She has been instructed to cover her
lesions when she interacts with her 18month-old daughter. She
also had signs of bacterial superinfection of one of the lesions
for which she is being treated with bactroban.
.
#. Hyperbilirubinemia: There was concern on admission that Ms
[**Known lastname 55538**] tbili was 4.4 and she had RUQ pain. Abd US and CT
abdomen were negative for obstruction. She had an MRCP that was
negative for obstruction. The hyperbilirubinemia resolved with
antibiotic treatment making sepsis the likely source.
.
# HCV: Ms [**Known lastname 55537**] received her 4th treatment of pegylated IFN
+ ribaviring several days PTA. Her interferon was held x 1 dose
due to her sepsis and her ribavirin was briefly held due to
concern over her anemia. Her last viral load had shown good
response to IFN/ribavirin so the ribavirin was restarted with
plans to resume IFN in 1 week.
.
# anemia/thrombocytopenia: Ms [**Known lastname 55537**] presented with anemia
and thrombocytopenia that improved with treatment of her sepsis.
Hemolysis labs were negative making ribavirin a less likely
culprit. Her hct on discharge was 30, which does not merit epo
treatment.
.
# Immunization: Ms [**Known lastname 55537**] was found to be negative for HAV
and HBV antibodies. She was therefore vaccinated with #1 of the
HAV and HBV series. These series should be completed in liver
clinic. She also received pneumococcal vaccine and influenza
vaccine.
Medications on Admission:
prednisone 10mg po qother day (took today)
cyclosporin 125 mg po qday
ribavirin 400mg po bid
interferon 120mcg (0.3mL) SQ QFri
trazodone 10mg po qhs prn
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOTHER DAY ().
2. Ribavirin 200 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
3. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): apply to lesions on upper lip until resolved.
Disp:*1 tube* Refills:*2*
4. Cipro 750 mg Tablet Sig: One (1) Tablet PO twice a day for 8
days.
Disp:*16 Tablet(s)* Refills:*0*
5. Valtrex 500 mg Tablet Sig: One (1) Tablet PO twice a day for
9 days.
Disp:*18 Tablet(s)* Refills:*0*
6. Cyclosporine 100 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*2*
7. Peg-Intron 120 mcg/0.5 mL Kit Sig: 0.3 ml Subcutaneous once a
week.
8. Outpatient Lab Work
cyclosporine trough
please draw in approximately 1 week
Discharge Disposition:
Home
Discharge Diagnosis:
E coli bacteremia
Urosepsis
hepatitis C
s/p orthotopic liver transplantation
herpes labalis
Discharge Condition:
good: afebrile, VSS
Discharge Instructions:
You should continue to take all medications as prescribed. You
were admitted with a blood infection and need to finish a 14-day
course of an antibiotic called ciprofloxacin (you have 9 more
days to take this). We are also giving you a medicine called
valtrex for your mouth sores to take for 8 days. Until the
lesions on your lips are crusted over, they are potentially
ifectious. You need to be careful around your daughter and not
[**Doctor Last Name **] her. You should continue to take your interferon and
ribavirin as scheduled.
.
Dr [**Last Name (STitle) 497**] wants you to decrease your cyclosporine dose to 100mg
twice per day. You should have your trough level drawn in about
a week (it should be drawn 1 hour before your next dose is due).
.
You should follow-up in clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as below.
.
Please seek immediate medical attention if you have abdominal
pain, fevers, chills, jaundice, eye pain, worsening headache, or
for any other concerns.
.
You were also given a hepatitis A vaccine, influenza vaccine,
pneumonia vaccine, and the first in the hepatitis B vaccine
series. You will need to finish the hepatitis B vaccine series
with 2 other shots. We will convey this to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2196-12-27**] 2:20
ICD9 Codes: 5990, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3976
} | Medical Text: Admission Date: [**2193-3-16**] Discharge Date: [**2193-3-22**]
Date of Birth: [**2141-4-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
51 y/o M transferred from [**First Name4 (NamePattern1) 8125**] [**Last Name (NamePattern1) **] with coffee ground emesis.
Recently admitted to [**Hospital Unit Name 196**] service with an NSTEMI/viral
myo-pericarditis. At that time cath demonstrated clean
coronaries, but trop reached 3.0, and regional LV systolic
dysfunction. No echo performed. Was treated with NSAIDS during
hospital stay. Since going home has he intermittent chills,
fevers. Black vomitus since Thursday. Went to OSH with coffee
ground emesis. No BRB. Guaiac positive from below. No NG
lavage done at OSH.
In the ED, initial vs were: T 99.0 P114 BP105/70 R93-94% 2LNC O2
sat. Hct stable at OSH. OG tube was flushed and did not clear,
but no BRB - was dark colored. No further emesis. CT torso
obtained given recent instrumentation that showed airspace
opacities in right, middle, and upper lobes, c/w aspiration and
pneumonia. Was given vancomycin in ED, had received levaquin at
OSH. GI consult felt this was likely not variceal bleed and
said would see first thing in AM. PPI gtt continued, and
octreotide d/c'd.
At time of transfer, HR 105, 124/69, RR16, 93%2-3L NC, patient
with 4 large guage peripheral IV's.
Past Medical History:
Hypertension
Alcohol abuse (quit 2 weeks ago)
PTSD
H/o knife wound to chest, with damage to pulmonary artery status
post repair
Recent h/o testicular torsion status post surgical repair
Hepatitis C
GERD
Pulmonary hypertension
Social History:
10PY smoking history, quit 3 years ago. Remote h/o cocaine
abuse. H/o EtOH abuse but clean x3 months.
Family History:
No FHx of early MI.
Physical Exam:
Gen: Comfortable in the hospital bed
HEENT: No JVD, CN II-XII intact to confrontation
CV: S1 & S2 regular without murmur
Pulm: B diffuse crackles and rhonchi
Abdominal: Soft, Tender
Extremities: R hip tenderness
Neurologic: Attentive, Follows simple commands
Pertinent Results:
[**2193-3-15**] 11:00PM PT-15.9* PTT-32.5 INR(PT)-1.4*
[**2193-3-15**] 11:00PM NEUTS-71* BANDS-14* LYMPHS-9* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2193-3-15**] 11:00PM WBC-19.4*# RBC-3.19* HGB-10.3* HCT-30.4*
MCV-95 MCH-32.3* MCHC-33.9 RDW-13.9
[**2193-3-15**] 11:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2193-3-15**] 11:00PM CK-MB-15* cTropnT-1.12*
[**2193-3-15**] 11:00PM ALT(SGPT)-63* AST(SGOT)-87* ALK PHOS-63 TOT
BILI-0.7
[**2193-3-15**] 11:00PM LIPASE-11
[**2193-3-16**] 03:01AM LACTATE-1.6
[**2193-3-16**] 05:28AM WBC-14.2* RBC-2.72* HGB-9.0* HCT-26.0* MCV-96
MCH-33.0* MCHC-34.6 RDW-13.8
[**3-16**] Echo:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF 70-80%). There
is no ventricular septal defect. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output. Mild (1+)
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 a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
[**3-16**] CT Torso:
1. Inflammatory change of the right colon and mesenteric/portal
venous gas is highly concerning for ischemia.
2. Extensive right diffuse airspace opacification in a pattern
that suggests aspiration or bronchopneumonia.
[**3-16**] Upper GI Endoscopy:
Findings: Esophagus: Excavated Lesions [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear was
seen in the gastroesophageal junction.
Stomach: Mucosa: Erythema, congestion and friability of the
mucosa with contact bleeding were noted in the antrum. These
findings are compatible with gastritis.
Duodenum: Normal duodenum.
Impression: Erythema, congestion and friability in the antrum
compatible with gastritis. [**Doctor First Name **]-[**Doctor Last Name **] tear.
Otherwise normal EGD to second part of the duodenum
Recommendations: No active bleeding seen, no varices. Continue
PPI twice daily. Continue to monitor Hct and transfuse to
Hct>26.
CTA abdomen/pelvis ([**3-17**]): The lung bases demonstrate scattered
patchy opacities which are more prominent on the right and may
represent small foci of pneumonia. There are small bilateral
effusions, right greater than left. Heart size is normal. There
is no pericardial effusion. The liver, spleen, adrenals,
pancreas and intra-abdominal loops of small bowel are
unremarkable. Post-cholecystectomy changes are stable. The
imaged venous and arterial vessels are patent. Wall thickening
and stranding along the hepatic flexure to the mid ascending
colon is slightly less conspicuous since [**2193-3-16**]. There are no
definite areas of pneumatosis, with air in the non dependant
portions of the cecum (3a:91-116) likely representing air. The
kidneys enhance and secrete contrast symmetrically. The imaged
small bowel is unremarkable. CT PELVIS: The rectum, prostate and
sigmoid are unremarkable. The bladder demonstrates a Foley
catheter and a small amount of air. Bone windows demonstrate no
evidence of lesions that is suspicious for metastatic or
infectious focus, with multilevel degenerative changes in the
thoracolumbar spine which are similar to [**2193-3-16**]. A linear
lucency along the superior right acetabulum (3B:372) likely
represents nondisplaced fracture.
IMPRESSION:
1. There is no evidence of ischemia with resolution of portal
venous and
mesenteric air since yesterday. Colitis involving the hepatic
flexure to the mid ascending colon is less prominent since
yesterday.
2. Likely Nondisplaced right acetabulum rim fracture.
CXR ([**3-19**]): Bilateral airspace with greater involvement on the
right is
slightly improved. There are small bilateral pleural effusions.
Heart size
and mediastinal contours are unchanged. Old rib fracture noted
on the right. IMPRESSION: Improving aspiration pneumonitis or
pneumonia.
Microbiology:
urine cx ([**3-16**]) negative
blood cx ([**3-16**]) no growth to date
MRSA screen ([**3-16**]) negative
Influenza a/b antigen negative ([**3-16**])
C diff toxin negative ([**3-18**])
Brief Hospital Course:
This is a 51 y/o M w/ hep C who presented with UGIB after 3d of
high dose ibuprofen for new dx of myopericarditis manifested by
coffee ground emesis and aspiration pneumonia.
# GI Bleed: Evidence of gastritis and [**Doctor First Name 329**] [**Doctor Last Name **] tear on
endoscopy with hematocrits stable after 2 U prbcs given in the
ICU. He also had a new finding of colitis on colonoscopy but
this was not likely source for bleed. He has tolerated PO BID
PPI and should continue this until follow up with his PCP. [**Name10 (NameIs) **]
should avoid NSAIDs.
- PPI [**Hospital1 **]
- Monitor Hct daily
# Aspiration pneumonia: The patient presented after vomiting
with fever, elevated WBC count, and CXR/CT findings of
infiltrate, making pneumonia likely [**2-25**] to aspiration of gastric
contents. He was negative for influenza on admission. His
infiltrate persisted over days. He will finish a 14-day course
of levofloxacin/flagyl (for both pneumonia and colitis) on
[**2193-3-31**]. Sputum culture was contaminated but did not show MRSA so
vancomycin discontinued on transfer to medical floor.
Supplemental oxygen was used as necessary to maintain oxygen
saturation > 92%.
# Tachycardia: Tachycardia on admission resolved with volume
repletion, likely resultant from bleeding. He denied recent
alcohol use on admission. He does take benzodiazepines as an
outpatient so this was continued. Tamponade was considered but
echocardiogram showed a trivial pericardial effusion. He
tolerated beta blockade once blood pressure and hematocrit were
found to be stable.
# Myo-pericarditis: Enzymes were trending down on admission.
Echo showed trivial effusion as above. Continued beta blockade.
# Colitis: Unclear etiology but considered etiologies include
ischemic vs. inflammatory. Surgery evaluated the patient after
portal gas was seen on his first CT chest; on repeat CTA the
next day, there was no evidence of portal gas. He was maintained
NPO/sips for bowel rest and then regular diet was restarted
without any adverse effects. He will receive a total 14 day
treatment with levofloxacin 500 mg daily and flagyl 500 mg TID.
This will end on [**2193-3-31**]. The patient was C diff toxin
negative X 2. He will need an outpatient colonoscopy once this
acute episode resolves. Pain was controlled with PO morphine.
# Acetabular rim fracture: The patient was found to have a
fracture on CT scan of the abdomen. Orthopedic consultation was
obtained who recommended two months of touchdown weight bearing
and two months of posterior hip dislocation precautions. He will
follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/Dr. [**Last Name (STitle) **] at [**Hospital1 18**] in
orthopedics. Once hematocrit stabilized he was started on
lovenox 40 mg daily to continue until fully ambulatory.
# Hepatitis: No evidence of varices on endoscopy. Should resume
prior follow up plan.
Medications on Admission:
1. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. LeVETiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
9. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
11. Prazosin 1 mg Capsule Sig: One (1) Capsule PO at bedtime.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
5. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO once a day.
6. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily) for 1 months: Until fully ambulatory.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days: To end [**2193-3-31**].
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 10 days: To end [**2193-3-31**].
9. Terazosin 2 mg Capsule Sig: One (1) Capsule PO at bedtime.
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for Anxiety: Please hold for sedation.
Patient should not drive after taking this medication.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed for dyspnea/wheeze.
12. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: Hold for sedation. Patient should not
drive after taking this medication. Please wean as tolerated.
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 1474**] Veteran's Hospital
Discharge Diagnosis:
Aspiration pneumonia
Right-sided colitis, NOS
Gastritis, probably NSAID-induced
Upper GI bleed secondary to [**Doctor First Name **]-[**Doctor Last Name **] tear
Right acetabular rim fracture
Recent viral myopericarditis
Discharge Condition:
Afebrile, normotensive, comfortable on room air/ 2L NC
Discharge Instructions:
You have been evaluated for your nausea/vomiting and were found
to have an irritation of the stomach ("gastritis") as well as a
small tear in the lining of the esophagus. Your blood counts
have been stable since this finding. You will need to continue
protonix to protect your stomach.
You were also found to have a right hip fracture; you will need
to continue touchdown weight-bearing only for two months. You
should also continue posterior hip dislocation precautions for
two months.
You were treated for a pneumonia while in the hospital. This may
have been related to your vomiting.
You are being treated for an inflammation of the colon. This
will continue for a total of two weeks of treatment.
Please take your medications as prescribed and keep your follow
up appointments.
Please contact your primary care physician or return to the
emergency room should you develop any of the following: fever >
101, chills, difficulty breathing, increased cough, increased
abdominal pain, inability to take in liquids or medications due
to nausea or vomiting, blood in the stools, or any other
concerns.
Followup Instructions:
Please contact Dr. [**Last Name (STitle) **], your primary care physician, [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 54768**] within 1-2 weeks for a follow up appointment.
You should follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] / Dr. [**Last Name (STitle) **] in
Orthopedics on Thursday, [**4-4**], at 10:00 am on the [**Location (un) 1385**] of the [**Hospital Ward Name 23**] Clinical Center at [**Hospital1 18**]. Please call his
office at ([**Telephone/Fax (1) 2007**] if there are any problems with this
appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
ICD9 Codes: 5070, 2851, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3977
} | Medical Text: Admission Date: [**2102-3-27**] Discharge Date: [**2102-4-8**]
Date of Birth: [**2036-3-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional angina
Major Surgical or Invasive Procedure:
[**4-3**] CABGx5 (LIMA>LAD,SVG>Diag,SVG>Ramus,SVG>OM,SVG>dRCA)
History of Present Illness:
66 yo M with history of untreated prostate cancer x 11 years who
presented to ED with chest pain.
Past Medical History:
prostate ca x 11 years, hyperlipidemia
Social History:
works as film director
denies tobacco
5 glasses of wine/week
Family History:
father with MI at ages 48, 53 and 58
Physical Exam:
HR 61 BP 120/72
NAD, flat after cath
Lungs CTAB
Heart RRR, no murmur
Abdomen benign
Extrem warm, no edema
No varicose veins
Pertinent Results:
[**2102-4-8**] 06:50AM BLOOD WBC-6.6 RBC-3.30*# Hgb-10.1*# Hct-28.8*#
MCV-87 MCH-30.5 MCHC-34.9 RDW-14.0 Plt Ct-243
[**2102-4-3**] 12:40PM BLOOD PT-14.6* PTT-38.8* INR(PT)-1.3*
[**2102-4-8**] 06:50AM BLOOD Glucose-104 UreaN-21* Creat-1.2 Na-140
K-4.6 Cl-102 HCO3-31 AnGap-12
Neurophysiology Report EEG Study Date of [**2102-4-7**]
OBJECT: STATUS POST CABG, NOW WITH VISUAL DISTURBANCES, RULE OUT
SEIZURES.
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 14691**]
FINDINGS:
BACKGROUND: A well-formed 8 Hz posterior dominant rhythm was
noted in
wakefulness which attenuated appropriately with eye opening. The
anterior to posterior voltage gradient was preserved.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: The patient progressed from the waking to drowsy state
but did
not attain stage II sleep during the recording.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 84 beats per minute.
IMPRESSION: This is a normal routine EEG in the waking and
drowsy
state. There were no areas of prominent focal slowing. There
were no
epileptic features.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2102-4-6**] 8:02 AM
CHEST (PORTABLE AP)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
66 year old man s/p CABG
REASON FOR THIS EXAMINATION:
eval for pleural effusions
CHEST RADIOGRAPH
INDICATION: Followup.
COMPARISON: [**2102-4-4**].
As compared to the previous radiograph, the left-sided pleural
effusion has minimally increased. On the right, there is no
evidence of effusion. Unchanged retrocardiac atelectasis. No
newly occurred parenchymal opacities suggestive of pneumonia.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: [**Doctor First Name **] [**2102-4-6**] 10:53 AM
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 7495**] B.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 14692**], [**Known firstname 5445**] [**Hospital1 18**] [**Numeric Identifier 14693**] (Complete)
Done [**2102-4-3**] at 9:10:54 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2036-3-22**]
Age (years): 66 M Hgt (in): 66
BP (mm Hg): 120/70 Wgt (lb): 150
HR (bpm): 70 BSA (m2): 1.77 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 410.91, 786.05, 786.51, 440.0, 424.1
Test Information
Date/Time: [**2102-4-3**] at 09:10 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW3-: Machine: [**Pager number 14694**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: *3.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Findings
LEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection
velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened
aortic valve leaflets. Mildly thickened aortic valve leaflets
(3). Significant AR, but cannot be quantified. Eccentric AR jet
directed toward the anterior mitral leaflet.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Pulmonic valve not well seen.
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. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. The aortic valve leaflets are mildly
thickened. The aortic valve leaflets (3) are mildly thickened.
Significant aortic regurgitation is present, but cannot be
quantified. The aortic regurgitation jet is eccentric, directed
toward the anterior mitral leaflet.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and was
in normal sinus rhythm.
1. Regional and global left ventricular systolic function are
normal.
2. Right ventricular systolic function is normal.
3. Valves are the same as noted pre-bypass.
4. Aortic contours are intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician
Brief Hospital Course:
He was admitted to cardiology. He ruled in for an NSTEMI. He
refused cardiac catheterization and was started on heparin,
[**Last Name (LF) 4532**], [**First Name3 (LF) **], metoprolol, and ACE-I and a statin. He underwent
[**First Name3 (LF) **] test on [**3-29**] where he had ST changed with minimal
exercise. He agreed to cardiac cath which showed moderate left
main and severe 3 vessel disease. He was referred for cardiac
surgery. His [**Month/Day (4) 4532**] was dc'd and he was started on heparin. He
awaited [**Month/Day (4) 4532**] washout prior to being taken to the operating
room on [**4-3**] where he underwent a CABG x5. He was transferred to
the ICU in stable conditon. He was extubated post op. His chest
tubes were dc'd and he was transferred to the floor on POD #1.
Bladder scan post void showed 1 liter residual and foley was
reinserted. He had a fever for which he was pancultured. He was
evaluated by neurology for visual changes. Pacing wires removed
on POD #3. Oncology also consulted. Beta blockade titrated and
he was gently diuresed toward his preop weight. On POD#3 he
complained of visual changes, seeing frames in front of his
eyes, and neurology was consulted. He had an EEG which was
negative and then underwent CTA of the head and neck as he did
not want to have an MRI/MRA. The CTA was negative for CVA and
he was instructed to follow up with Dr. [**First Name (STitle) **] from neurology as
an outpatient. The visual changes improved and he was dischared
to home on POD#5 in stable condition.
Medications on Admission:
ambien 5', [**First Name (STitle) **] 81', celebrex 200', diazepam 2.5', uroxatral 10',
viagra prn
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Uroxatral 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Packet(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
CAD s/p CABG
PMH: prostate ca x 11 years, hyperlipidemia
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower daily, no baths, no lotions, creams or powders to
incisions.
No lifting more than 10 pounds for 10 weeks or driving until
follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 2 weeks
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9834**] [**Telephone/Fax (1) 14695**] 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2102-5-10**] 10:30
Provider: [**Name Initial (NameIs) 10081**]/EXERCISE LAB Phone:[**Telephone/Fax (1) 1566**]
Date/Time:[**2102-4-26**] 10:30
Completed by:[**2102-4-8**]
ICD9 Codes: 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3978
} | Medical Text: Admission Date: [**2104-6-22**] Discharge Date: [**2104-7-4**]
Date of Birth: [**2031-12-1**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Trileptal / Dilantin / Depakote / Soma
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
blood transfusions
History of Present Illness:
72 y/o female s/p recent elective cardiac cath on [**6-17**] where she
underwent stent to RCA. She was noted to have episodes of
bradycardia and hypotesion in the lab and was eventually
admitted to the CCU. She was discharged to Heb. Rehab and was
noted to have decreased Hct and hypotension in concert with dark
stools. She reportedly had a massive bowel movement and
developed hypotension. She currently denies chest pain, although
has some shortness of breath. She denies abdominal pain or
dysuria.
In the emergency room, noted to have a Hct of 22.3 (down from
30) was NG lavage negative and WBC of 31.9. She was also noted
to have ST depressions in 2,3,V4-V6 with a troponin of .13 (no
prior value)
Past Medical History:
1. COPD
2. Anxiety
3. Depression
4. Bilat carpal tunnel s/p release
5. seizure d/o
6. hiatal hernia
7. left radical mastectomy
8. D&C
9. GERD(?)
10. vertigo
11. TKR [**2104-6-9**]
12. ETT [**2100**] - negative
13. Dobutamine Echo [**5-/2104**] - normal augmentation, 2mm ST dep
Social History:
>30 pack year smoker
No etoh, illicit drug use.
Lives alone. has assistance with ADL's
Family History:
f: d. MI
s: d. lung ca
Physical Exam:
97.5 110-140/60-70, 134/72, 80-100, 88, 24, 100% 2L
general: sitting up in bed, alert, appropriate
heent: eomi, mmm
heart: rrr loud systolic murmur heard thru-out, loudest at LLHB
lungs: mild crackles throughout
abd: soft nontender nondistended
Ext: trace pitting edema, DP/PT 2 bilaterally, left knee with
healing surgical incision, staples now removed
neuro: non focal
OB positive stool
Pertinent Results:
[**2104-6-22**] 11:00PM CK-MB-NotDone cTropnT-0.13*
[**2104-6-22**] 04:04PM WBC-31.9* RBC-2.48*# HGB-7.8* HCT-22.3*#
MCV-90 MCH-31.5 MCHC-35.0 RDW-14.6
[**2104-6-22**] 04:04PM PT-12.6 PTT-28.7 INR(PT)-1.1
Brief Hospital Course:
GI: Ms. [**Known lastname 106373**] had intermittent bleeding from a duodenal ulcer.
She was placed on telemetry and on [**Hospital1 **] protonix and her
hematocrit was followed several times per day. She underwent 3
endoscopies in an effort to secure hemostasis. However, her
ulcer was so large and had an adherent clot, that it was not
possible to properly determine what was under the clot or to
cauterize it. Her vitals remained stable despite having
continued bleeding evidenced by several OB positive stools and
hematocrits that fell to 25. Although she was transfused 6 units
over a 3 day period, it was felt that her [**Hospital1 4532**] and aspirin
could not be discontinued in light of her recent placement of
bare metal stent. When she developed subjective lightheadedness
and her pressures fell to systolic 90's she was transferred to
the MICU.
In the MICU she underwent a procedure with interventional
radiology to sclerose the bleeding duodenal vessel. Upon
transfer to the MICU, her [**Hospital1 4532**] and aspirin was stopped and she
was transfused more PRBCs to maintain her hematocrit above 30.
Pt then transfered to [**Hospital Unit Name 196**]. Her HCT was stable in the low 30s.
[**Hospital Unit Name **] and [**Hospital Unit Name **] resumed. Sulfacrate and high dose PPI resumed.
Musculoskeletal: She had a total knee replacement 2 weeks prior
to admission and was prophylaxed with lovenox which was
discontinued shortly before this hospitalization.
Pulmonary: Ms. [**Known lastname 106373**] has COPD and was admitted to this service
on oxygen via nasal cannula. She underwent a brief steroid
taper. Her dyspnea resolved with fluticase and albuterol
inhalers and nebulizer treatments. Her oxygen was weaned to room
air, which she tolerated well.
Upon [**Hospital Unit Name 196**] transfer, she had two episodes of SOB which responded
to both albuterol/atrovent as well as diuresis. She was
subsequently weaned off O2.
Cardiology: Ms. [**Known lastname 106373**] has CAD s/p stent placement which was
medically managed with [**Last Name (LF) 4532**], [**First Name3 (LF) **], statin, BB, and captopril.
Her BB and captopril were discontinued during her acute bleeds
and then restarted once she was stable.
Medications on Admission:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
7. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
8. Haloperidol 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed.
9. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Paroxetine HCl 10 mg Tablet Sig: 0.5 Tablet PO QOD (every
other day).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
13. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*0*
3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*0*
7. Haloperidol 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Paroxetine HCl 10 mg Tablet Sig: 0.5 Tablet PO QOD (every
other day).
Disp:*30 Tablet(s)* Refills:*2*
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*2*
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
15. Salmeterol Xinafoate 50 mcg/DOSE Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
Disp:*1 Disk with Device(s)* Refills:*2*
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
HS (at bedtime).
Disp:*q/s 1 mo 1* Refills:*2*
19. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
GI bleed
total knee replacement
CAD
hypertension
hypercholesterolemia
depression
Discharge Condition:
good
Discharge Instructions:
Call your doctor if you feel dizzy, weak, notice black stools,
have bright red blood in your stool. You should also call if you
have chest pain, shortness of breath, or have leg swelling.
Followup Instructions:
On [**2104-7-7**], at the rehab facility, have the doctors [**Name5 (PTitle) 4169**] your
[**Name5 (PTitle) **], potassium, and hematocrit.
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Where: [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[**2104-7-16**] 12:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2104-8-29**] 12:30
ICD9 Codes: 2851, 496, 4280, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3979
} | Medical Text: Admission Date: [**2198-10-31**] Discharge Date: [**2198-11-7**]
Date of Birth: [**2120-8-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
1. Colonoscopy x 2
History of Present Illness:
This is a 78-year-old woman who presents with two days of rectal
bleeding. She had a colonoscopy with polypectomy on [**2198-10-25**].
The polyp was a 4 cm distal transverse [**Date Range 499**] polyp on a stalk
that was completely removed using a single-piece polypectomy
with a hot snare (path = adenoma, completely excised). She was
also noted to have mild diverticulosis of the transverse [**Date Range 499**]
as well as small internal hemorrhoids. She has actually had
small amounts of red blood following straining and passage of
firm stool over the past few months. Following her colonoscopy
six days ago, she noticed again a small amount of red blood
passing with each loose stool ([**12-24**] BMs/day, small volume,
painless). She has not had any melena, fevers, chills,
abdominal pain, nausea, or vomiting. She has not had any
lightheadedness, or syncope. Over the past two days, she has
had two episodes of larger amounts of hematochezia that turn the
toilet bowel red. She has not used any aspirin or non-steroidal
anti-inflammatory medications.
In the Emergency Department, she was hemodynamically stable with
a HR of 78 and a BP of 140/77. Her rectal exam was notable for
red blood.
Past Medical History:
Diverticulosis
History of [**Month/Day (3) 499**] adenomas
Grade I internal hemorrhoids
Adrenal insufficiency
S/p adrenal tumor resection 30 years ago ?
Social History:
She lives alone. She does not smoke or drink alcohol.
Family History:
Her brother had [**Name2 (NI) 499**] cancer diagnosed in his 70's.
Physical Exam:
VITALS: T 96.6, HR 75, BP 159/92, RR 18, O2 sat 98 RA
GEN: Well-appearing, thin female. No acute distress.
HEENT: Anicteric sclera. Supple neck. No cervical or
supraclavicular lymphadenopathy. Clear oropharynx.
CV: RRR. ? Faint systolic murmur at the apex.
LUNGS: CTAB.
ABD: Soft. Normal bowel sounds. Nontender. Nondistended. ? CCY
scar. Very little abdominal wall fat. Mildly protuberant
abdomen that protrudes slightly to the left. Easily palpable
aortic impulse which does not feel enlarged or diffuse.
EXT: Trace bilateral pedal edema R>L.
SKIN: No rashes and no jaundice.
NEURO: Alert & oriented. Grossly non-focal exam.
Pertinent Results:
Admit labs:
[**2198-10-31**] 04:00PM WBC-6.2 RBC-3.08* HGB-10.0* HCT-28.8* MCV-93
MCH-32.4* MCHC-34.7 RDW-14.4
[**2198-10-31**] 04:00PM NEUTS-77.7* LYMPHS-18.1 MONOS-3.2 EOS-0.8
BASOS-0.2
[**2198-10-31**] 04:00PM PLT COUNT-349
[**2198-10-31**] 04:00PM PT-12.3 PTT-30.0 INR(PT)-1.0
[**2198-10-31**] 04:00PM GLUCOSE-113* UREA N-22* CREAT-0.7 SODIUM-134
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-30 ANION GAP-11
[**2198-10-31**] 04:00PM ALT(SGPT)-21 AST(SGOT)-24 ALK PHOS-53
AMYLASE-128* TOT BILI-0.4
.
Dishcarge labs:
[**2198-11-7**] 10:30AM BLOOD WBC-8.2 RBC-3.65* Hgb-11.4* Hct-34.0*
MCV-93 MCH-31.2 MCHC-33.5 RDW-16.2* Plt Ct-369
[**2198-11-7**] 10:30AM BLOOD Plt Ct-369
[**2198-11-7**] 07:45AM BLOOD Glucose-86 UreaN-8 Creat-0.6 Na-137 K-3.9
Cl-100 HCO3-29 AnGap-12
[**2198-11-7**] 07:45AM BLOOD Mg-1.9
Please see OMR for details of multiple colonoscopies, angio,
bleeding studies
Brief Hospital Course:
This is a 78-year-old woman who presents with hematochezia six
days after colonoscopy with a polypectomy(done [**10-25**]).
GI bleed: Patient admitted to floor transiently on [**10-31**].
Patient had syncopal episode with crit drop and transferred to
ICU. Given 3 units pRBC's and colonoscopy on [**11-1**].
Demonstrated significant clots, no clear bleeding source. Angio
done [**11-1**] negative. Patient transferred to floor [**11-2**] evening
with stable crits. Began having recurrent hematochezia
[**Date range (1) 18319**] with stable CBC. Bleeding scan [**11-5**] negative.
REpeat colonoscopy on [**11-6**] with clipping to polypectomy site,
stigmata of recent bleeding. Patient discharged on
[**11-7**]-tolerated full diet, no further hematochezia, crit stable,
hemodynamically stable. Patient instructed to follow up with
her PCP for crit check late this week.
Endocrine: Patient with history of pheo s/p resection, adrenal
insufficiency and hypothyroidism. Patient on stress dose
steroids in ICU in setting GI bleed. Transitioned back to
outpatient PO regimen of hydrocortisone and fludrocortisone with
stabilization of hematocrit. Maintained on levothyroxine
outpatient dosing
Hypertension: On labetelol as outpatient. Held in setting of GI
bleeding. BP gradually increased to systolics in 160's-170's by
[**11-5**] but very labile and on [**2203-11-8**] generally 130's to
140's. Labetelol not re-started. Patient will see her primary
care doctor before re-starting labetelol
Hypokalemia: Repleted throughout. 3.9 on day of discharge.
Social: Paitent expressed decision to transition to [**Hospital 4382**]. Provided resources by case management and social work
to assist with this.
Medications on Admission:
Florinef 0.1 mg daily
Cortisone 12.5 mg [**Hospital1 **]
Synthroid 100 mcg daily
Labetolol 200 mg [**Hospital1 **]
Discharge Medications:
1. Hydrocortisone 5 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Outpatient Lab Work
CBC to be checked [**11-8**]. Results to Dr. [**Last Name (STitle) 40323**] at [**Hospital1 **]. Hematocrit 34 on [**11-6**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Gi bleeding
2.Acute blood loss anemia
Secondary:
1. Adrenal insufficiency
2. Hypothyroidism
3. Hypertension
Discharge Condition:
Stable, HD stable, hematocrit stable, tolerating PO's,
ambulating
Discharge Instructions:
follow up as below
all medications as prescribed. you should take all the
medications you were taken before admission except for your
labetolol for blood pressure. Hold this medication until you
are seen by Dr. [**Last Name (STitle) 40323**].
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 40323**] on Friday as scheduled. You should
have a 'CBC' checked when you see Dr. [**Last Name (STitle) 40323**]. This is to make
sure you are not still bleeding. I have given you a prescription
for this. Your hmatocrit is 34 on discharge.
You alos have the following previously scheduled
appointment:Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2199-8-1**] 2:45
ICD9 Codes: 2851, 2768, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3980
} | Medical Text: Admission Date: [**2121-10-20**] Discharge Date: [**2121-10-27**]
Date of Birth: [**2055-8-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine Containing Agents Classifier
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain with activity
Major Surgical or Invasive Procedure:
coronary rtery bypass grafts x3(LIMA-LAD,SVG-OM,DVG-DG) [**2121-10-23**]
Reoperation for bleeding [**2121-10-23**]
closed right thoracostomy [**2121-10-24**]
History of Present Illness:
66 year old male has a history of
carotid artery disease s/p left endarterectomy in [**2117**]. He is
normally very active with karate three times a week but recently
he has noticed episodes of exertional chest aching with moderate
levels of activity. He has even had one episode that woke him
from sleep, described as a mild chest pain that radiated to the
back, resolving with one SL nitroglycerin. He is now referred
for
cardiac catheterization to further evaluate. He is now referred
to cardiac surgery for revascularization.
Past Medical History:
Hyperlipidemia
Hypertension
Hx of TIA's
Carotid stenosis s/p left endarterectomy in [**2118-4-19**]
Asthma
Cyclothymic Disorder, patient reports this is not currently an
active issue
Sleep apnea- CPAP
BPH per outside records (patient denies)
Bilateral rotator cuff repair
Right hand trigger finger, s/p cortisone injection
Right arm fracture s/p surgery
Social History:
Lives with:wife
Occupation: [**Name2 (NI) **]
Tobacco:quit 36 years ago
ETOH:[**12-21**] glasses of wine/night
Family History:
Mother CABG
Physical Exam:
Pulse:67 Resp:16 O2 sat:100&/RA
B/P Right:142/80 Left:135/88
Height: 6' Weight:255 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] L CEA incision
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: dressing Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0 incision
Pertinent Results:
[**2121-10-26**] 04:18AM BLOOD WBC-6.9 RBC-2.91* Hgb-9.1* Hct-25.7*
MCV-88 MCH-31.5 MCHC-35.6* RDW-14.4 Plt Ct-114*
[**2121-10-25**] 08:30PM BLOOD WBC-7.8 RBC-2.93* Hgb-9.2* Hct-25.8*
MCV-88 MCH-31.3 MCHC-35.6* RDW-14.4 Plt Ct-103*
[**2121-10-23**] 11:19PM BLOOD PT-15.0* PTT-30.0 INR(PT)-1.3*
[**2121-10-27**] 05:50AM BLOOD Na-136 K-4.1 Cl-99
[**2121-10-26**] 04:18AM BLOOD Glucose-101* UreaN-20 Creat-0.8 Na-133
K-3.6 Cl-96 HCO3-30 AnGap-11
[**2121-10-25**] 03:34AM BLOOD Glucose-109* UreaN-19 Creat-0.8 Na-132*
K-4.0 Cl-99 HCO3-28 AnGap-9
Intra-op echo [**2121-10-23**]
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. Turbulence on color flow Doppler and an
increased velocity (`2 m/sec) by Doppler were demonstrated in
the pulmonary artery however a PDA was NOT visualized by TEE or
epi-aortic scanning.
POSTBYPASS
There is preserved biventricular systolic function. The study is
otherwise unchanged from prebypass. Elevated PA velocities
remain.
Brief Hospital Course:
The patient was brought to the operating room on [**2121-10-23**] where
the patient underwent CABG x 3. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
He did return to the operating room within hours of arrival to
the CVICU for re-exploration for bleeding. He was loaded with
Plavix 3 days preop. Hemostasis was achieved and the patient
returned to [**Location 42137**]. Vancomycin was used for surgical antibiotic
prophylaxis, given his preoperative length of stay of greater
than 24 hours.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. His chest tubes were discontinued and he
did develop right sided pneumothorax. Bedside tube thoracostomy
was performed, and the right lung re-expanded. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. He had a tiny
right sided pneumothorax on CXR, which was stable at the time of
discharge. He also developed a brief burst of atrial
fibrillation which converted to sinus rhythm with lopressor.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4, the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to home in good condition with
appropriate follow up instructions.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - (Prescribed by Other Provider)
- 90 mcg HFA Aerosol Inhaler - 1 puff as needed
FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) -
Dosage uncertain
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth every morning
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth every
morning
LISINOPRIL - (Prescribed by Other Provider) - 30 mg Tablet - 1
Tablet(s) by mouth every morning
LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth as needed for anxiety
NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet,
Sublingual - 1 Tablet(s) sublingually every five minutes for
chest discomfort. Call 911 if pain persists longer than 15
minutes
ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth every morning
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth every morning
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- Dosage uncertain
ZINC-PUMPKIN SEED OIL-SAW PALM [SAW [**Location (un) **] COMPLEX(PUMK& ZN)]
-
(Prescribed by Other Provider) - Dosage uncertain
Discharge Medications:
1. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO TID (3 times a day)
for 1 weeks.
Disp:*21 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day: **Resume [**2121-11-4**], after lasix is finished**.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Corornary artery disease
s/p coronary artery bypass grafts
hypertension
obstructive sleep apnea
obesity
hyperlipidemia
s/p left carotid endarterectomy
asthma
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema: 2+ bilaterally
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) 914**] on Date/Time:[**2121-11-18**] 2:00 [**Telephone/Fax (1) 170**]
Cardiologist: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2121-12-18**] 3:40
Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35852**] ([**Telephone/Fax (1) 34088**]) in [**3-24**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2121-10-27**]
ICD9 Codes: 4111, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3981
} | Medical Text: Admission Date: [**2148-5-20**] Discharge Date: [**2148-5-30**]
Date of Birth: [**2067-6-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2148-5-22**] Aortic valve replacement(#25mm St. [**Male First Name (un) 923**] Epic porcine
valve)
[**2148-5-20**] Cardiac Cath
History of Present Illness:
80 yo female followed by serial echos for aortic stenosis and
worsening symptoms in past 2 years.
Past Medical History:
Aortic Stenosis
Coronary artery disease
Chronic obstructive pulmonary disease
stage I lung CA ( resection [**2141**])
obesity
metabolic syndrome
osteoarthritis
hypothyroidism
skin CA
psoriasis
s/p left upper lobectomy [**2141**]
s/p LUL wedge resection [**2138**]
s/p Tonsillectomy
s/p total abdominal hysterectomy
s/p cholecystectomy
s/p bilat. hand surgs.
s/p bilat. cataract surgs.
s/p bladder suspensions
s/p left knee surgery
Social History:
retired ICU unit clerk
Last Dental Exam: 6 months ago
Lives alone ( daughter nearby) [**Name2 (NI) **]: Caucasian
Tobacco: 120 pack/yrs; quit 2 years ago ETOH:none
Family History:
sister with CABG in her 40's
mother with CAD in her 70's
Physical Exam:
Pulse:80 reg. Resp: O2 sat:
B/P Right: 148/74 Left: 138/68
Height: 5' 3 [**1-17**]" Weight: 188 #
General:obese
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
left pupil 1mm greater than right (prior eye [**Doctor First Name **])
anicteric sclera;OP teeth in fair repair
Neck: Supple [x] Full ROM [] no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: 4/6 systolic murmur
radiates throughout precordium and into carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
obese; well-healed abd scars;
fungal erythematous areas both groin creases
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x] chronic venous stasis changes in BLE with
petechiae noted above ankles to feet
Neuro: Grossly intact, non-focal exam; MAE except RUE with 5/5
strengths; RUE [**2-18**] strengths ( multiple wrist ortho issues)
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 : murmur radiates bilat to carotids
Pertinent Results:
[**5-20**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis <40%
[**2148-5-22**] Echo: Pre-CPB: No spontaneous echo contrast is seen in
the left atrial appendage. Overall left ventricular systolic
function is low normal (LVEF 50-55%). with mild global free wall
hypokinesis. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are severely thickened/deformed. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
Post-CPB: The patient is AV-Paced, on low dose phenylephrine.
There is a well-seated prosthetic aortic valve with no leak and
no AI. The MR is mild. No [**Male First Name (un) **]. The aorta is intact. Dr
[**Last Name (STitle) **] present and aware. Other parameters are as
pre-bypass
[**5-22**] Ct of head: 1. Unremarkable head CT, without evidence of an
acute infarct. 2. Unremarkable CTA of the head, without evidence
of a hemodynamically significant stenosis or aneurysm. 3.
Unremarkable CTA of the vessels of the neck, without evidence of
a hemodynamically significant stenosis or dissection. 4.
Extensive postoperative changes as detailed above, including
pneumomediastinum, small right pneumothorax, subcutaneous
emphysema which extends into the neck, and lines and tubes as
described above.
Brief Hospital Course:
[**5-22**] Ms.[**Known lastname 32859**] was taken to the operating room and underwent
Aortic Valve Replacement (#25mm St.[**Male First Name (un) 923**] Epic Porcine Valve).
Cross Clamp Time=83 minutes. Cardiopulmonary Bypass Time=94
minutes. Please refer to Dr[**Doctor Last Name **] operative report for
further details. She tolerated the procedure well and was
transferred to the CVICU in critical but stable condition
requiring Neo for optimal blood pressure support. She awoke
neurologically intact and was extubated in a timely fashion.
Following extubation, she was unable to move her right side, and
unable to withdraw to pain. Neurology was consulted. Head and
neck CTA scan performed which showed no evidence of any acute
changes. Ms.[**Known lastname 32860**] ability to move her right side improved and
her deficit resolved completely. All drips were weaned to off.
Lines and drains were discontinued in a timely fashion.
Beta-blocker and diuresis initiated. She continued to progress
and on POD# 2 she transferred to the step down unit for further
monitoring. Physical therapy consulted and evaluated her. She
was gently diuresed towards her preoperative weight. The
hematology service was consulted for evaluation for leukocytosis
as there was no evidence of infection. Work-up was unremarkable
and a follow-up appointment was scheduled. The remainder of her
postoperative course was essentially uneventful and on POD# 8
she was cleared for discharge to rehab. All follow up
appointments were advised.
Medications on Admission:
cardizem CD 120 mg daily, L-thyroxine 137 mcg daily, relafen
1000 mg daily, zetia 10 mg daily, fentanyl patch 100mcg q 72
hours, fosamax + D 70 mg Q SUN, detrol LA 4 mg daily, ASA 81 mg
daily, glucosamine 1500 mg/chondroitin 1000 mg [**Hospital1 **], lisinopril
2.5 mg daily, fish oil 1200 mg [**Hospital1 **], calcium 500mg + D [**Hospital1 **], MVI
daily, Vit. B 12 1000mg daily, spiriva IH daily, advair 150/50
mcg IH [**Hospital1 **], biotin 1000 mg daily, quinine 300 mg prn leg cramps,
lidoderm patch 750 mg prn pain, tylox 5/500 mg prn q6 hrs pain
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
3. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: for breakthrough pain.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to back.
11. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: Take with potassium daily for 7 days then stop.
15. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO BID
PRN () as needed for leg pain.
16. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic valve replacement
Coronary artery disease
Chronic obstructive pulmonary disease
stage I lung CA ( resection [**2141**])
obesity
metabolic syndrome
osteoarthritis
hypothyroidism
skin CA
psoriasis
s/p left upper lobectomy [**2141**]
s/p LUL wedge resection [**2138**]
s/p Tonsillectomy
s/p total abdominal hysterectomy
s/p cholecystectomy
s/p bilat. hand surgs.
s/p bilat. cataract surgs.
s/p bladder suspensions
s/p left knee surgery
Discharge Condition:
Good
Discharge Instructions:
1) No lotions, creams, powders or ointments to incision
2) No driving for one month
3) No lifting greater than 10 pounds for 10 weeks
4) Please call for fever greater than 100, redness or drainage
from wound.
5) Please call for weight gain of 2 pounds in 2 days or 5 pounds
in one week.
6) shower daily and pat incison dry; no baths or swimming for 5
weeks.
7) take lasix with potassium for 1 week then reevaluate. Monitor
and replete elctrolytes as needed.
8) Call with any questions or concerns
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks, please call for appointment [**Telephone/Fax (1) **]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] in [**12-19**] weeks
Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in [**11-17**] weeks
Please call all providers for appointments.
Scheduled appointments:
Provider: [**First Name8 (NamePattern2) 25**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2148-7-25**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2148-7-25**] 1:30
*****please check WBC at rehab Friday [**5-31**] and Monday Julay 20
and call results to Dr.[**Name (NI) 11272**] office 617-632-
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2148-5-30**]
ICD9 Codes: 4241, 2851, 4280, 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3982
} | Medical Text: Admission Date: [**2173-8-26**] Discharge Date: [**2173-9-7**]
Date of Birth: [**2101-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
chest pain.
Major Surgical or Invasive Procedure:
[**2173-8-30**] - CABG x 3(LIMA->LAD, SVG->OM, RCA)
History of Present Illness:
72yoM with h/o CAD s/p recent stenting x 2 to LAD ([**2173-8-11**]), and
recent admission to [**Hospital1 18**] (discharged [**2173-8-25**]) for intermittent
chest/abdominal pain anorexia and fatigue, at which time he
ruled out for MI (please refer to discharge summary for details
of this admission). Hospital course was complicated by ARF
(likely due to dehydration and medications), guaiac positive
stool with hct drop (?gastritis - LFTs nl, abd u/s nl, endoscopy
planned as outpatient). His antihypertensive regimen was
optimized and he was switched to EC aspirin to prevent
medication-related gastritis prior to discharge.
A few hours after returning home, he ate some frozen pizza, then
began to feel diaphoretic. Soon after that he began to have
severe [**9-20**] chest pressure radiating to his jaw and the back of
his neck. This was similar to anginal pain that he has had
before, and if anything it was even more severe than the pain he
had prior to his recent stents. He then presented the following
day to an OSH with CP and SOB. He was found to be in rapid afib
with rate in 140s. He was started on cardizem drip and given
metoprolol 50mg [**Hospital1 **], heparin drip, aspirin, and plavix. He also
received IV nitroglycerin for CP. He was not completely CP free
until aruond 11pm when he had been on nitro gtt for some time.
Troponin was 4.9 at the OSH. According to the discharge summary,
the patient was in SR at the time of transfer. He was also
started on levoquin for a UTI.
Past Medical History:
CAD, s/p stents and angioplasty
GERD
PUD
Hyperlipidemia
Hypertension
Social History:
lives with wife.
Family History:
+CAD in family.
Physical Exam:
VS: 98.5, 170/74, 58, 18, 96% on RA
gen: NAD, resting comfortably
CV: RRR, nl s1/s2, III/VI systolic murmur at LUSB.
chest: CTA b/l, no crackles or wheezes
abd: soft, NT/ND, +bs, no organomegaly,
groin: cath site well healed. b/l 1+ femoral artery bruits.
extr: warm, dry, no c/c/e, 2+ radial and DP pulses b/l
neuro: a&ox3, grossly non-focal
Pertinent Results:
[**2173-8-30**] 05:40AM BLOOD WBC-11.2* RBC-3.43* Hgb-10.2* Hct-30.6*
MCV-89 MCH-29.8 MCHC-33.4 RDW-14.2 Plt Ct-457*
[**2173-8-27**] 05:40AM BLOOD Neuts-63.5 Lymphs-23.5 Monos-5.5 Eos-7.2*
Baso-0.3
[**2173-8-30**] 05:40AM BLOOD Plt Ct-457*
[**2173-8-30**] 05:40AM BLOOD PT-13.6* INR(PT)-1.2
[**2173-8-30**] 05:40AM BLOOD Glucose-94 UreaN-41* Creat-2.4* Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
[**2173-8-30**] 05:40AM BLOOD ALT-33 AST-20 LD(LDH)-157 AlkPhos-115
TotBili-0.5
[**2173-8-28**] 07:07AM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2173-8-27**] 10:45AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2173-8-26**] 09:30PM BLOOD CK-MB-NotDone cTropnT-0.17*
[**2173-8-30**] 05:40AM BLOOD Albumin-3.2*
[**2173-8-29**] 06:32AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.8
.
CXR: The heart, mediastinal and hilar contours are within normal
limits. Minimal blunting of the left costophrenic angle is noted
posteriorly. The lungs are clear without focal areas of
consolidation. The osseous structures are within normal limits
with the previously noted prominence of the left anterior 7th
rib no longer evident. IMPRESSION: No evidence of CHF or
pneumonia.
.
Coronary Angiogram (OSH, [**2173-8-11**]): severe 3VD; drug eluting
stent to 90% ramus lesion, 100% proximal RCA lesion, 60%
proximal LAD lesion; collateral filling of R PDA and PLB.
[**2173-9-7**] 06:05AM BLOOD WBC-16.1* RBC-3.86* Hgb-11.6* Hct-34.6*
MCV-90 MCH-30.0 MCHC-33.4 RDW-15.5 Plt Ct-629*
[**2173-9-7**] 06:05AM BLOOD Plt Ct-629*
[**2173-9-6**] 05:00PM BLOOD Glucose-158* UreaN-50* Creat-2.7* Na-139
K-4.6 Cl-102 HCO3-27 AnGap-15
[**2173-9-2**] 02:00AM BLOOD ALT-42* AST-36 LD(LDH)-310* AlkPhos-92
[**2173-9-2**] Renal Ultrasound
The right kidney measures 10 cm, with normal echogenicity,
without evidence of mass, stones, or hydronephrosis. The left
kidney measures 8.5 cm, and appears to be atrophic. Foley
catheter is noted.
[**2173-9-1**] Right upper quadrant Ultrasound
Normal son[**Name (NI) 493**] appearance of the gallbladder
[**2173-8-30**] EKG
Sinus rhythm with borderline short PR interval but with out
evidence of
ventricular pre-excitation
Otherwise normal ECG
Since previous tracing of [**2173-8-29**], probably no significant
change
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2173-8-26**] for further
management of his chest pain and rapid atrial fibrillation.
Diltiazem and beta blockade was used with good rate control.
Heparin was started for anticoagulation in addition to his
current plavix and aspirin use. Given his known severe coronary
artery disease, the cardiac surgical service was consulted for
surgical revascularization. Mr. [**Known lastname **] was worked-up in the
usual preoperative manner. Levofloxacin was started for a
urinary tract infection. Given his history of guaiac positive
stool and anemia, his hematocrit was watched closely and
remained stable. Although he had known, asymptomatic carotid
artery stenosis, it was decided to delay intervention until
after his surgical revascularization. On [**2173-8-30**], Mr. [**Known lastname **] was
taken to the operating room where he underwent coronary artery
bypass grafting to three vessels. Postoperatively he was taken
to the cardiac surgical intensive care unit for monitoring. On
postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. Beta blockade, aspirin and plavix were
resumed. He converted back into atrial fibrillation which was
rate controlled with beta blockade and the addition of
amiodarone. He was pancultured for leukocytosis which was
negative. The renal service was consulted for an elevated
creatinine. Urinary eosinophils were negative and a renal
ultrasound showed an atrophic left kidney. It was presumed that
he had acute tubular necrosis from bypass and that his
creatinine would likely recover. Mr. [**Known lastname **] was transfused for
postoperative anemia. As he remained in atrial fibrillation,
coumadin was started for anticoagulation. His pacing wires and
chest tubes were removed when protocol was met. His renal
function slowly improved. A right upper quadrant ultrasound was
performed for elevated liver enzymes and nausea which was
negative. On postoperative day five, Mr. [**Known lastname **] was transferred
to the cardiac surgical step down unit for further recovery. He
continued to be gently diuresed towards his preoperative weight.
The physical therapy service worked with him daily to help with
his postoperative strength and mobility. Mr. [**Known lastname **] continued to
make steady progress and was discharged home on postoperative
day eight. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist
and his primary care physician as an outpatient.
Medications on Admission:
Meds on discharge from [**Hospital1 18**]:
1. Nitroglycerin SL prn
2. Clopidogrel 75 mg daily
3. Nifedipine SR 30 mg daily
4. Hydralazine 50 mg Q6H
5. Nitroglycerin 0.2 mg/hr Patch q24HR
6. Pantoprazole 40 mg q12h
7. Metoprolol Tartrate 50 mg [**Hospital1 **]
8. Aspirin EC 81 mg daily
9. Sucralfate 1 g QID
10. Clonidine 0.2 mg/24 hr Patch Weekly
.
Meds on Transfer:
plavix 75
nifedipine SR 60
hydralazine 50 q8h
protonix 40 daily
metoprolol 50 [**Hospital1 **]
aspirin EC 81mg
sucralfate 1g QID
clonidine patch
morphine sulfate 2mg IV prn
levaquin 500mg daily
heparin gtt
cardizem gtt
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*150 Tablet(s)* Refills:*2*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 7 days: Then decrease dose to 200 mg PO daily .
Disp:*35 Tablet(s)* Refills:*0*
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: Take
as directed by Dr. [**Last Name (STitle) **] INR goal of [**1-13**].5.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Coronary artery disease.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not lift more than 10 lbs. for 2 months.
You should not drive for 4 weeks.
Do not use lotions, creams, or powders on wounds.
You should shower daily, let water flow over wounds, pat dry
with a towel.
Call our office for sternal drainage, temp>101.5.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
See Dr. [**Last Name (STitle) 39450**] on Wed. [**9-15**] @ 11AM. Office# is: [**2173**]
Make an appointment with Dr. [**Telephone/Fax (1) 39451**]
Completed by:[**2173-9-8**]
ICD9 Codes: 5845, 496, 5990, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3983
} | Medical Text: Admission Date: [**2103-3-7**] Discharge Date: [**2103-3-13**]
Service: SURGERY
Allergies:
Codeine / Aspirin / Ibuprofen / Lipitor / Crestor
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
fall down stairs, syncope
Major Surgical or Invasive Procedure:
Paravertebral block by Acute Pain Service
History of Present Illness:
This is a [**Age over 90 **] y/o F, with h/o previous C7 vertebral body
compression fx last year after a syncopal event while
defecating, who presents to [**Hospital1 18**] ED after falling down flight
of stairs today. Pt was carrying laundry up a flight of stairs
and fell when she had a syncopal event. Pt aroused at bottom of
stairs and called for help. At presentation she complained of
right sided back pain. She had head, c-spine, and torso CT scan
which showed multiple right sided rib fractures. Pt does have
chronic neck pain after compression fx last year. She wears a
neck brace as needed at night for comfort. She currently denies
neck pain, headache, abdominal pain or distension, and
additionally denies any chest pain or SOB or palpitations prior
to the fall.
Past Medical History:
PMH:
1. A-fib
2. Type II DM
3. Hx of PE 20 yrs ago
4. Hyperlipidemia
5. Osteoporosis
6. Osteoarthritis
7. Anxiety
8. C7 compression fracture s/p fall
PSH: None
Social History:
Patient lives at home, engages in water aerobics everyday,
denies use of tobacco, alcohol, or IV drug use
Family History:
Father died from MI at age 50
Brother died from MI at age 37
Physical Exam:
At discharge
VS: Afebrile, VSS
96.2 87 158/82 16 98%2L
Constitutional: Well appearing, no acute distress
Neck: No masses
CV: RRR, no murmurs.
Resp: CTAB, no wheezes or crackles, IS 300. + TTP R ant/post
chest. No crepitus.
Abd: Soft, no TTP, nondistended, +BS
Ext: Warm, distal pulses palpable bilaterally
Skin: Face, neck and chest is normal
Musculoskeletal: Normal to gait and station
Spine, Pelvis and Extremities: Stable
Psychiatric: Normal to judgment, insight, memory, mood and
affect
Pertinent Results:
[**2103-3-7**]
Lactate:3.8
UA negative
132 95 22 AGap=19
-------------328
4.8 23 0.8
CK: 270 MB: 5 Trop-T: <0.01
ALT: 70 AP: 55 Tbili: 0.7 Alb:
AST: 102 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
Dig: 0.7
13.0
15.4 ----- 165
39.1
N:91 Band:5 L:2 M:2 E:0 Bas:0
Poiklo: OCCASIONAL Ovalocy: OCCASIONAL
PT: 24.8 PTT: 24.5 INR: 2.4
.
[**2103-3-7**] Carotid Duplex: 60-69% stenosis of L ICA, 40-59%
stenosis of R ICA
.
[**2103-3-6**] CT head: no acute intracranial process
.
[**2103-3-6**] CT c-spine: interval C7 vertebral body height loss new
since prior but could represent
.
[**2103-3-6**] CT abd/pelvis: 1. Multiple acute right rib fractures
without evidence of flail chest or
segmental fractures.
2. Asymmetric pulmonary edema, right greater than left, with
trace right
pleural effusion and bibasilar atelectasis.
3. 1.5 cm left lower lobe pulmonary nodule, not included in the
field of view
of the prior study. If clinically indicated, a three-month
followup is
recommended.
4. Unchanged left adnexal cyst.
Brief Hospital Course:
The patient was admitted to the trauma surgery service on
[**2103-3-7**] after a syncopal episode causing a fall down stairs
resulting in multiple broken ribs, but no other injuries.
Neuro: Pain control was [**Last Name **] problem for this patient during her
hospitalization and the acute pain service was consulted to
provide recommendations to better manage the patient's rib pain.
She initially received IV pain medicaions, including a PCA, and
also had a paravertebral block performed by APS. When tolerating
oral intake, the patient was transitioned to oral pain
medications, on a regimen including neurontin, lidoderm patch,
standing tylenol, tramadol and dilaudid for break-through pain,
with fair pain control. The pt also underwent carotid duplex
ultrasound in the evaluation for syncope, which showed 60-69%
stenosis of L ICA, 40-59% stenosis of R ICA. She will follow up
with vascular surgery in 6 months for this, but this is not
likely the cause of her syncope.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. She was kept on telemetry
which was reassuring. ECG on admission was not thought to be
consistent with STEMI. Additionally, cardiac enzymes were
negative x 1. Vital signs were routinely monitored and were
stable. She needs follow up with her regular doctor, as she may
need an echo or holter monitoring as an out-patient.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. She did require 2L of O2
nasal cannula at discharge, this was thought to be due to poor
deep breathing [**2-20**] mild persistent rib pain. Chest xrays did not
reveal any pneumonia or fluid overload. The pt did have a 1.5 cm
left lower lobe pulmonary nodule noted on CT chest. She will
need follow up by her regular doctor, likely with repeat CT
chest to eval for interval change.
GI/GU: At admission, the patient was resuscitated with IV fluids
until tolerating oral intake. Her diet was advanced when
appropriate, which was tolerated well. She was also started on a
bowel regimen to encourage bowel movement. Foley was removed on
HD#2. Intake and output were closely monitored and were normal.
She did have some episodes of incontinence.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible with PT.
At the time of discharge on HD#7, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
working with PT, voiding without assistance, and pain was fairly
well controlled.
Medications on Admission:
Digoxin 250 mcg 6 out of 7 days of the week, Zetia 10',
Lisinopril 5', Toprol XL 25', Coumadin, Vitamin C, Vitamin D,
MVI
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO 6X/WEEK
([**Doctor First Name **],MO,TU,WE,TH,FR).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q12 (): 12 hours with
patch on, 12 hours with patch off.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO every [**4-24**]
hours as needed for pain for 30 days: Hold for sedation, RR <
12.
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain for 30 days: Do not exceed
more than 4g tylenol daily.
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 30 days: Hold for sedation.
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 2.5 Tablet Sustained Release 24 hrs PO DAILY (Daily): Hold
for SBP < 100 and HR < 60 .
14. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day)
for 30 days.
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
Disp:*120 neb* Refills:*0*
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation for 10
days.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **]
Discharge Diagnosis:
Primary: 1) fall (trauma), 2) syncope, 3) right posterior [**7-28**]
rib fractures, 4) right anterior 6th rib fx
Secondary: 1) atrial fibrillation, 2) Osteoporosis, 3) diabetes
mellitus II, 4) PE 20 years ago, 5) previous C7 fx
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
*You were admitted to [**Hospital1 18**] to the trauma service after a fall
due to losing consciousness.
*You were found to have 5 rib fractures on CT scan. The most
important treatment for this kind of fracture is pain control to
optimize deep breathing. There is no surgery or brace for
support that is recommended. Optimization of pain control is
imperative because splinting (weak breathing due to pain) can
result in pneumonia.
* You should expect to have rib pain for 4-6 weeks from your
injury until your ribs have begun to heal. Please continue to
take the pain medication prescribed until then. Please also
continue to use the incentive spirometer (breathing machine) 10
times per hour in order to keep your lungs adequately inflated
(like a balloon).
* You had CT scan of your head, neck, abdomen and pelvis which
revealed no other injuries. CT scan of the chest did show a
small nodule in your left lung. You should follow up with your
regular doctor to discuss imaging the lung in several months
evaluate for growth.
* In evaluation for your loss of consciousness, we did blood
tests that look at heart strain or decreased blood flow
(troponins) which were normal. Additionally you were kept on
telemetry (continuous heart monitoring) which was reassuring.
Finally, you underwent an ultrasound study of your carotids,
which showed some degree of narrowing but not narrowing
significant enough to have caused your syncopal episodes. You
need to follow up with vascular surgery Dr. [**Last Name (STitle) 1391**] in 6 months
for this. You may also need additional evaluation for heart
monitoring, and should follow up with your regular doctor to
discuss this.
Please call your doctor, talk to your doctor at rehab or return
to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, chest pain, cough, shortness of
breath, or anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Call Dr.[**Name (NI) 1392**] office for a follow up appointment in 6
months, tell them that you will need carotid ultrasound prior to
appointment.
Phone: [**Telephone/Fax (1) 1393**].
Please also follow up with Dr. [**Last Name (STitle) 853**] in [**2-21**] weeks. Call ([**Telephone/Fax (1) 1394**] for an appointment.
Please let your regular doctor know about this hospitalization
and follow up with him or her in [**1-20**] weeks. You may need
additional monitoring of your heart rhythm.
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3984
} | Medical Text: Admission Date: [**2107-11-13**] Discharge Date: [**2107-12-2**]
Date of Birth: [**2030-5-5**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 77 year old female
with a history of asthma who presented with acute shortness
of breath. She was not relieved with home MDI and so was
brought to the Emergency Department by EMS on 100%
non-rebreather. In the Emergency Department, the patient was
Solu-Medrol and subcutaneous epinephrine. Arterial blood
gases suggestive of hypercarbia failure and prompted led to
intubation and a Medical Intensive Care Unit admission.
The patient was intubated successfully, but was not sedated
enough, so she began to be active, causing the tube to slip
from the cord into the esophagus. A second intubation was
treated with fluids and pressors. Upright chest x-ray was
ordered because she had increased abdominal distention. The
upright chest x-ray showed free air which was not initially
noted. She developed abdominal distention and a KUB was
performed which revealed free air. In the interum she had
become hypotensive requiring pressor support and her
ventilation became difficult. Her pH fell to 6.99. Surgery w
as
consulted. The patient was quickly ressussitated with 3L of IV
fluid and no longer required pressors. She was was taken
emergently open laparotomy which revealed free air but no
site of perforation. There was no fluid or fibrinous exudate.
The laparotomy was completely negative except for the free air
.
She was then empirically treated with Ampicillin, Ceftriaxone
and Flagyl for one week. While in the SICU, the patient was
aggressively treated with steroids and nebulizers. On
[**2107-11-16**], the patient developed atrial fibrillation
and was treated with Amiodarone and Tylenol for rate control.
The patient was diuresed in the SICU and restarted on Zosyn
and Vancomycin on [**2107-11-18**] for leukocytosis.
Cardiology was consulted who agreed with the current atrial
fibrillation management. In actuality, the patient did not
receive more than a day dose of Zosyn and Vancomycin. She
was then slowly diuresed over the next few days.
The patient also received a hydrocortisone taper from [**11-18**]
until [**2107-11-20**]. Pulmonary was consulted and found the
patient to have increasing wheezes and recommended starting
steroids. At this time, the patient was then transferred to
the Medical Intensive Care Unit on [**2107-11-24**].
PAST MEDICAL HISTORY:
1. Asthma, non-steroid dependent and no prior intubations.
2. Hypertension.
3. Hypercholesterolemia.
4. Degenerative joint disease.
MEDICATIONS AT HOME:
1. Naproxen.
2. Flovent.
3. Accolade.
4. Zestril.
5. Fosamax.
6. Albuterol p.r.n.
ALLERGIES: None.
SOCIAL HISTORY: The patient lives at home with her son in
[**Name (NI) **].
PHYSICAL EXAMINATION: Upon admission, the patient's vital
signs were pulse of 139, blood pressure 117/56; respiratory
rate 35; 97% saturation on two liters nasal cannula and
Heliox. In general, the patient was in marked respiratory
distress with the use of accessory muscles. HEENT: Pupils
are equal, round and reactive to light. Extraocular muscles
are intact. Oropharynx is clear. Pulmonary was with
diffuse wheezes bilaterally. Cardiovascular is tachycardic,
no appreciable murmurs noted. Abdomen was soft and
nontender, nondistended, with normoactive bowel sounds.
Extremities with trace pitting edema in the lower extremities
bilaterally. No clubbing or cyanosis noted. Two plus radial
pulse and one plus dorsalis pedis bilaterally.
Neurologically: The patient is alert and oriented times
three.
PHYSICAL EXAMINATION: Upon transfer is temperature of 98.6
F.; blood pressure 133/45; pulse 78; respiratory rate 25,
ventilator setting of pressure support 15 with PEEP of 7.5
and 40% FIO2 with pooling and total volumes of 400 to 700.
Vent setting was 7.44 for pH, 44 for carbon dioxide and 256
for pO2. The patient was on a Lasix drip of 1.5 mg an hour.
Generally, she was resting comfortably, intubated, sleepy but
arousable. HEENT: Endotracheal tube in place. Mucous
membranes were moist. Sclerae nonicteric. Pupils are equal,
round, and reactive to light and accommodation. Extraocular
muscles are intact. Neck supple; jugular venous pressure of
9 centimeters. Cardiovascular: Regular rate and rhythm with
a II/VI systolic ejection murmur. Lungs with decreased
breath sounds at the bases with occasional wheezes. Abdomen:
Surgical site with staples that are clean, dry and intact.
Abdomen is soft, nontender, nondistended, with positive bowel
sounds with no hepatosplenomegaly. Extremities with diffuse
edema in all extremities with two plus pulses times four. No
rashes noted. Neurological: Moving all four extremities.
Line at left IJ site.
LABORATORY: Upon admission, white blood cell count 23.0,
hematocrit 33.8, platelets 408, white count differential was
56% neutrophils, 29% lymphocytes, 3% monocytes, 11%
eosinophils. Sodium 146, potassium 5.2, chloride 109,
bicarbonate 21, BUN 31, creatinine 1.6. Glucose 147.
Chest x-ray showed no acute air space disease.
EKG is narrow complex, tachycardia in the 130s with shaky at
baseline making it hard to interpret.
Her labs upon transfer were sodium of 147, potassium 3.6,
chloride 107, bicarbonate 28, BUN 48, creatinine 1.7, glucose
132, white blood cell count 37.4, down from 21.6 day prior to
transfer. Hematocrit 25.8, 294 for platelets, sedimentation
rate was 10, amylase 232, lipase 6, LDH 346, lactate 1.6,
free calcium 1.15. CK was 81 on [**11-23**] on [**11-22**] and 68 on
[**11-22**].
Urinalysis on [**11-13**] showed no protein, blood or nitrites.
As far as Microbiology on transfer, [**2107-11-13**], blood, urine
and sputum cultures were negative. On [**2107-11-16**] Methicillin
resistant Staphylococcus aureus screening from sputum was
positive. On [**11-21**] and [**2107-11-23**], the sputum showed
moderate coagulase positive, moderate Gram negative rods,
moderate yeast. On [**2107-11-23**], the blood cultures showed one
out of four Gram positive cocci. On [**11-23**], catheter tip
cultures and Clostridium difficile are pending.
HOSPITAL COURSE:
1. PULMONARY: The patient is quite difficult to wean
secondary to volume overload and a sepsis that was later
found. In regards to her pulmonary edema, the patient was
diuresed with a goal of negative 1.5 to 2 liters a day.
However, even at a Lasix drip of 7 mg an hour, the patient is
only being able to diurese at most 100 cc. Negative per day.
We will not aggressively diurese her until her bacteremia is
partially resolved.
In regards to her asthma, the patient was put on Solu-Medrol
taper of 30 mg intravenously three times a day times two days
and 30 mg intravenously twice a day times two days, and then
finally Solu-Medrol 30 mg q. day times two days. She was
also given Albuterol, Atrovent nebulizers scheduled q. four
to six with her Flovent inhalers for her asthma. She did not
develop any wheezes and showed very little obstructions when
looking at her peak inspiratory pressures and plateau
pressures, which give a difference of only 7 centimeters of
water. Her peak inspiratory pressure was good at 35.2.
The patient was also given Klonopin 0.5 mg p.o. twice a day
to control her anxiety. She was also given Ativan 0.5 mg q.
six p.o. p.r.n. for further anxiety. By [**2107-11-27**], the
patient was able to wean from pressure support of 15, PEEP of
7.5, FIO2 of 40 down to pressure support of 12, PEEP of 7.5
and FIO2 of 40%.
2. CARDIOVASCULAR: Although the patient did develop atrial
fibrillation back on [**2107-11-16**], she is now in sinus rhythm.
Her amiodarone continued but her Diltiazem was discontinued
due to the fact that her pulse was holding between 60 and 80.
It is recommended that her amiodarone be continued one month
after discharge from hospital and can be discontinued if she
remains in rhythm.
Her blood pressures were well controlled between 100 to 150
systolic with her ACE inhibitor.
3. INFECTIOUS DISEASE: The patient is on Flagyl for her
Clostridium difficile, Vancomycin for Methicillin resistant
Staphylococcus aureus that grew in four out of four bottles
on [**2107-11-23**], and Cefepime for Gram negative rods found in
her culture. On [**2107-11-26**], the patient was started on
Bactrim at one double strength tablet p.o. twice a day
because Stenotrophomonas maltophilia was found in her sputum.
Cefepime was discontinued on [**2107-11-27**] since it was felt
that the Gram negative rods were more colonizers in the
sputum. The patient's transthoracic echocardiogram showed no
vegetations.
If blood cultures from [**11-24**], [**11-25**] and [**2107-11-26**] become
positive, it is recommended that the patient receive a
transesophageal echocardiogram to rule out any vegetations.
She, however, remains to lack any stigmata of endocarditis.
Since her blood cultures on [**2107-11-23**] were taken from a
right IJ, the left IJ was capped because it was new. The
left IJ will have to be removed if her cultures from [**11-26**]
and [**2107-11-27**] become positive.
4. HEMATOLOGIC: The patient's hematocrit tended to trend
downward down to 24.6 so she was transfused with one unit of
blood because the transfusion would also help with pulling
her fluid from the interstitial space to the intervascular
space. Her hematocrit then increased to 27.8 and remained
around that range. Guaiac of the stool was negative. She
had normal [**Year (4 digits) **] studies.
According to her primary care physician, [**Name10 (NameIs) **] patient has no
problems with [**Name2 (NI) **] deficiency or hemolysis.
She was treated with Epogen six months ago for her chronic
anemia. The patient received no further treatment for her
anemia and her hematocrit is just monitored daily.
5. ENDOCRINE: While the patient is on Solu-Medrol, she will
receive fingerstick blood sugar checks four times with an
insulin sliding scale.
6. FLUIDS, ELECTROLYTES AND NUTRITION: The patient
continues to be diuresed on a Lasix drip with a goal of one
to 1.5 liters negative per day. She is also to receive
potassium checks twice a day. Nutrition wise, she is
receiving tube feeds.
7. TUBES, LINES AND DRAINS: Currently, she has an
endotracheal tube, Foley and left IJ in place.
8. PROPHYLAXIS: The patient is receiving subcutaneous
heparin and proton pump inhibitor.
9. CODE IS FULL. Contact is son.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28129**], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2107-11-27**] 18:00
T: [**2107-11-27**] 20:30
JOB#: [**Job Number 37158**]
ICD9 Codes: 7907, 4280, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3985
} | Medical Text: Admission Date: [**2129-7-20**] Discharge Date: [**2129-8-3**]
Date of Birth: [**2052-11-25**] Sex: F
Service: MEDICINE
Allergies:
Hydralazine / Heparin,Porcine
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
GI bleed
Respiratory distress
Major Surgical or Invasive Procedure:
Ultrafiltration
Hemodialysis
History of Present Illness:
(History obtained from son and OSH record)
76 yo F with history of CKD recently started on hemodialysis (2
cycles as of [**7-20**]), h/o CVA x2, h/o RCC s/p nephrectomy, and
recent known [**Hospital **] transferred from the OSH to the ICU for planned
GI work-up; however, was in respiratory distress requiring
intubation in the [**Hospital1 **] ED.
.
Per the son, she has been having increased lethargy, decreased
energy, as well as LE swelling. Patient reported having had at
least 1 week of melena and 1 day of hematemesis on [**2129-7-15**].
This led to her admission to [**Hospital **] Hospital on [**2129-7-15**].
At the OSH ED, she was noteded to have BRBPR and initial Hct of
25.3 from 30.5 on [**7-12**] and 34.4 on [**6-7**]. Per OSH record, her NG
lavage in the ED was negative. Her hemodynamics remained
stable. Subsequently, she was on Protonix gtt and IV hydration
with GI consult. Her plavix was held. She apparently underwent
an endoscopy by DR. [**Last Name (STitle) 30885**], which showed a bleeding friable
large pyloric channel stalk polyp 4-5 cm as well as gastric
mucosal friability. Per discharge summary, patient vomited
blood on [**7-19**] and received DDAVP. During her time in the OSH,
she was initiated on hemodialysis per her nephrologist's
recommendations. Per the son, patient was supposed to be
transferred over on [**7-19**] but did not get here until [**7-20**].
.
Per the son, she had a colonoscopy that was not remarkable,
except for polyps, last year.
.
Patient received a cycle of dialysis today before transfer.
.
Per ED report, patient became hypoxic en route to the 70s to
endoscopy, so was rerouted to the ED. At triage, HR 69, BP
167/66, RR 25, O2Sat 85% on BiPAP. There was concern of
pneumonia vs. fluid overload. She was placed on BiPAP then was
intubated for hypoxic respiratory distress on fentanyl and
propofol. Apparently, OG tube lavage did not show blood. Per
ED report, patient had a living will from [**2117**] with DNR/DNI, but
this was discussed with patient prior to intubation, and she
agreed to it. She was given protonix 80 mg IV 1x, vancomycin,
levofloxacin, and zosyn. Nephrology and GI were made aware of
her. Bedside echocardiogram showed small pericardial effusion
with left sided pleural effusion. Upon transfer, HR 58, BP
142/58, RR 16, O2Sat 100% on FiO2 80%, TV 400, RR set 18, and
PEEP of 10 with fentanyl and propofol for sedation.
.
In the [**Hospital Unit Name 153**], she was quickly extubated without complication on
[**7-21**] after HD ultrafiltration. She has been on 2L NC since. Echo
showed EF 50% with apical hypokinesis attributed NSTEMI during
this admission although trop elevations are only modest
considering renal function and CK/MB not elevated. EKG notable
for non-specific t-wave changes. She is on plavix as an outpt
for hx of CVA, but this has been held in setting of GIB.
.
In terms of her GI bleed, she was found to have a large polyp
leading to obstruction of pylorus. She was transfused [**2129-7-23**] 1
unit of pRBCs. Patient also noted to have bleeding [**Doctor First Name **]-[**Doctor Last Name **]
tear on EGD on Monday [**2129-7-25**], after which she had 20 cc
hematemesis but has had none since and has been hemodynamically
stable the entire hospitalization throughout [**Hospital Unit Name 153**] stay. She has
been on [**Hospital1 **] IV PPI, transitioned to PO PPI today and tolerating
po intake. Her last transfusion was today [**7-27**] with HD, at which
time she got 1 unit PRBC. She has received total 2 units (one
today, one on [**7-23**]).
.
Her course was also complicated by MSSA bacteremia and a
hematoma next to her AV fistula. Blood cultures drawn on
admission to [**Hospital1 18**] grew MSSA, one out of four bottles. She is on
cefazolin with Hemodialysis (2/2/3 g after HD on M/W/F, today
day 7 of 14 - last day [**8-3**]). Initial concern for infected
fistula given mild tenderness but ultrasound ok and vascular
felt it was very unlikely (no graft). Subsequent cultures x 6
days no growth to date.
.
She also had thrombocytopenia and Plt 142 on presentation, that
decreased to nadir of 69. Patient has not been on heparin at
[**Hospital1 18**], but unclear if received at OSH or with hemodialysis. PF4
neg. Plts since rose to 110.
In terms of ESRD, patient received HD session prior to transfer
to the floor.
Vitals in [**Hospital Unit Name 153**] prior to transfer to floor were as follows: T
98.7, BP 128/64, P 70, RR 14, O2sat 99% 2L. Pt arrived at the
floor with no complaint of pain.
Past Medical History:
(per [**Hospital **] Hospital record)
- Upper GIB from bleeding large pyloric channel stalk polyp with
diffuse gastric friability
- Lower GIB
- history of CVAs x2, was on plavix (until OSH admission.
Initially on ASA-> Plavix. Did not tolerate Aggrenox per OSH
record)
- CKD stage 4, on dialysis (2 cycles as of [**7-20**])
- h/o renal cell cancer s/p nephrectomy
- HTN
- HLD
- Anemia of chronic disease
Social History:
- lived at home with son
- has 3 grown children: son [**Name (NI) **], daughter [**Name (NI) **] and another
daughter
- no tobacco or alcohol use per son
- has been physically inactive for at least 1 year
- stays at home most of the time, but has a good friend that she
talks to twice a day
Family History:
- father deceased at 66 with MI
- mother deceased at 91 to colon cancer
- 1 sister is in good health
Physical Exam:
On admission:
Vitals: T:97.1 BP:109/67 P:77 R:17 O2: 97%, CMV Vt450, PEEP 10,
RR set at 18
General: intubated
HEENT: Sclera anicteric, MMM
Neck: supple, no LAD
Lungs: bronchial breath sounds, clear to auscultation, no w/c/r
appreciated
CV: RRR, normal S1 and S2, soft [**2-10**] holosystolic and diastolic
murmur, no rub or gallops
Abd: soft, NT, ND, BS present, no guarding, no organomegaly, +
old scar
GU: Foley draining clear urine
Ext: Cool extremities, 1+ edema to the thighs, 2+ DP and radial
pulses bilaterally, no clubbing or cyanosis.
On discharge:
Vitals: T:98.9 BP:164/70 P:72 R:20 95% on 2L O2
General: Pleasant, older woman in NAD. Friendly, cooperative.
AAOx3
HEENT: Sclera anicteric, MMM
Neck: supple, no LAD
Lungs: breaths slightly shallow but unlabored, good air
movement, no use of supplementary muscles, clear to auscultation
bilaterally, no w/c/r appreciated
CV: RRR, normal S1 and S2, no murmur, rub, or gallops
Abd: soft, NT, ND, BS present, no guarding, no organomegaly, +
old scar
Ext: Warm extremities, minimal edema to the thighs, 2+ DP and
radial pulses bilaterally, no clubbing or cyanosis.
Pertinent Results:
1. Labs on admission:
[**2129-7-20**] 01:55PM BLOOD WBC-10.9 RBC-4.35 Hgb-13.3 Hct-38.9
MCV-89 MCH-30.5 MCHC-34.1 RDW-17.2* Plt Ct-138*
[**2129-7-20**] 01:55PM BLOOD Neuts-83.4* Lymphs-10.0* Monos-4.7
Eos-1.1 Baso-0.8
[**2129-7-20**] 01:55PM BLOOD PT-11.7 PTT-21.7* INR(PT)-1.0
[**2129-7-20**] 01:55PM BLOOD Glucose-54* UreaN-27* Creat-2.8* Na-144
K-4.1 Cl-106 HCO3-26 AnGap-16
[**2129-7-20**] 01:55PM BLOOD ALT-23 AST-35 LD(LDH)-291* CK(CPK)-141
AlkPhos-86 TotBili-0.6
[**2129-7-20**] 01:55PM BLOOD CK-MB-10 MB Indx-7.1* proBNP-[**Numeric Identifier 88886**]*
[**2129-7-20**] 01:55PM BLOOD cTropnT-0.20*
[**2129-7-20**] 09:22PM BLOOD CK-MB-11* MB Indx-8.3* cTropnT-0.28*
[**2129-7-21**] 05:44AM BLOOD CK-MB-9 cTropnT-0.22*
[**2129-7-20**] 09:22PM BLOOD Calcium-7.2* Phos-3.7 Mg-1.8
[**2129-7-21**] 05:44AM BLOOD Triglyc-150*
[**2129-7-21**] 05:44AM BLOOD TSH-51*
.
2. Labs on discharge:
Test Name Value Reference Range Units
[**2129-8-3**] 07:30
COMPLETE BLOOD COUNT
White Blood Cells 7.6 4.0 - 11.0 K/uL
Red Blood Cells 3.26* 4.2 - 5.4 m/uL
Hemoglobin 10.0* 12.0 - 16.0 g/dL
Hematocrit 29.6* 36 - 48 %
MCV 91 82 - 98 fL
MCH 30.5 27 - 32 pg
MCHC 33.6 31 - 35 %
RDW 15.9* 10.5 - 15.5 %
Platelet Count [**Telephone/Fax (3) 88887**] K/uL
[**2129-8-3**] 07:30
RENAL & GLUCOSE
Glucose 138* 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
Urea Nitrogen 44* 6 - 20 mg/dL
Creatinine 3.8* 0.4 - 1.1 mg/dL
Sodium 138 133 - 145 mEq/L
Potassium 3.4 3.3 - 5.1 mEq/L
Chloride 101 96 - 108 mEq/L
Bicarbonate 26 22 - 32 mEq/L
Anion Gap 14 8 - 20 mEq/L
Calcium, Total 7.9* 8.4 - 10.3 mg/dL
Phosphate 2.5* 2.7 - 4.5 mg/dL
Magnesium 2.3 1.6 - 2.6 mg/dL
.
3. Imaging/diagnostics:
- CXR ([**2129-7-20**]):
1. Enlarged cardiac silhouette, may be due to pericardial
effusion and/or
cardiomyopathy, not optimally evaluated due to the bibasilar
opacities.
2. Bilateral mid-to-lower lung opacities likely represent
layering bilateral pleural effusions with overlying atelectasis,
underlying consolidation cannot be excluded.
.
- CXR ([**2129-7-22**]):
.
- Echocardiogram ([**2129-7-21**]):
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with distal
septal/anterior/apical hypokinesis. The remaining segments
contract normally (LVEF = 50%). No masses or thrombi are seen in
the left ventricle. The right ventricular cavity is mildly
dilated with focal hypokinesis of the apical free wall. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Moderate (2+) 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 mild pulmonary artery systolic hypertension.
There is a small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Moderate aortic regurgitation. Mild mitral
regurgitation. Small circumferential pericardial effusion
without signs of tamponade. Bilateral pleural effusions with
atelectatic lung.
.
- Upper extremity ultrasound ([**2129-7-22**]):
Extensive soft tissue edema, without focal fluid collection.
These findings could reflect cellulitis. Clinical correlation is
advised.
.
- CXR ([**2129-7-25**]):
In comparison with the study of [**7-24**], there is no evidence of
pneumomediastinum or pneumothorax. Bibasilar opacification is
consistent with pleural effusions, compressive atelectasis, and
increased pulmonary venous pressure or pulmonary edema. Some of
the diffuse opacification could represent aspiration.
.
- EGD ([**2129-7-25**]):
A 4cm pedunculated gastric polyp was found at the pylorus,
prolapsing into duodenum. The tip of the polyp was erythematous
and ulcerated. An endoloop was placed at the base of the polyp
and the polyp was pulled into the stomach for better
visualization.
A single-piece polypectomy was then performed using a hot snare
in the gastric polyp. The polyp was completely removed. There
was no evidence of bleeding from the polypectomy site.
Two additional smalll polyps (<1cm) were found in the stomach
body.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear was seen at the GE junction, continuing
into the cardia. There was no evidence of bleeding initially,
however at the end of the procedure, there was a moderate amount
of fresh blood seen arising from the GE junction. The area was
flushed with water vigorously, and the bleeding appeared to stop
spontaneously.
Otherwise normal EGD to 3rd portion of duodenum.
Brief Hospital Course:
76 yo F with CKD on HD, h/o CVA, h/o RCC s/p nephroctomy
presents after recently initiating hemodialysis with GI bleed
transferred to [**Hospital Unit Name 153**] for hypoxic respiratory failure requiring
intubation, found to have troponin leak, also found to have
profound hypothyroidism and ?MSSA bacteremia.
# Hypoxic respiratory failure.
CXR on admission to [**Hospital1 18**] most consistent with fluid overload,
potentially from flash pulmonary edema in the setting of demand
ischemia. Echocardiogram showed pericardial effusion without
tamponade. Ultrafiltration and hemodialysis performed with
marked improvement in respiratory status. Patient successfully
extubated without complication. She continued to have large
pleural effusions and oxygen requirement of 3L NC on the floor.
Ultrafiltration was limited by blood pressures; because pt's
blood pressures could not tolerate pulling off significant
volume, she will require rehabilitation stay for period of time
until enough fluid is removed to decrease oxygen requirement
back to baseline. Pt does not require oxygen at home.
# ?NSTEMI vs Demand Ischemia
Cardiac enzymes elevated with troponin 0.22 on admission and
downtrended slowly, likely secondary to demand ischemia in
setting of GI bleed. She may have otherwise had an NSTEMI prior
to presentation. Echocardiogram showed mild regional left
ventricular systolic dysfunction with distal
septal/anterior/apical hypokinesis. EKG was noted for anterior
Qs in V1 V2 and TWI in V1-V4. Patient was asymptomatic. Patient
was not given ASA or heparin in setting of her GIB. Beta
blocker (metoprolol) and captopril were started. She continued
on home rosuvastatin. Aspirin 81mg and Plavix 75mg were held
temporarily due to the risk of reemergent GI bleed. Per GI
recommendations, the patient was started on Aspirin 81mg daily
[**7-29**], while hematocrit continued to be stable, and she was
transitioned from Aspirin 81mg to Plavix 75mg on [**8-2**]. She was
also transitioned from captopril as an inpatient to lisinopril
as an outpatient as its long half-life allows for once-daily
dosing.
# GI bleed.
Patient was transfered to [**Hospital1 18**] from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in setting of
GI bleed with known gastric polyp. Gastric polyp and pyloric
channel polyp biopsied at OSH, with pathology result showing
tublar adenoma. Patient was hemodynamically stable throughout
without bleeding. Maintained on IV pantoprazole 40 mg [**Hospital1 **].
Required 1 unit of pRBC transfusion for Hct drop of ~ [**10-15**]
points over the course of [**2-6**] days but no obvious melena or
BRBPR. GI was consulted and performed EGD with removal of
polyp. Patient also noted to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear at the GE
junction which was bleeding when endoscope was removed. Patient
had one episode of hematemesis after EGD but stayed
hemodynamically stable. Tranfused a total of 2 units pRBC during
dialysis. Plavix 75mg was restarted in [**8-2**] for stroke risk.
# MSSA Bacteremia/hypotension:
[**2-8**] Blood cultures on presentation to [**Hospital1 18**] grew Methicillin
Sensitive Staph Aureus. Patient was recently initiated on
hemodialysis through left arm fistula, although transplant
surgery does not believe the site to be infected. U/S of the
extremity showed edema but no abscess. Echocardiogram showed AR
and MR, but there is no history of echocardiogram at PCP's
office for comparison. No blood culture was done in the OSH.
She was initially started on vancomycin for presumed MRSA, which
then transitioned to cefazolin for MSSA and ease of dosing with
dialysis. ID was consulted and recommended 2-week course.
Cefazolin was dosed at dialysis as follows: 2g IV Mondays after
HD, 2g IV Wednesdays after HD, 3g IV on Fridays after HD. The
course was completed with the last dose of cefazolin was given
[**2129-8-3**].
# Hypothyroidism
Patient was found to have TSH>50, for which she was started on
levothyroxine 50mcg daily. TFTs should be rechecked in 5 weeks
as an outpatient.
# Thrombocytopenia.
She was noted to have an acute drop of platelets by half in the
MICU since her admission to the hospital. Patient did not
receive heparin products while in this hospital given her GIB.
Per nephrology, heparin was not being used with her
ultrafiltration. It is unclear if she got heparin at the OSH.
Medications such as vancomycin and PPI could also potentially
cause thrombocytopenia, and patient is now on Cefazolin. PPI
was continued in setting of her GI bleed. Anti-PF4 antibody was
negative and platelet counts improved spontaneously.
# Chronic/End-stage renal failure on Hemodialysis.
Patient was recently started on dialysis (2 session) by the time
of her transfer to the ICU. Outpatient nephrologist reported
recent [**Doctor First Name **]/ANCA nephropathy from ?hydralazine. Baseline
creatinine 8.5. Renal team was consulted and started
hemodialysis Monday/Wednesday/Friday. Epo was held off given
the history of renal cell carcinoma. PPD was placed and read as
negative, and patient was set up for outpatient hemodialysis on
M/W/F schedule in [**Hospital1 **]. She does have a left arm hematoma
near the site of her AV fistula which has been stable and does
not disrupt use of the fistula for hemodialysis.
# H/o CVA.
Continued on Rosuvastatin Calcium 40 mg po daily and held off on
plavix in the setting of the GI bleed. Plavix was restarted on
[**8-2**].
# HTN.
As her clinical pictures, her SBP also improved, requiring
reinitiation of the beta blocker. She was started on metoprolol
as well as captopril, and will switch from captopril to
lisinopril at discharge.
# CODE STATUS:
# Health Care Proxy = son [**Name (NI) **] [**Name (NI) 54371**] [**Telephone/Fax (1) 88888**]
Transition of Care Issues:
[ ] Discuss epo with outpatient nephrologist
[ ] Need TSH/T3/free T4 checked in 5 weeks
[ ] Taper PPI after 8 weeks at 40mg [**Hospital1 **]
[ ] Repeat EGD in 3 months to confirm adequate removal of polyp
[ ] Pathology report from gastric polyp
Medications on Admission:
Upon transfer from [**Hospital **] Hospital:
- labetolol 100 mg po BID
- Crestor 40 mg daily
- Vitamin B12 1000 mcg po daily
- Renvela 800 mg with meals TID
- Sodium bicarb 648 mg po TID
- Prilosec 20 mg po BID
- nephrocaps 1 cap daily
- Tylenol 650 mg q6h prn
- Ambien 5 mg po qHS prn
- Zofran 4 mg IV q6h prn
.
Home medications (per OSH record)
- labetolol 200 mg [**Hospital1 **]
- Crestor 40 mg daily
- Plavix 75 mg daily
- Calcitriol 0.25 mcg daily
- B12 1000 mcg daily
Discharge Medications:
1. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every 4-6 hours as needed
for SOB.
8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Outpatient Lab Work
Please check CBC, Chem-10 daily while on hemodialysis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary Diagnoses:
End Stage Renal Disease on Hemodialysis
Demand Ischemia
Upper Gastrointestinal Bleed secondary to gastric polyp
Pleural Effusions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 54371**],
You were admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital to start
hemodialysis, but there you started bleeding from your gastric
polyp, so they transfered you to the [**Hospital1 18**]. Here, you were
having significant difficulty breathing in the Emergency [**Hospital1 **],
so you were intubated and placed on a ventilator machine for one
day in the medical intensive care unit. With another round of
hemodialysis, they were able to take off enough fluid to make
your breathing better, so the tube could be removed without any
difficulties.
You also had an endoscopy in the intensive care unit during
which we removed a large bleeding polyp in your stomach. You
were also found to have a tear in your esophageal mucosa, called
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear, which could have also caused some of the
bleeding. You were given two units of blood transfusion.
Your blood counts have been stable.
Dear Ms. [**Known lastname 54371**],
You were admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital to start
hemodialysis, but there you started bleeding from your gastric
polyp, so they transfered you to the [**Hospital1 18**]. Here, you were
having significant difficulty breathing in the Emergency [**Hospital1 **],
so you were intubated and placed on a ventilator machine for one
day in the medical intensive care unit. With another round of
hemodialysis, they were able to take off enough fluid to make
your breathing better, so the tube could be removed without any
difficulties.
In evaluation of your gastrointestinal bleed an endoscopy was
performed in the intensive care unit during which we removed a
large bleeding polyp in your stomach. You were also found to
have a tear in your esophageal mucosa, called [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]
tear, which could have also caused some of the bleeding. You
were transfused two units of blood after which your blood counts
have been stable.
There is some question of whether or not you had a small heart
attack before you came into our hospital. You should have your
primary care doctor set you up with a cardiologist after you go
home.
The following changes have been made to your medications:
1. please stop your labetalol
2. please stop your calcitriol
3. please start protonix (pantoprazole) 40 mg every 12 hours
4. please start metoprolol tartrate 37.5mg every 12 hours
*** please hold metoprolol on mornings before dialysis ***
5. please start lisinopril 10 mg once daily
6. please start levothyroxine 50 micrograms daily (please take
this medication on an empty stomach an hour prior to taking your
other medications)
.
Again it was a pleasure taking care of you. Please contact with
questions or concerns.
Followup Instructions:
Please be sure to keep all of your followup appointments.
You will be discharged to Rehab, but after you return home,
please set up an appointment with your primary care physician,
[**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as soon as possible.
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 13553**]
Please also have your primary care physician set you up with a
cardiologist after you are discharged.
Please also be sure to follow up with AV Care for your fistula.
You may have an area of narrowing with part of your fistula, so
you will need a study called a fistulagram to further evaluate
whether or not you will need a procedure to fix it.
Please follow up with AV care within the next month:
([**Telephone/Fax (1) 87407**]
FMC - [**Location (un) 1121**] Dialysis Center
[**Street Address(2) 88889**]
[**Hospital1 **] [**Numeric Identifier 26668**]
Phone: [**Telephone/Fax (1) 30127**]
Nephrologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Outpt hd schedule will be every Mon, Wed & Fri at 5:00pm
Department: DIV. OF GASTROENTEROLOGY
When: THURSDAY [**2129-9-8**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2129-8-6**]
ICD9 Codes: 5856, 7907, 2851, 4280, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3986
} | Medical Text: Admission Date: [**2180-12-2**] Discharge Date: [**2180-12-7**]
Date of Birth: [**2129-5-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
attempted thoracentesis [**12-3**]
History of Present Illness:
Mr. [**Known lastname 4711**] is a 51yo male with stage IV clear cell renal
carcinoma s/p R laparoscopic nephrostomy on [**2180-9-5**], who
presented with shortness of breath worsening over the last 48
hours. The patient was recently admission for hypercalcemia,
acute renal failure and a large left pleural effusion. A Pleurex
catheter was placed during that admission but was removed prior
to discharge. The patient stated that he was home from rehab for
approximately one week and felt as if he was getting his
strength back. Two days prior to admission the patient stated
that he began to feel short of breath when working with his
physical therapist. He remained home until the next evening when
a friend took him to [**Hospital2 **] [**Hospital3 **] because he felt he could no
longer catch his breath. He was immediately transferred here. He
denied any recent fevers or chills, chest pain or dizziness. He
further denied any nausea, vomiting, constipation or diarrhea.
.
In the ER, VS were T 98.5, BP 125/70, HR 120, but his HR came
down to 90, RR 20 and saturations to 95% after the patient was
placed on 3L of O2 by nasal canula. A CXR was performed that was
concerning for bilateral pleural effusions.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- began to have fatigue, dizziness and flu symptoms in [**Month (only) 404**]
[**2180**]
- on routine visit in [**Month (only) 116**], found to have RUQ mass
- CT abd/pelvis on [**2180-6-24**] showed a large exophytic mass in R
kidney, 9.6 x 9.3 cm, with associated abdominal lymphadenopathy
and pulmonary metastasis
- CT chest showed diffuse pulmonary metastases
- CT guided needle biopsy of the kidney on [**2180-7-17**] showed high
grade carcinoma, favoring renal cell cancer, with necrosis
- enrolled in protocol 04-117: Tumor/DC fusion in patients with
Renal Cell Carcinoma on [**2180-8-16**]
- s/p R laparoscopic radical nephrectomy on [**2180-9-5**]
- path showed clear cell renal cell carcinoma with sarcomatoid
features (60%), [**Last Name (un) 19076**] grade [**5-14**], with extension into
perinephric fat (T3a, N0, M1); margins clear, LVI indeterminate
- post-surgical CT showed rapid disease progression and he was
taken off study on [**2180-10-9**]
- Completed recent two week course of Sutent and is currently
taking two weeks off
.
PAST MEDICAL HISTORY:
# Hypercholesterolemia
# Bilateral shoulder and hand surgery
Social History:
He is divorced, lives and works on [**Hospital3 **] as an electrician.
He quit smoking at age 51, one pack per week x15 years.
Previously drank 1-2 drinks several times per week, but none in
last 1-2 weeks due to feeling ill. No recreational drug use.
Family History:
Negative for kidney, prostate or bladder cancer. Father has CAD,
but is alive and well.
Physical Exam:
At admission:
VS: T 96.4, BP 130/72, HR 104, R 18, sats 95% on 2L
GEN: uncomfortable appearing, laboring to breath but NAD
HEENT: sclera anicteric, dry mucus membranes, no nasal flaring
NECK: no cervical LAD, no JVD
CV: tachycardic, regular rhythm, normal S1, S2, no m/r/g
LUNGS: decreased breath sounds at the bases bilaterally, left
worse than right, dullness to percussion
ABD: S/NT/ND, BS+
EXT: warm, well-perfused, no palpable cords, no TTP
NEURO: CN II-XII grossly intact, moving all extremities,
sensation to light touch in tact
Pertinent Results:
At admission:
[**2180-12-2**] 01:20AM BLOOD WBC-5.5 RBC-4.05* Hgb-12.6* Hct-36.5*
MCV-90 MCH-31.2 MCHC-34.6 RDW-19.6* Plt Ct-248#
[**2180-12-2**] 01:20AM BLOOD Neuts-80* Bands-4 Lymphs-12* Monos-3
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2180-12-2**] 01:20AM BLOOD PT-12.1 PTT-25.2 INR(PT)-1.0
[**2180-12-2**] 01:20AM BLOOD Glucose-103* UreaN-17 Creat-0.9 Na-136
K-4.8 Cl-103 HCO3-24 AnGap-14
[**2180-12-2**] 01:20AM BLOOD Albumin-3.2* Calcium-10.9* Phos-2.6*
Mg-1.8
[**2180-12-3**] 02:06PM BLOOD Type-ART pO2-84* pCO2-46* pH-7.43
calTCO2-32* Base XS-4
[**2180-12-2**] 01:34AM BLOOD Lactate-2.5*
[**2180-12-2**] 01:36AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
On Discharge:
[**2180-12-7**] 05:46AM BLOOD WBC-4.8 RBC-3.26* Hgb-10.2* Hct-29.3*
MCV-90 MCH-31.4 MCHC-34.9 RDW-18.8* Plt Ct-326
[**2180-12-7**] 05:46AM BLOOD Glucose-90 UreaN-23* Creat-0.9 Na-131*
K-5.2* Cl-96 HCO3-27 AnGap-13
[**2180-12-7**] 05:46AM BLOOD Calcium-9.9 Phos-2.1* Mg-2.0
Blood cultures 10/23, no growth as of [**12-7**]
CTA chest [**12-2**]
IMPRESSION:
1. Progression of multiple bilateral pulmonary metastatic
lesions.
2. No evidence of pulmonary embolism.
3. Progression of right adrenal, likely metastatic lesion.
[**12-5**] AP CXR - FINDINGS: In comparison with the study of [**12-4**],
there is little overall change in the diffuse bilateral
pulmonary opacifications consistent with multiple pulmonary
metastases apparently complicated by a pulmonary edema or
hemorrhage. Enlargement of the cardiac silhouette persists and
there is mediastinal widening reflecting diffuse adenopathy.
Brief Hospital Course:
Mr. [**Known lastname 4711**] is a 51 year old male with stage IV clear cell
renal carcinoma with known lung mets who presented with
worsening shortness of breath and hypoxia.
# Dyspnea, Hypoxia - Patient initially required 2L O2 to
maintain O2 sats 94%. CTA chest on admission was negative for
PE. By hospital day two he required 4L by nasal canula. A
thoracentesis was attempted, but there was insufficient fluid to
tap. On hospital day 3 he triggered for O2 sat of 86% on 4L
nasal canula and was increased to 6L nasal canula and then
transferred to the ICU for closer monitoring and placed on a
face tent. Chest x-ray demonstrated worsening bilateral patchy
opacities. He was treated with broad spectrum antibiotics for
48 hours (vancomycin, levofloxacin, cefepime, and bactrim),
however, his respiratory status failed to improve and cultures
remained negative so antibiotics were stopped. He did not
tolerate oral bactrim due to nausea. His hypoxia and dyspnea
are most likely secondary to his widespread pulmonary metastatic
disease. He was given morphine and nebs to treat his dyspnea
and guiafenesin with codeine and benzonatate for cough.
#. Metastatic Renal Cell Carcinoma: He recently completed a
cycle of Sutent. The patient was continued on dexamethasone per
his outpatient regimen which was initiated at the time of his
whole brain radiation. It is unclear if he is continuing to
derive benefit from this medication so consideration to stopping
this medication can be given. As he has been on this medication
for almost a month, it will need to be tapered before stopping
completely. He has stage 4 disease with poor prognosis. There
are no further treatment options per the patient's oncologist.
After discussion with his oncologist following transfer to the
ICU the patient changed his code status to DNR/DNI. Palliative
care was consulted and made [**Known lastname 7219**] for symptom
management including dyspnea, nausea, and insomnia. He is being
discharged to inpatient hospice for further symptom management
and due to his high oxygen requirement.
#. Hypercalcemia: Patient was noted to have elevated calcium on
presentation. He was given IVF and lasix and calcium remained
elevated. He was also treated with a dose of pamidronate and
calcitonin.
# Hyperkalemia: The patient had intermittently elevated serum
potassiums that peaked at 5.2. Etiology is unclear but may be
secondary to dexamethasone or tumor burden causing increased
lactate due to increased metabolic demand. There was no
evidence of renal failure or acidemia.
#. Contact: friend and HCP [**Name (NI) **] [**Name (NI) 85654**] [**Telephone/Fax (1) 85655**] or
[**Telephone/Fax (1) 85656**]
Medications on Admission:
MEDICATIONS (per patient):
Dexamethasone 2 mg PO BID
Pantoprazole 40 mg PO daily
Sunitinib 12.5 mg PO daily for two weeks, then two weeks off
Lorazepam 0.5 mg PO daily Q8H
Senna 8.6 mg, 1-2 tabs PO daily as needed
.
ALLERGIES: NKDA
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for nausea or anxiety.
Disp:*60 Tablet(s)* Refills:*0*
4. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
5. morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime) as needed for shortness of
breath.
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
6. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
8. 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.
9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath.
10. Zofran 2 mg/mL Solution Sig: Four (4) mg Intravenous every
eight (8) hours as needed for nausea.
11. morphine in 0.9 % NaCl 2 mg/mL (1 mL) Syringe Sig: 1-4 mg
Intravenous Q2H as needed for shortness of breath or pain.
Disp:*50 mL* Refills:*0*
12. Prochlorperazine 10 mg IV Q6H:PRN nausea
13. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): If stopped, this medication will need to be tapered
off.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospice
Discharge Diagnosis:
Primary:
Dyspnea and hypoxia
Renal cell carcinoma metastatic to lung
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Requires 50% face tent to maintain O2 sats > 93%
Discharge Instructions:
You were admitted to [**Hospital1 69**]
because of shortness of breath. While you were here, you had
imaging which showed that the cancer in your lungs has
progressed and is likely what is causing your symptoms. There
is no further treatment available for your cancer at this time.
You were seen by the palliative care doctors who made
[**Name5 (PTitle) 7219**] for helping to manage your symptoms.
While you were here some of your medications were changed.
-You were started on morphine and nebulized albuterol and
ipratroprium to help alleviate your shortness of breath.
-You were also given zofran and compazine as needed to treat
your nausea.
-You were given benzonatate and guiafenesin with codeine for
your cough.
-You were given lorazepam as needed for anxiety.
-You were given trazodone as needed for insomnia.
Followup Instructions:
Please follow-up with your primary care doctor,
[**Last Name (LF) **],[**First Name3 (LF) 85657**], as needed ([**Telephone/Fax (1) 85658**])
ICD9 Codes: 2761, 2767, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3987
} | Medical Text: Admission Date: [**2197-11-14**] Discharge Date: [**2197-11-24**]
Date of Birth: [**2133-12-13**] Sex: M
Service:
ADMISSION DIAGNOSIS: Rectal cancer.
DISCHARGE DIAGNOSIS: Rectal cancer, status post
abdominoperineal resection.
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old man
with a known history of right colon adenocarcinoma, staging
T3 N0, rectal adenocarcinoma staging T1 N0, status post
chemotherapy and radiation therapy in [**Month (only) 216**] and [**2197-9-3**]. The patient had had previous resections for the known
cancers. He now has a recurrence of a rectal cancer at the
suture line. The patient comes for further surgical
resection of the recurrent cancer.
PHYSICAL EXAMINATION: In general, the patient is in no acute
distress. Chest is clear to auscultation bilaterally.
Cardiovascular is regular rate and rhythm, without murmurs,
rubs or gallops. The abdomen is soft, nontender,
nondistended. Incisional scars consistent with previous
surgery. Extremities - The patient does have some mild
pitting edema of the bilateral lower extremities. Otherwise,
the extremities are warm, noncyanotic, nonedematous.
Neurologically, the patient is grossly intact.
PAST MEDICAL HISTORY:
1. Right colon adenocarcinoma, T3 N0.
2. Rectal adenocarcinoma, T1 N0.
3. Status post chemotherapy and radiation treatment in
[**Month (only) 216**] and [**2197-9-3**].
4. Hypertension.
5. History of atrial fibrillation.
6. History of Clostridium difficile infection.
7. Status post right colectomy and sigmoid resection in
[**2194-12-3**].
8. Transurethral resection of prostate [**2197-10-3**].
9. Port-a-cath placement [**2197-8-3**].
MEDICATIONS ON ADMISSION:
1. Lasix 40 mg once daily.
2. Diltiazem extended release 120 mg once daily.
3. Accupril 10 mg once daily.
4. Potassium Chloride 10 meq once daily.
5. Albuterol inhaler two puffs four times a day.
6. Atrovent inhaler two puffs four times a day.
7. Digoxin 250 mcg once daily.
8. Warfarin 1 mg once daily, has been off Warfarin
preoperatively.
9. Azmacort inhaler p.r.n.
HOSPITAL COURSE: The patient was admitted for further
surgical therapy of his recurrent rectal cancer. In the
operating room, the decision was made to proceed with
abdominoperineal resection. The patient seemed to tolerate
the procedure well without complication.
Postoperatively, the patient was recovering nicely on bedrest
until the morning of [**2197-11-16**], postoperative day number two.
The patient on postoperative day number two had some mental
status changes and was initially somewhat lethargic and
became agitated and intermittently violent. The patient
became disoriented although he was alert. Initial workup
including cardiac and metabolic workups proved to be
negative. The patient did have some crackles on physical
examination throughout his lung fields. After speaking with
the family, the patient had a history of some altered mental
status changes preceding a previous episode of pneumonia that
he had had. Working diagnosis at that time was pneumonia
versus hospital psychosis. The patient's mental status did
not improve over the course of the following two days with
some intermittent agitation. The patient was medicated with
Haldol and Ativan. This had some success.
On the evening of postoperative day number four, the patient
had an acute episode of respiratory distress and required
intubation on the floor. Subsequent to this, the patient was
transferred to the Intensive Care Unit for closer monitoring
and ventilatory management. In the Intensive Care Unit, the
patient did well and was extubated postoperative day number
six. The patient was empirically covered for a probable
aspiration pneumonia with Levaquin, a seven day course. The
patient was transferred back to the floor on postoperative
day number six. His mental status was normal at that time.
Throughout the rest of his hospital course, the patient did
quite well. His diet was advanced as tolerated. The patient
was discharged on postoperative day number ten tolerating a
regular diet and having regular ostomy output, good pain
control on p.o. pain medications.
CONDITION ON DISCHARGE: Good.
DISPOSITION: To home.
DIET: Ad lib.
MEDICATIONS ON DISCHARGE:
1. Lasix 40 mg once daily.
2. Diltiazem extended release 120 mg once daily.
3. Accupril 10 mg once daily.
4. Potassium Chloride 10 meq once daily.
5. Albuterol inhaler two puffs four times a day.
6. Atrovent inhaler two puffs four times a day.
7. Digoxin 250 mcg once daily.
8. Warfarin 1 mg once daily, has been off Warfarin
preoperatively.
9. Azmacort inhaler p.r.n.
10. Amiodarone 400 mg twice a day.
11. Percocet 5/325 mg one to two tablets q4hours p.r.n.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] on
[**2197-11-27**]. He is being sent home with VNA for ostomy care and
[**Known lastname 1661**]-[**Location (un) 1662**] teaching. [**Known lastname 1661**]-[**Location (un) 1662**] will likely be
discontinued at subsequent office visit with Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2197-11-24**] 08:21
T: [**2197-11-26**] 09:18
JOB#: [**Job Number **]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3988
} | Medical Text: Admission Date: [**2135-6-30**] Discharge Date: [**2135-7-7**]
Date of Birth: [**2056-6-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: This is a 79 y/o M with h/o of HTN, DM, recent CVA [**Month (only) **],
chronic respiratory failure on vent, trached, ESRD on HD who was
sent from rehab facility fro wrosening mental status.
.
Per refferal notes, he went to hemodyalisis today in the
morning. 1 L was removed. At about 2:30 pm, he was found to have
worsening mental status. In that setting he was hypotensive down
to the 92/45, and was given 1 L NS. Fs was also checked 179. At
that time, it seems that he had been on T peace since 4 am
today. At 2:30 he was also found with sats in the 90%. ABG done
7.1, 89/72- he was placed on AC 600/0.4 and 6 PEEP- sats up to
94%.
Given persistent lethargy, patient was sent to Falkener ED.
.
Of note, after interview with HCP, at around [**5-17**], patient
started having episodes of dizziness, and had unstable gait.
he was taken to [**Last Name (un) 33526**] ICU until [**6-3**] when he was
discharged to [**Hospital **] Rehab. he had a peg tube and tracheostomy
prior to d/c. He had been chronicallyl vent dependent. His
companion states that they have been trying to wean him down at
rehab. his basline mental staus apparently responds with his
head shaking, and also try to write sentences.
.
In the ED: VS T 103 rectal BP90/44 HR: 84 RR 16 Sats: 98
+ guiac stool. He received tylenol, levofloxacin 500 mg IV,
Flagyl 500mg and Vancomycin and I L NS.
.
ROS: difficult to obtain 2x2 to patient mental status baselin
Past Medical History:
CVA [**Month (only) **]/[**2134**]
HTN
DM
CRI on HD since [**Month (only) **] (Tu, Thurs, Sat)
Neuropathy right leg
s/p cCY
Social History:
Uset to be truck driver. Retired 15 years ago. He has 1 son,
two grandson. smoking (-), alcohol -
Family History:
brother died cerebral aneurysm
Brother [**Name (NI) **] cancer
brother prostate cancer
father [**Name (NI) 107681**]
Physical Exam:
Physical Exam:
Vitals: T: 99 P:84 BP: 145/62
AC: 600, x12/0.5/5 SaO2: 100%
General: Awake, alert, responding to voice.
HEENT: PEERLA, no JVD. + tracheostomy
Pulmonary: clear anteriorly. decrease breath sounds bases.
Cardiac: RRR, nl. S1S2, soft holosytolic murmur apex
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. + g tube
Extremities: Left arm AVF
1+ trace edemalymphadenopathy noted.
Skin: no rashes, small decubit in the back.
Neurologic: alert, awake, partially interacting and responding
to comands.
decreased reflexes Lower extremities. bilaterally. spastic right
upper extremity.
Pertinent Results:
141 103 53 167 AGap=14
------------->
5.7 30 3.6
CK: 29 MB: Notdone Trop-*T*: 0.44
Comments: Notified [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2135-6-30**] 6:50p
Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 8.6 Mg: 2.4 P: 5.0
Other Blood Chemistry:
proBNP: [**Numeric Identifier 107682**]
WBC 15.2 Plat 395
HCT: 28.4
N:89.8 Band:0 L:5.8 M:4.1 E:0.3 Bas:0.1
PT: 12.1 PTT: 37.5 INR: 1.0
[**2135-6-30**]
5:04p
Green Top
K:5.5 Lactate:1.3
.
Brief Hospital Course:
Assessment and Plan:
This is a 79y/o M with h/o HTN, DM, recent CVA, chronic
ventilatory failure, CRI on HD who presents with change in MS
and febrile in the ED, admitted to MICU.
.
# Altered mental status: Ct scan with no evidence of new
intracraneal bleeding. Patient febrile in the ED. High WBC. It
was thought that it could have been a combination of
hypotension, hypercapnia and infection. He was initially started
on broad spectrum antibiotics. Despite having a profund
limitation communicating given his neurological status, his
mental changes seemed to improved initially. However later on
during his course, his mental status deteriorated, being even
less responsive.
.
#ID:
Patient febrile and with a high WBC on admission. After starting
broad spectrum antibiotics-cefepime-vancomycin and flagyl(for
initial concern of aspiration pneumonia), he responded
clinically. Urine cx from Rehab showed gram negative rods >100K
enterobacter cloacae. Urine Cx in house grew Citrobacter Freundi
and his sputum grew Acinetobacter Baummani. Since there was no
more evidence of gram positive infections, vancomycin was
discontinued and cefepime was kept.
.
# Fevers: in the ED, high WBC, possible pneumonia. Also possible
source sinus infections given findings on intial CT (see summary
in significant studies). He did not spike any fevers after being
transfer to the MICU from the ED.
.
# Resp: Patient was intermitentely switched from AC to Pressure
support trials.
However, after
Patient did well. Then trach mask trials were done. He
tolerated this well, although he required PS overnight.
.
# ESRD on hemodyalisis: Renal service was consulted and HD was
continued.
.
# CV:
Rhythm: NSR, not tachycardic.
.
Pump: With trace of lower extremity edema. X ray suggested some
pulmonary edema on admission. Despite this findings, he was
supported with 40% FIO2 most of the time.
.
CAD: On admission Ck low normal, MB not done. Troponin 0.44. It
was more likely due to CRI. Second set 12 hours apart, showed no
changes.
.
s/p stroke: continue aspirin, statin, plavix
.
# Hypotension: per referral form. Intially concern for sepsis in
the setting of fevers and high blood count. His BP medications
were held on admission. Patient di dnot require pressors. His
blood pressure remained stable and BP meds were restarted.
.
#FEN:
Tube feedings were started thorugh peg tube. On [**2135-7-3**], patient
pulled out peg tube. Temporary foley was placed and on [**2135-7-6**],
On [**2135-7-7**] after deterioration of his mental status and also of
his blood pressure, goals of care were discussed with his HCP.
It was decided to direct goals of care towards confort care.
Patient passed away accompanied by his significant other.
Medications on Admission:
Novolin 16 U q 12h
Aranesp 40 mcg sc
Prozac liquid 20 mg qam
Heparin 3000 U tu, thursday saturday
Norvasc 10 mg daily GT
Tylenol PRN
Reglan 5 mg q6h,
fergon 300 mg [**Hospital1 **]
Plavix 75 mg GT
nephrocaps 1 daily
novolin Sliding scale
heparin sc 5000 q8h
Protonix 40 mg daily GT
Combivent 2 puff qid inh
zocor 10 mg Tab /day GT
aspirin 325 mg tab
Ferrlecit Sodium ferric gluconate Mo-We Fr IV
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Change in Mental status
2. Urinary tract Infection
3. Chronic respiratory failure
.
Secondary:
1. Hypertension
2. Diabetes Mellitus
3. End stage renal disease on HD
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2135-9-6**]
ICD9 Codes: 5070, 5990, 5856, 4280, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3989
} | Medical Text: Admission Date: [**2200-5-27**] Discharge Date: [**2200-6-4**]
Date of Birth: [**2150-5-27**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p pedestrian struck by auto
Major Surgical or Invasive Procedure:
s/p ORIF left humerus fracture [**2200-5-30**]
s/p ORIF left acetabular fracture [**2200-5-30**]
History of Present Illness:
50 yo female pedestrian struck by auto; no LOC at scene, GCS 15
Past Medical History:
Hepatitis B
PSH: C-section
Family History:
Noncontributory
Physical Exam:
Heent-PERRL, TM clear, calp avrasion/laceration x2
Neck- cervical collar
Cor- RRR, + bilat radial and DP pulses
Chest- CTA bilat
Back/Spine- No stepoffs/tenderness
Abd- soft, non tender
Rectum- normal tone; guaiac negative
Extr- +motor, + strength x4; grooss deformity LUE, LLE shortened
with internal rotation; left hip tender
Neuro- awake and alert
Pertinent Results:
[**2200-5-27**] 09:47PM HCT-24.5*
[**2200-5-27**] 05:41PM WBC-17.3*# RBC-3.00* HGB-9.5* HCT-27.3*
MCV-91 MCH-31.6 MCHC-34.7 RDW-13.3
[**2200-5-27**] 05:41PM PLT COUNT-148*
[**2200-5-27**] 12:24PM GLUCOSE-183* LACTATE-1.7 NA+-139 K+-3.5
CL--104 TCO2-24
[**2200-5-27**] 12:21PM UREA N-16 CREAT-0.8
[**2200-5-27**] 12:21PM AMYLASE-72
Brief Hospital Course:
Patient admitted to trauma service; Vascular surgery consulted
for pelvic injuries, recommended serial hematocrits and
angiography if patient became unstable. Her admission Hct was
24, patient transfused, total 7 units during her hospital stay,
most recent Hct 29.9 on [**2200-5-31**]. Patient evaluated by Othopedics
and taken to OR on [**2200-5-30**] for repair of her left humerus and
left acetabular fractures. Postoperatively she has done fairly
well, pain controlled with prn Percocet. Was treated early
during her hospitalization for a UTI with Levofloxacin.
Levofloxacin 500 mg qd po started on [**5-31**] for total 10 day
course for a pneumonia. She was started on Lovenox injections on
[**2200-5-31**] and will need to continue for total 8 weeks. She is to
remain non-weight bearing for total 2 months both LUE/LLE, but
may be PWB LUE for transfers only.
Medications on Admission:
none
Discharge Medications:
1. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours). Continue for another 8
weeks.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for Fever.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): d/c after last dose on [**2200-6-12**].
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
s/p pedestrian struck by auto
left humerus fracture
left acetabular fracture
complex pelvic fracture
Discharge Condition:
Stable
Discharge Instructions:
Follow up with Orthopedics in [**1-23**] weeks
Continue with your antibiotics through [**2200-6-12**]
Followup Instructions:
Follow up with Orthopedics in [**1-23**] weeks, call for an appointment
[**Telephone/Fax (1) 1228**]
Completed by:[**2200-6-4**]
ICD9 Codes: 486, 2851, 5990, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3990
} | Medical Text: Admission Date: [**2184-10-15**] Discharge Date: [**2184-10-19**]
Date of Birth: [**2104-1-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 yo female with Type I DM with several admissions for DKA this
year ([**2184-5-10**] and [**2184-9-3**]) presents from MD's office after
noting elevated FS to high 400s the night before. She gave
herself extra doses of insulin and went to sleep with plan to
see Dr [**Last Name (STitle) 16258**] in AM. This morning she developed nausea and
vomiting and was unable to get blood for FS. Was seen in
doctor's office this AM with persistent nausea and vomiting.
They were still unable to get FS. She was then transferred to
the ED.
In the ED, VS: T97.1 BP 104/54 HR 88 RR20 100%RA. Her BP dropped
to 78/27 while being evaluated. She received 2L of NS and BP
improved to 115/43. In total she received 4L of IVFs and
vanco/zosyn. She was given regular insulin 10 U x1 and started
on insulin gtt.
On ROS: Denies fever, chills, abdominal pain, diarrhea. Does
report cough.
Past Medical History:
DM1 - Diagnosed over 40 years ago, has been on insulin pump for
several years
Macular degeneration, legally blind
Basal cell carcinoma on nose, removed [**2182**]
HTN
Social History:
Denies tobacco use or illicit drug use. Reports one alcohol
beverage every evening. Currently lives alone; husband died one
year ago.
Family History:
Mother diet of ovarian cancer in her 80s. [**Name (NI) 1094**] father lived to
his 90s. Son with 'heart problems.
Physical Exam:
on discharge:
Vitals: 97.1 120/54 80 18 98%RA
Accuchecks: 417, 178, 206, 363 (this am)
Pain: 0/10
Access: PIV
Gen: nad, sitting up in bed
HEENT: o/p clear, mmm
CV: RRR, no m
Resp: CTAB, no crackles or wheezing
Abd; soft, nontender, +BS
Ext; no edema
Neuro: A&OX3, baseline near blindness, nonfocal
Skin: no changes
psych: appropriate
.
Pertinent Results:
BUN/Creat 38/1.9-->15/0.7
WBC 16.6-->6.1
.
Other labs/interpretation:
.
MICRO:
blood cx [**10-15**] 1 of 2 cornybacterium and propionibacterium
blood cx [**10-18**] pending
UA and UCX- negative
.
.
Imaging/results:
CXR: unremarkable.
Brief Hospital Course:
80 yo female with DMI on insulin pump, HTN, near blindness [**2-14**]
macular degeneration admitted [**10-15**] for 3rd time this year with
DKA, acute renal failure. Was admitted to [**Hospital Unit Name 153**] for elevated GAP
24. Got IVFs, insulin gtt. Sugars better by next morning,
transfered to Gen Med. As for triggers, ruled out for infection
(1 of 2 BC pos cornybacterium, likely contaminant) and MI with
trops. Thought to be possibily [**2-14**] not taking enough insulin
from ?error/near blindness/underdosing. ARF improved with IVFs
(prerenal from osmotic diuresis). On floor remained with sugars
in 300s, was getting approx 10U insulin wiht meals in addition
to basal insulin via pump (0.8U/hr from 8am-8pm and 0.3U/hr
8pm-8am). Discussed this problem with patient regarding her near
blindness and inability to reliably take insulin which has been
addressed multiple times by Dr. [**Last Name (STitle) 16258**], her endocrinologist. Dr.
[**Last Name (STitle) 16258**] saw pt while here. He has provided her with a sliding
scale to follow (she uses magnifying glass and special light to
see at home) and he will arrange for her to have home visits and
close follow up. Plan was discussed with her nephew, who is a
physician and her HCP and it is reccommended that they think
about [**Hospital3 **]. She was discharged in stable condition.
Her insulin pump resorvoir was running low and she had arranged
to have delivery of her refil on returning home as we were
unable to get this refil for her despite attempts.
.
.
Medications on Admission:
Lisinopril 2.5 mg PO DAILY
Dextrose (Diabetic Use) 300 mg 2-4 Tablets PO PRN
Novolin N 18 units Subcutaneous Q AMisp:*QS bottle* Refills:*3*
Fosamax 70 mg PO once a week
Calcium 500 With D 500 (1,250)-400 mg-unit PO twice a day
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): Use your Pump as directed.
2. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Dextrose (Diabetic Use) 40 % Gel Sig: Two (2) PO four times
a day as needed for hypoglycemia.
4. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
5. Calcium 500 with Vitamin D 500 (1,250)-200 mg-unit Tablet
Sig: One (1) Tablet PO twice a day.
6. Insulin PUMP 0.8U/hr 8am-8pm and 0.3U/hr 8pm-8am
Discharge Disposition:
Home
Discharge Diagnosis:
Uncontrolled Diabetes with DKA
Near blindness due to macular degeneration
Discharge Condition:
GOOD
Discharge Instructions:
You were admitted for elevated sugars resulting in diabetic
ketoacidosis. You need to be very careful about not letting your
sugars get too high. You will continue on your insulin pump and
you will need to use the sliding scale that Dr. [**Last Name (STitle) 16258**] provided
you with for your premeal sugars.
Please call Dr. [**Last Name (STitle) 16258**] if your sugars are persistantly >300.
When your sugars are persistantly >200, you need drink extra
fluids to not get too dehydrated.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 16258**] as he has instructed you to do
so. He has arranged for someone to assist you over the phone and
with home visits.
Please follow up with Dr. [**First Name (STitle) **] as needed.
ICD9 Codes: 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3991
} | Medical Text: Admission Date: [**2109-1-17**] Discharge Date: [**2109-1-23**]
Date of Birth: [**2039-9-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV contrast dye
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, this is a 69 yo F with a recent PMH significant for
weight loss, anorexia, electrolyte abnormalities, who was sent
in to the ED by her PCP for [**Name9 (PRE) 108827**] and tremor and had a
tonic-clonic seizure in the ED likely related to alcohol
withdrawal +/- electrolyte abnormalities. The patient had a head
CT that was negative for acute intracranial process. The patient
was seen by neurology who recommend continuing CIWA scale and
attributed much of her confusion, confabulation, and ataxia to
Wernickes Disease. The patient recieved IV folate, thiamine, as
well as electrolyte repletion.
.
Prior to transfer, VS 98.7, 74, 141/86, 10, 95% RA. The patient
was alert and oriented x [**12-28**], although she was extremely
tangential with her thought process. She had poor attention and
was easily distractable. She had no acute complaints, otherwise.
.
Review of systems:
(+) Per HPI, complains of chronic diarrhea, some mild abdominal
pain
Past Medical History:
Diabetes mellitus type 2, controlled
Hypomagnesemia
Collagenous colitis
Diverticulitis
Reflux
Peripheral vascular disease
COPD (chronic obstructive pulmonary disease)
Tobacco abuse
Thyroid nodule
Hyperlipidemia LDL goal < 130
Lower extremity edema
Fibrocystic disease of breast
Obese
Skin cancer
Hypertension goal BP (blood pressure) < 130/80
Proteinuria
Colon polyp
Chest pain
Transaminitis
Chronic left shoulder pain
Osteoporosis screening
Vitamin D deficiency
Sciatica
Heart murmur
Social History:
- Tobacco: 1ppdX45 yrs
- Alcohol: 2 drinks per day/unknown last drink. Likely
underestimating the amount that she drinks
- Illicits: denies
Family History:
Noncontributory
Physical Exam:
Vitals: T: 98.7 BP: 141/82 P: 74 R: 10 O2: 95% RA
General: AOx2-3, tangential, distractable
HEENT: dry skin, conjunctival pallor, coarse hair, tongue with
some cuts on sides
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, bronchial breath
sounds, prolonged expiratory phase
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, no dullness
to percussion, no shifting dullness
Ext: dry, coarse skin, poor nail care
Skin: palmar erythema, spider angiomas, no caput, coarse, dry
skin
Neuro: Poor at following commands, decreased sensation stocking
and glove pattern, slowed rapid alternating movements, able to
do months of the year backwards, 0/3 recall at 5minutes.
Pertinent Results:
ADMISSION LABS
[**2109-1-17**] 02:10PM BLOOD WBC-6.8 RBC-3.52* Hgb-12.6 Hct-35.8*
MCV-102* MCH-35.7* MCHC-35.1* RDW-12.8 Plt Ct-161
[**2109-1-17**] 02:10PM BLOOD Neuts-75.4* Lymphs-17.6* Monos-5.2
Eos-0.9 Baso-1.0
[**2109-1-17**] 05:34PM BLOOD PT-10.3 PTT-31.6 INR(PT)-0.9
[**2109-1-17**] 02:10PM BLOOD Glucose-103* UreaN-14 Creat-1.0 Na-143
K-3.6 Cl-106 HCO3-22.3 AnGap-18
[**2109-1-17**] 02:10PM BLOOD ALT-34 AST-43* AlkPhos-52 TotBili-0.6
[**2109-1-17**] 02:10PM BLOOD Albumin-3.9 Calcium-6.9* Phos-4.1 Mg-0.6*
[**2109-1-17**] 10:12PM BLOOD 25VitD-6*
[**2109-1-17**] 02:10PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2109-1-17**] 06:02PM BLOOD Ethanol-NEG
CT head:
NONCONTRAST HEAD CT: There is no evidence of hemorrhage, mass,
mass effect, or infarction. There is no shift of the usually
midline structures. Suprasellar and basilar cisterns are widely
patent. Mild periventricular and deep white matter
hypoattenuation is suggestive of chronic small vessel ischemic
changes. Proportional enlargement of the ventricles and sulci is
suggestive of age-related cortical atrophy. There is no scalp
hematoma or acute skull fracture. The visualized paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION: No acute intracranial process
Liver US:Small simple hepatic cyst. Otherwise, normal-appearing
liver. No ascites. Aneurysmal abdominal aorta, measuring up to
3.2 cm. Absent left kidney, possibly congenital versus
post-surgical. Clinical correlation recommended. Tiny
gallbladder polyps or adherent stones.
[**2109-1-18**] 04:03AM BLOOD WBC-5.7 RBC-3.24* Hgb-11.7* Hct-32.9*
MCV-102* MCH-36.2* MCHC-35.6* RDW-12.8 Plt Ct-150
[**2109-1-19**] 07:23AM BLOOD WBC-7.1 RBC-3.09* Hgb-11.5* Hct-31.3*
MCV-101* MCH-37.3* MCHC-36.8* RDW-13.1 Plt Ct-153
[**2109-1-20**] 07:30AM BLOOD WBC-4.0 RBC-3.06* Hgb-11.1* Hct-31.3*
MCV-102* MCH-36.4* MCHC-35.6* RDW-12.6 Plt Ct-123*
[**2109-1-21**] 06:10AM BLOOD WBC-5.4 RBC-3.25* Hgb-11.7* Hct-32.6*
MCV-100* MCH-35.8* MCHC-35.7* RDW-12.8 Plt Ct-153
[**2109-1-22**] 06:05AM BLOOD WBC-5.0 RBC-3.08* Hgb-11.1* Hct-31.0*
MCV-101* MCH-36.2* MCHC-35.9* RDW-12.8 Plt Ct-149*
[**2109-1-23**] 06:10AM BLOOD WBC-4.5 RBC-3.02* Hgb-10.7* Hct-31.0*
MCV-103* MCH-35.6* MCHC-34.7 RDW-12.3 Plt Ct-175
[**2109-1-18**] 04:03AM BLOOD Glucose-313* UreaN-10 Creat-0.7 Na-133
K-7.1* Cl-103 HCO3-21* AnGap-16
[**2109-1-18**] 05:08AM BLOOD Glucose-148* UreaN-9 Creat-0.6 Na-137
K-4.2 Cl-105 HCO3-21* AnGap-15
[**2109-1-18**] 10:33AM BLOOD UreaN-9 Creat-0.7 Na-140 K-4.1 Cl-107
HCO3-20* AnGap-17
[**2109-1-18**] 06:50PM BLOOD Glucose-138* UreaN-13 Creat-0.9 Na-140
K-4.8 Cl-107 HCO3-23 AnGap-15
[**2109-1-19**] 07:23AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-138
K-5.0 Cl-108 HCO3-20* AnGap-15
[**2109-1-19**] 04:00PM BLOOD Glucose-119* UreaN-12 Creat-0.8 Na-137
K-4.7 Cl-103 HCO3-22 AnGap-17
[**2109-1-20**] 07:30AM BLOOD Glucose-123* UreaN-10 Creat-0.7 Na-139
K-4.1 Cl-106 HCO3-22 AnGap-15
[**2109-1-21**] 06:10AM BLOOD Glucose-127* UreaN-7 Creat-0.8 Na-138
K-3.7 Cl-104 HCO3-24 AnGap-14
[**2109-1-22**] 06:05AM BLOOD Glucose-98 UreaN-8 Creat-0.7 Na-142 K-3.8
Cl-109* HCO3-25 AnGap-12
[**2109-1-22**] 06:05AM BLOOD Glucose-98 UreaN-8 Creat-0.7 Na-142 K-3.8
Cl-109* HCO3-25 AnGap-12
[**2109-1-23**] 06:10AM BLOOD Glucose-106* UreaN-8 Creat-0.7 Na-142
K-4.0 Cl-109* HCO3-24 AnGap-13
[**2109-1-18**] 04:03AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.1
[**2109-1-18**] 05:08AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1
[**2109-1-18**] 10:33AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8
[**2109-1-18**] 06:50PM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1
[**2109-1-19**] 07:23AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.8
[**2109-1-19**] 04:00PM BLOOD Calcium-9.4 Phos-3.6 Mg-2.3
[**2109-1-20**] 07:30AM BLOOD Calcium-8.9 Phos-4.8* Mg-1.6
[**2109-1-21**] 06:10AM BLOOD Calcium-9.2 Phos-4.9* Mg-1.3*
[**2109-1-22**] 06:05AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.4*
[**2109-1-23**] 06:10AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.5*
[**2109-1-19**] 07:23AM BLOOD VitB12-268
[**2109-1-21**] 06:10AM BLOOD TSH-3.2
Brief Hospital Course:
Ms. [**Known lastname **] is a 69F with PMH hypomagnesemia, collagenous
colitis, T2DM, COPD, who presents with seizure, electrolyte
abnormalities, and confusion.
#Altered Mental Status--Per PCP, [**Name10 (NameIs) **] has had a slow decline
over the past couple of months but previously very redirectable
and making her outpatient appointments. Per friend [**Name (NI) **], patient
has sensical conversations and is able to take care of herself.
During admission, patient was intermittently nonsensical. CT
head showed chronic small vessel ischemic changes and age
related cortical atrophy. Patient has reportedly abused ETOH in
the past and is currently confabulating, however history, exam,
and labs are not convincing for withdrawal, wernicke's or
korsikoffs dementia. Patient has not scored on CIWA and does not
have evidence of cirrhosis on abd US. B12 was low-nml, on folate
and thiamine supplementation. Electrolyte disturbances could be
causing AMS (esp hypomagnesemia). Patient additionally was found
on the ground on [**1-19**], without complaints, no focal signs of
head trauma. Concern low for stroke (strong family history per
patient), but no focal neuro abnormalities. Currently patient is
refusing HIV test and MRI brain. TSH 3.2. RPR negative. Mental
status continued to improve throughout admission and with
additional input from her long-time partner that her mental
status continued to improve. Based on this collateral
information and [**Hospital 228**] medical stability, plan for discharge
to rehab for further therapy.
#Electrolyte abnormalities--Pt presents with hypomagnesemia 0.6
mg/dl on presentation, hypocalcemia (6.9), and hypokalemia
(3.6-->3.2). Hypomagnesemia is ongoing, pt was prescribed PO
magnesium supplementation 2 months ago, as Mg was 1.0 on
[**2108-11-6**]. The patient was non-compliant with this therapy.
Hypomagnesemia is likely due to chronic diarrhea from
collagenous colitis, PPI use, EtOH, as well as poor nutrition.
It does not seem as though she is having renal wasting of her
electrolytes, given her FE of magnesium. After repletion with IV
magnesium, she was transitioned to PO magnesim oxide. She
initially got diarrhea as a result of the magnesium oxide which
resolved with concurrent administration of immodium. Immodium
should be minimized to avoid constipation and obstruction.
# EtOH Abuse -- Pt states she usually has 1-2 drinks/night of
vodka. Unclear about last drink. Pt has s/s of alcohol abuse and
her seizure in the ED was likely due to withdrawal. Neurology
agress with this assessement. The patient has skin
manifestations of alcohol abuse including palmar erythema and
telangectasias although palmar erythema may be dishydrotic
eczema. However she had an Abd US that showed no evidence of
chirrosis. She will continue supplementation with Thiamine and
Folate. SW saw patient but evaluation was limited by patients
confusion
# Seizure -- Pt had a shaking episode in the ED that was thought
to be a seizure, for which she received ativan. This was likely
due to EtOH withdrawal and electrolyte abnormalities. The
patient was monitored on CIWA but did not score making
withdrawal unlikely. She did not require anti-epileptics and she
had no further seizures during her stay.
#Collagenous colitis--Diagnosed by colonic biopsy in 10/[**2108**]. Pt
has ongoing diarrhea, improved from previously, only once per
week according to PCP. [**Name10 (NameIs) **] is unable to provide detailed history.
Home budesonide dose was continued.
#GERD--PPI was d/c'd on [**1-16**] due to hypomagnesemia. No current
complaints. If pt has symptoms, you should use H2 blocker.
#HTN-- Her home HTN medications were continued (losartan 100mg
daily and atenolol 50mg daily), However she continuned to have
elevated BPs to 200s and had to be covered with Iv hydralazine
and Labetolol. Amlodipine 5mg was added to her regimen and this
improved her BPs.
#COPD--~40 pack year smoking history. No O2 requirement or SOB
at present. Ipratropium inhaler at home.
#DM2--Diet controlled, HbA1c 5.3 in 1/[**2108**]. Diabetic diet
TRANSITION OF CARE ISSUES
-Added Amlodipine 5mg daily
-Added Magnesium Oxide 400mg [**Hospital1 **] to be taken with immodium and
meals
-Methylmalonic acid level Pending
-Added 50000U Vitamin D per week which she will need to continue
for 7 weeks
-She may need an MRI brain to asess for infarcts or other
possible etiologies of her confusion, however, patient declined
at this [**Doctor First Name **]
-Health Care Proxy form signed after consistent statements that
her long-time partner of 30 years be her HCP. She will need
further home evaluation
-Hypomagnesemia and electrolyte management should be closely
monitored.
Medications on Admission:
-Budesonide (ENTOCORT EC) 3 mg Oral Capsule, Delayed &
Ext.Release 2 tablets daily
-Losartan 100 mg Oral Tablet Take 1 tablet daily
-magnesium chloride (SLOW-MAG) 71.5 mg Oral Tablet, Delayed
Release (E.C.) take 1 tablet 4 times per day
-Potassium Chloride 20 mEq Oral Tablet, ER Particles/Crystals
Take 1 tablet daily
-Atenolol 50 mg Oral Tablet Take One Tablet Daily
-Aspirin 81 mg Oral Tablet Take 1 tablet daily.
-Ipratropium Bromide (ATROVENT HFA) 17 mcg/Actuation Inhalation
HFA Aerosol Inhaler
Discharge Medications:
1. budesonide 3 mg Capsule, Delayed & Ext.Release Sig: Two (2)
Capsule, Delayed & Ext.Release PO DAILY (Daily).
2. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation once a day.
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (SA) for 7 weeks.
Disp:*7 Capsule(s)* Refills:*0*
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. loperamide 2 mg Capsule Sig: One (1) Capsule PO once a day:
with morning magnesium oxide.
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Dementia
Alcohol Withdrawal Seizures
Hypomagnesemia
Chronic Alcohol Abuse
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with confusion, low magnesium,
potassium, and calcium. In the ED, you had a seizure that was
most likely due to your low electrolytes and also alcohol
withdrawal. Your low electrolytes were attributed to your
chronic diarrhea, alcohol use, and poor nutrition. A CT scan of
your head did not show any acute problems. Our neurology
colleagues saw you and recommended correction of your
electrolytes and abstinence from alcohol. You were seen by PT,
OT and social work who are concerned about your ability to care
for yourself at home. You are being discharged to a rehab
facility to help you regain your strength and ensure a safe
return home.
The following changes were made in your medications:
START Magnesium Oxide 400 mg twice daily with breakfast and
dinner
START Amlodipine 5 mg by mouth daily
START Folic Acid 1 mg daily
START Thiamine 100 mg daily
START Vitamin D 50,000 units weekly (on Saturdays) for 6 weeks
DISCONTINUE
Magnesium Chloride
You may changed the Magnesium Oxide to Magnesium Chloride if you
continue to have difficulties tolerating the medication.
Followup Instructions:
Please call to arrange an appointment with your primary care
provider and gastroenterologist after discharge.
ICD9 Codes: 496, 2724, 3051, 2768, 4019, 2875, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3992
} | Medical Text: Admission Date: [**2166-2-14**] Discharge Date: [**2166-2-23**]
Service: General Surgery ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] MD)
DISCHARGE DIAGNOSES:
1. Choledocholithiasis with cholelithiasis.
2. Endoscopic retrograde cholangiopancreatography complicated
by retroperitoneal perforation and pneumomediastinum.
3. Hypovolemia requiring fluid resuscitation.
4. Subcutaneous tissue emphysema requiring intubation.
5. Hypercholesterolemia.
6. Hypothyroidism.
7. Depression.
8. Hiatal hernia with gastroesophageal reflux.
9. Osteoporosis.
10. Sigmoid diverticulosis.
INVASIVE PROCEDURES THIS ADMISSION:
1. Endoscopic retrograde cholangiopancreatography with
sphincterotomy.
2. Flexible upper endoscopy.
3. Invasive line placement.
CHIEF COMPLAINT: [**Known firstname **] [**Known lastname 18473**] is an 82 year old woman
transferred from an outside hospital with choledocholithiasis
for ERCP with plan to return to the outside hospital, which
did not have that capability on the weekends. During the
procedure, the procedure was complicated by subcutaneous
emphysema and pneumomediastinum, which prompted emergent
intubation and a thoracic and general surgical consultation.
HISTORY OF PRESENT ILLNESS: [**Known firstname **] [**Known lastname 18473**] is an 82 year
old woman who presented to the [**Hospital6 2561**] on
[**2165-12-14**] with nausea and vomiting of 24 hours' duration. She
had elevated transaminases, elevated amylase and a white
blood cell count of 12,000 with 12 percent bands. Right
upper quadrant ultrasound revealed cholecystitis with stones
and common bile duct dilation. She was transferred to our
institution for an emergent ERCP. The procedure was notable
for an uneventful removal of a common bile duct stone with a
sphincterotomy. During the procedure, she developed swelling
and crepitus in her neck. On chest x-ray, she had
pneumomediastinum and subdiaphragmatic air. This was
suspicious for esophagus versus gastric perforation. She
underwent an upper gastrointestinal swallow with water
soluble contrast, but did not demonstrate extravasation of
contrast. She then underwent a CT scan of the chest and
abdomen. These confirmed the findings, but there was no
extravasation of contrast. She was admitted to the thoracic
surgery service and plan for operative intervention was made.
PAST MEDICAL HISTORY: Gastroesophageal reflux, hiatal
hernia, hypercholesterolemia, hypothyroidism, depression,
hiatal hernia, osteoporosis. History of deep vein thromboses
and a history of sigmoid diverticulosis with diverticulitis.
PAST SURGICAL HISTORY: Bilateral inguinal hernia repairs and
bunionectomy.
MEDICATIONS: Lipitor, Protonix, aspirin, Fosamax.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives with a close friend in [**Name (NI) 10059**] who
is her power of attorney. She denies current smoking, but
quit smoking approximately 20 years ago. She occasionally
uses alcohol. She is not currently employed. She is
retired.
FAMILY HISTORY: Both of her parents died of coronary artery
disease.
REVIEW OF SYSTEMS: Could not be obtained at the time of her
admission, as she was intubated.
PHYSICAL EXAMINATION: Her temperature is 96.6, her heart
rate was 91, her respiratory rate was 21, blood pressure
130/50, and she was satting 100 percent on face ten on
presentation to the intensive care unit after ERCP.
Generally, she was awake and alert. There was marked
swelling of the periorbital region and the bilateral cheeks.
She had positive crepitus on palpation, and she denied pain.
Her neck was supple. She had no upper airway stridor.
Sclerae could not be evaluated. Her chest had diminished
breath sounds at the bases and there were diffuse crackles on
the upper lung fields. Her heart was regular rate and rhythm
with a holosystolic ejection murmur, II/VI. Her abdomen was
soft. She had mild right upper quadrant tenderness. She had
decreased bowel sounds without rebound or guarding. Her
extremities were warm with one plus pitting edema.
On chest x-ray, she had extensive subcutaneous emphysema with
subcutaneous pneumomediastinum and subdiaphragmatic air. She
had atelectasis of the right base. Her lab values were white
count of 12 with hematocrit of 37, platelet count 341. She
had 83 percent neutrophils, 12 bands. Sodium 137, potassium
4.1, chloride 102, bicarbonate 23, BUN 16, creatinine 1.0,
glucose 121. Her alkaline phosphatase was 228, ALT 131, AST
265. Total bilirubin was 1.2 and amylase 126, lipase 224.
EKG showed normal sinus rhythm without significant or
alarming ST changes.
CT scan of the chest and abdomen showed no extravasation of
contrast and pneumomediastinum and intraperitoneal air.
HOSPITAL COURSE: [**Known firstname **] underwent an ERCP complicated by
air dissection. She was admitted to the [**Hospital Ward Name **] ICU and
progressively resuscitated, placed on antibiotic therapy, and
general surgery and thoracic consults were obtained. She was
taken emergently to the operating room, where flexible upper
endoscopy was performed. There was no evidence of an
esophageal or gastric perforation. She subsequently
underwent a CT scan of the abdomen and pelvis with oral
contrast that showed no extravasation of contrast in the
esophagus, stomach or small bowel. This was thought to be
retroperitoneal air dissection secondary to the
sphincterotomy. The plan was to treat her cholecystitis and
her biliary obstruction, and plan a future cholecystectomy at
her discretion.
An ENT consultation was obtained, which did not demonstrate
and pharyngeal injury on [**Last Name (un) 18474**] scope. She was transferred
to the general surgical service after her direct laryngoscopy
and esophagogastroduodenoscopy were negative. There were no
complications during that surgery. She required a re-ERCP on
[**2165-12-23**] for a routine common duct stone despite the
sphincterotomy. This procedure was without complication, and
a large stone was removed from the common bile duct. She was
subsequently discharged to home tolerating a regular diet,
completing a course of antibiotics therapy, with a plan for
followup for an elective laparoscopic cholecystectomy.
DISCHARGE STATUS: The patient was discharged to home without
significant nursing services.
PLAN: Follow up for planning elective cholecystectomy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 18475**]
Dictated By:[**Last Name (NamePattern4) 9859**]
MEDQUIST36
D: [**2166-3-24**] 15:03:09
T: [**2166-3-24**] 16:01:10
Job#: [**Job Number 18476**]
ICD9 Codes: 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3993
} | Medical Text: Admission Date: [**2181-2-8**] Discharge Date: [**2181-2-9**]
Date of Birth: [**2118-5-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ace Inhibitors / Acebutolol / Atenolol / Betaxolol
/ Bisoprolol / Carvedilol / Labetalol / Metoprolol / Nadolol /
Penbutolol / Pindolol / Propranolol / Timolol
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Infected [**Hospital1 **]-V ICD leads and device
Major Surgical or Invasive Procedure:
s/p ICD lead and device extraction on [**2181-2-8**]
History of Present Illness:
62 year old male patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26237**], Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 5051**], and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who has an extensive past
medical history including non-ischemic cardiomyopathy with an EF
15-20%, s/p initial implantation of an ICD in [**2175**] and a BiV
lead upgrade in [**2179-8-21**]. Following the lead upgrade, the
patient developed an erosion of the overlying skin which was
complicated by an infection in the device pocket. The pocket
was debrided on [**2180-8-18**]. Since that time, the patient
has required multiple courses of antibiotics, both intravenous
and oral. He is currently taking a 3-week course of oral
cephalexin. He was referred for extraction of the ICD leads and
device.
Past Medical History:
Past Medical History:
1. Nonischemic cardiomyopathy, chronic systolic heart failure.
2. Mitral regurgitation with pulmonary hypertension.
3. Ventricular tachycardia s/p ICD implantation [**2175**]
4. COPD.
5. Morbid obesity.
6. Spinal stenosis.
7. Right malignant renal tumor, s/p right nephrectomy
8. Stage 4 chronic renal failure.
9. Hypertension.
10. Leg ulcers.
11. Gout
Other Past Surgeries: laparoscopic cholecystectomy in [**2174**],
mini
thoracotomy [**8-27**], hernia repair.
Social History:
The patient is a disabled former truck driver who currently
helps run a home daycare center. He is married with adult
children and lives with his wife. [**Name (NI) **] quit smoking at age 35.
No alcohol,no drugs.
Family History:
No family history of premature CAD, sudden cardiac death, or
arryhtmias. His father has a history of a cerebral hemmorhage.
Physical Exam:
General: Obese white male in no acute distress lying in bed.
Neuro: Alert and oriented to person, place, and time.
Cardiac: Regular rate and rhythm. Normal S1,S2. No
murmurs/rubs/gallops.
Resp: Lungs are diminished throughout.
GI: Abdomen is large and softly distended. Bowel sounds are
present.
GU: Voids concentrated yellow urine.
Integ: Left chest incision is covered with dry sterile dressing.
Surrounding skin is reddened. No drainage noted.
Periph vasc: Right femoral vein access site is intact. No
hematoma or bruit. Distal pulses are present. Bilateral lower
extremities are scaly, dusky, and dry. Feet are warm with
decreased sensation. Right ankle ulcer is approximately [**12-22**]
inch and no drainage is noted.
Pertinent Results:
[**2181-2-9**] 05:20AM BLOOD WBC-9.0 RBC-4.05* Hgb-11.2* Hct-34.8*
MCV-86 MCH-27.7 MCHC-32.2 RDW-15.6* Plt Ct-203
[**2181-2-9**] 05:20AM BLOOD Plt Ct-203
[**2181-2-9**] 05:20AM BLOOD UreaN-54* Creat-3.1*
Brief Hospital Course:
ICD site infection: Patient was admitted to [**Hospital1 **] on [**2181-2-8**] and underwent extraction of ICD lead and
device. He was admitted to the inpatient cardiac unit for
observation and continuous cardiac monitoring. He was continued
on all of his home medications. Oral cephalexin was continued
as part of 3-week outpatient course. The patient remained
afebrile with all vital signs stable during his hospitalization.
Stage 4 chronic renal failure: Patient has a history of a
malignant right renal tumor and a right nephrectomy [**2180-3-21**].
Creatinine at admission was 3.4 and on [**2-9**] was 3.1.
Right foot ulcer: Patient has history of right ankle skin graft
[**2180-2-19**] for a non-healing ulcer. An open area that remains
is approximately [**12-22**] inch and was evaluated by a wound/ostomy
nurse. Dressing changes were recommended and should be
continued after transfer.
Medications on Admission:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Lasix 80 mg Tablet Sig: one and a half Tablet PO twice a
day.
4. Imdur 30 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO QAM (once a day (in the
morning)).
7. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO BID (2 times a day): one tablet
in afternoon and one tablet in evening, in addition to two
tablets in the morning .
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
9. Mexiletine 200 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
10. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): one capsule in the afternoon and one capsule in
the evening in addition to two capsules every morning.
11. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
13. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Lasix 80 mg Tablet Sig: one and a half Tablet PO twice a
day.
4. Imdur 30 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO QAM (once a day (in the
morning)).
7. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO BID (2 times a day): one tablet
in afternoon and one tablet in evening, in addition to two
tablets in the morning .
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
9. Mexiletine 200 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
10. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): one capsule in the afternoon and one capsule in
the evening in addition to two capsules every morning.
11. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
13. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
s/p ICD lead and device extraction secondary to infected pocket
Discharge Condition:
Vitals: 97.3 - 93/48 - 76 - 20 - 95% on room air
Labs: BUN 54 Cre 3.1 WBC 9.0 Hgb 11.2 Hct 34.8 Plt 203
Neuro: Alert and oriented X 3.
Cardiac: Regular rate and rhythm. Normal S1,S2. No murmurs
appreciated.
Respiratory: Lungs are diminished throughout.
Peripheral vascular: Right femoral vein access site intact. No
bleeding, hematoma, or bruit. Distal pulses are present.
Skin: Left chest wall incision is intact and covered with a dry,
sterile dressing. Surrounding skin has considerable erythema,
but scant drainage.
Discharge Instructions:
Continue your current medications as prescribed. It is
important that you complete your 3-week course of Cephalexin.
Keep your chest dressing dry. The nurses at the rehabilitation
facility will change the dressing daily.
If you develop a fever, chills, or signs of worsening infection
at the incision site, notify your doctor.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on Friday, [**2181-2-23**] at 3:40 p.m.
***Patient should be transported by ACLS ambluance to this
appointment to maintain continuous cardiac monitoring.***
Completed by:[**2181-2-9**]
ICD9 Codes: 4254, 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3994
} | Medical Text: Admission Date: [**2198-5-8**] Discharge Date: [**2198-5-11**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy
Exploratory laparotomy, cholecystectomy, hemodialysis catheter
placement
History of Present Illness:
Mr. [**Known lastname 19442**] was an 88 year old man who presented to [**Hospital1 18**] [**Location (un) 620**]
with 2 days of right sided abdominal pain. He was transferred
to [**Hospital1 18**] [**Location (un) 86**] for testing and evaluation of this pain, which
he decribed as sharp and constant in the right upper and lower
quadrants. He denied stool changes, nausea, and vomiting.
Past Medical History:
- s/p MI in [**2167**] Tx medically
- DM - glucotrol and diet control 120-200s at home
- HTN
- CAD
- dyslipidemia
- s/p R CEA in [**2191**] (by Dr. [**Last Name (STitle) **]-patient says he was
asymptomatic, but notes indicate prior TIA
- CRI 2.9; [**2196-1-17**] ARF/CRI with Cr to 5.4 -> 2.2 with IVFs; Dr.
[**Last Name (STitle) 33568**] - nephrologist following, unclear etiology.
- hyperPTH - most likely [**1-19**] to CRI/ARF,
- anemia, ? GI bleed with full ASA. Pt also started on Epo while
as inpatient during his admission in [**Month (only) 205**].
- MM, per patient, followed by Dr. [**Last Name (STitle) 33569**], his heme/onc Md [**First Name8 (NamePattern2) **] [**Location (un) 33570**].
Social History:
Former smoker-quit [**2167**], 4 cigarettes per day x 40 years. 1
scotch per day. NO IVDU or recreational drugs.
Family History:
No hx of MI, CAD, CVA, DM, HTN
Physical Exam:
T 100.6/98.9 P 75, BP 138/61, RR 26, Sat 97 on 4L NC
Decreased breath sounds at the bases bilaterally
Heart rate regular
Abdomen mildly distended and tympanitic. Right upper and lower
quadrant tenderness to mild palpation with guarding.
Rectal exam with normal tone, brown, trace heme-positive stool.
Pertinent Results:
[**5-8**] RUQ U/S: Findings most consistent with acute cholecystitis,
as discussed with General Surgery houseofficer, and posted to
the ED dashboard, at the time of dictation
[**5-8**] CT Abdomen/Pelvis: 1. Inflammatory process involving the
right upper abdomen as described, which appears more likely
centered on a distended gallbladder with sludge and stones,
rather than on the ascending colonic diverticula, though there
is a spastic-appearing colonic segment in the vicinity.
2. Evidence of chronic pancreatitis with calcifications and
atrophy.
3. No evidence of inflammatory process in the right lower
abdomen.
4. Extensive vascular calcification with no aneurysms seen.
5. Small-moderate right pleural effusion with basilar
atelectasis.
[**5-10**] Cholecystostomy: Successful ultrasound-guided percutaneous
cholecystostomy tube placement. 200 cc of bilious fluid was
aspirated, a portion which was sent for microbiology.
[**5-11**] RUQ U/S: Large biloma in gallbladder fossa with
decompressed gallbladder with thickened, ruptured wall. Findings
including possible percutaneous drainage of the biloma were
discussed with Dr. [**Last Name (STitle) **] by Dr. [**Last Name (STitle) **] at completion of
examination
[**5-11**]: CT Abdomen/Pelvis: 1.Compared to prior CT from [**2198-5-8**],
there is increased eccentric fluid collection adjacent to the
anterolateral aspect of the gallbladder fundus with marked
pericholeycstic stranding, concerning for rupture. In addition,
since the prior exam, the patient has developed increased
peripancreatic stranding, which may be related to the
gallbladder, however, an acute pancreatitis cannot be entirely
excluded. No pancreatic ductal dilatation or stone within the
duct is identified. Recommend correlation with pancreatic
enzymes.
2. Bilateral ground-glass opacity and pleural effusion with an
area of consolidation within the right lung base.
Brief Hospital Course:
Mr. [**Known lastname 19442**] was admitted to [**Hospital1 18**] under the care of Dr. [**Last Name (STitle) **]
and cared for in the Trauma SICU. He and his wife initially
declined surgery and cholecystostomy tube; he ultimately did
receive cholecystostomy tube once his status declined. This
was performed on HD3. He became anuric with an elevated lactate
after placement of this drain, receiving 8 L of IV fluids, and
forming only 500 cc of urine despite lasix. His blood pressure
dropped, and he required increasing amounts of Levophed. He was
then intubated for increased work of breathing. On HD4, Mr.
[**Known lastname 19442**] was brought ot the operating room by Dr. [**Last Name (STitle) **] for an
exploratory laparotomy, cholecystectomy, and hemodialysis line
placement. Details of this procedure may be found in his
operative note. Postoperatively, he became hypotensive and
developed pulseless electrical activity. After 60 minutes of
resuscitation, he recovered a perfusing rhythm. The patient's
family was notified, and the decision was made to change his
code status to DNR. At 1802, his code status was changed to
CMO, and he soon expired after pharmacologic supports were
withdrawn.
Medications on Admission:
Lasix, lipitor, toprol, plavix, gl;ipizide, isosorbide
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 4241, 4280, 5845, 4275, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3995
} | Medical Text: Admission Date: [**2152-12-6**] Discharge Date: [**2152-12-9**]
Date of Birth: [**2079-6-12**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI; 73 yo F with hx COPD, HTN, HLD, PVD s/p R CFA to AK [**Doctor Last Name **]
bypass with graft [**8-15**], transferred from [**Hospital6 2561**]
with IPH.
She presented to [**Last Name (un) 1724**] [**12-5**] with right leg pain, numbness, and
coldness, found not to have distal pulse, and with occluded R
fem-AK [**Doctor Last Name **] graft. She underwent RLE angiogram with TPA infusion
(3mg bolus then 1 mg/hr) and heparin 500 units/hr IA starting at
2:30 PM. At 8:30 PM she was found to have L facial droop, L
hemiparesis, and was lethargic. A CT head revealed a large
right
IPH (approximately 5.5cm x 2.5 cm x 4 cm) with 5mm midline
shift.
Heparin and TPA were discontinued. She was intubated, received
lasix 20 mg IV, mannitol 60 g and transferred to [**Hospital1 18**] for
further care.
Past Medical History:
-COPD
-HTN
-HLD
-PVD
Social History:
na
Family History:
na
Physical Exam:
VS; BP 200/106 P 104 RR 18 99% on vent
Gen; intubated, lying in bed, NAD
HEENT; NC/AT
CV; tachycardic, regular rate, no murmurs
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; cool and dark distal RLE
Neuro; (off sedation); opens eyes to voice. Follows commands
(shows thumb, opens hand). Pupils 3mm-->2mm, does not cross
midline with gaze, but does track to the right. Left facial
droop. + corneal, + cough, + gag. Lifts RUE and RLE
antigravity, appears somewhat weak RLE distally but able to
wiggle toes, and uncooperative with further assessment. 0/5
strength in LUE and LLE and no withdrawl to noxious stimuli.
Upgoing toe on left, mute on right.
Pertinent Results:
[**2152-12-6**] 09:57PM SODIUM-138 POTASSIUM-4.8 CHLORIDE-108
[**2152-12-6**] 09:57PM OSMOLAL-299
[**2152-12-6**] 04:34PM OSMOLAL-296
[**2152-12-6**] 02:58PM GLUCOSE-143* UREA N-15 CREAT-0.6 SODIUM-139
POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-23 ANION GAP-12
[**2152-12-6**] 02:58PM CK(CPK)-2630*
[**2152-12-6**] 02:58PM CK-MB-39* MB INDX-1.5 cTropnT-0.04*
[**2152-12-6**] 06:54AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2152-12-6**] 06:54AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2152-12-6**] 06:54AM URINE RBC-5* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2152-12-6**] 06:53AM GLUCOSE-209* UREA N-17 CREAT-0.8 SODIUM-138
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-22 ANION GAP-20
[**2152-12-6**] 06:53AM CK(CPK)-1683*
[**2152-12-6**] 06:53AM CK-MB-30* MB INDX-1.8 cTropnT-0.12*
[**2152-12-6**] 06:53AM CALCIUM-9.4 PHOSPHATE-3.6 MAGNESIUM-3.1*
[**2152-12-6**] 06:53AM WBC-18.2* RBC-3.54* HGB-11.7* HCT-33.5*
MCV-95 MCH-33.1* MCHC-35.0 RDW-14.5
[**2152-12-6**] 06:53AM PLT COUNT-236
[**2152-12-6**] 06:53AM PT-12.9 PTT-19.0* INR(PT)-1.1
[**2152-12-6**] 04:36AM TYPE-ART TEMP-35.9 RATES-14/ TIDAL VOL-500
O2-50 PO2-140* PCO2-32* PH-7.45 TOTAL CO2-23 BASE XS-0
INTUBATED-INTUBATED VENT-CONTROLLED
[**2152-12-6**] 04:36AM GLUCOSE-207*
[**2152-12-6**] 12:56AM TYPE-ART PO2-291* PCO2-32* PH-7.47* TOTAL
CO2-24 BASE XS-1
[**2152-12-6**] 12:56AM GLUCOSE-216* LACTATE-2.2*
[**2152-12-6**] 12:56AM freeCa-1.16
[**2152-12-6**] 12:40AM GLUCOSE-214* UREA N-17 CREAT-0.8 SODIUM-135
POTASSIUM-2.7* CHLORIDE-97 TOTAL CO2-20* ANION GAP-21*
[**2152-12-6**] 12:40AM estGFR-Using this
[**2152-12-6**] 12:40AM CK(CPK)-1637*
[**2152-12-6**] 12:40AM CK-MB-30* MB INDX-1.8 cTropnT-0.11*
[**2152-12-6**] 12:40AM CALCIUM-9.6 PHOSPHATE-2.9 MAGNESIUM-1.5*
[**2152-12-6**] 12:40AM OSMOLAL-305
[**2152-12-6**] 12:40AM WBC-15.1* RBC-3.78* HGB-12.7 HCT-35.6* MCV-94
MCH-33.7* MCHC-35.8* RDW-14.4
[**2152-12-6**] 12:40AM PLT COUNT-242
[**2152-12-6**] 12:40AM PT-14.3* PTT-22.7 INR(PT)-1.2*
Brief Hospital Course:
73 yo F with hx COPD, HTN, HLD, PVD s/p R CFA to AK [**Doctor Last Name **] bypass
with graft [**8-15**], found to have thrombosed graft at OSH and
receiving TPA and heparin drips, complicated by
large R IPH with 5mm midline shift, and transferred to [**Hospital1 18**] for
further evaluation. Bleed likely due to aggressive
anticoagulation possibly contributed to by hypertension.
Hospital Course:
Patient was admitted to the neuro ICU under attending [**Doctor Last Name **]. A
repeat head CT the morning after admission on [**2152-12-6**]
demonstrated Evolving right frontotemporal parenchymal
hemorrhage with interventricular extension, similar in size and
distribution compared to most recent prior. With some Subfalcine
herniation with trapping of the left lateral ventricle, similar
compared to most recent prior, but new compared to study dated
[**2152-12-5**]. Patient was kept with -HOB > 30 -SBP < 160. She
received mannitol at [**Last Name (un) 1724**] and in TSICU, switched to 3% NS once
CVL (0.5ml/kg/hr w/ q6h serum osmol and Na checks -- hold for
osmol >320 and Na >155) A follow up head CT on [**12-7**] demonstrated
the right parenchymal hemorrhage, slightly larger compared to
prior.
QUALITY OF CARE:On [**2152-12-7**] two family meetings were held and
family made patient DNR/I with poor prognosis. They held off on
any interventions and patient was made CMO. And passed on
[**2152-12-10**]
Medications on Admission:
-enalapril 40 mg daily
-atenolol 25 mg daily
-HCTZ
-ASA 81 mg daily
-MVT
-simvastatin (dose unknown)
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
passed away
Discharge Condition:
passed away
Discharge Instructions:
passed away
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2152-12-10**]
ICD9 Codes: 431, 496, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3996
} | Medical Text: Admission Date: [**2192-3-13**] Discharge Date: [**2192-3-23**]
Date of Birth: [**2119-9-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
Hematuria, Hemoptysis
Major Surgical or Invasive Procedure:
[**2192-3-15**] Right craniotomy for tumor resection
History of Present Illness:
ADMIT NOTE
Date: [**2192-3-13**]
Time: 2200
HPI: 72 yo M with NSCLC with brain mets s/p parietal/occipital
crani for tumor resection on [**2192-2-3**], relatively new bilateral
frontal hemorrhagic mets scheduled for neurosurgical resection
next week now s/p WB XRT with progressive weakness now with
hematuria x 1 week, worsening thrombocytopenia. Per patient's
son, his father and mother have been staying with him and he has
been providing much of the care for his father. [**Name (NI) **] was unaware
that his father was having hematuria until yesterday when his
urine was noted to be dark red. He has also had hemoptysis for a
number of months but worsening in the past 1-2 weeks with
tablespoon of hemoptysis nearly every time he coughs. The cough
is associated with right sided chest pain in the front and back.
Labs are significant for worsening thrombocytopenia of unclear
etiology.
In the ED: 98.8 85 117/71 18 98% RA. foley placed. CT head with
hemorrhagic mets stable from MRI on [**3-12**] but new from [**2192-2-3**].
Currently, he denies any pain but feels very tired.
Past Medical History:
Asthma
COPD
Appendectomy
NSCLC
Oncology TREATMENT HISTORY:
[**8-/2191**] Developed hemoptysis
[**9-/2191**] Saw a doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **], [**Country 5881**] and diagnosed with left
lung mass
[**2192-1-20**] Bronchoscopy
[**2192-1-20**] Pathology showed non small cell lung cancer
[**2192-1-27**] Brain MRI showed two left cerebral lesions with edema
[**2192-2-3**] Stereotactic resection of left parieto-occipital tumor
[**2192-2-14**] Completed radiation to lung
[**2192-3-13**] Completed WBI
Social History:
Originally from [**Country 5881**]. Currently lives in [**Location **]. Patient is
married and has two healthy children. He is retired painter.
He smoked 1.5 packs per day for 55 years and quit a few months
ago.
He was also a heavy drinker but he quit 5 months ago. He denies
any recreational drugs use.
Family History:
Three children, one died in an accident.
Maternal uncle with lung cancer.
Physical Exam:
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, not date (baseline).
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. R VF deficit.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Baseline left sided weakness. LUE [**1-15**], LLE [**3-15**], RUE and
RLE are full motor.
Pertinent Results:
[**2192-3-13**] 01:10PM cTropnT-0.014*
[**2192-3-13**] 01:10PM WBC-10.4 RBC-4.61 HGB-13.2* HCT-41.6 MCV-90
MCH-28.7 MCHC-31.8 RDW-18.0*
[**2192-3-13**] 01:10PM NEUTS-93* BANDS-4 LYMPHS-2* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2192-3-13**] 01:10PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
TEARDROP-OCCASIONAL
[**2192-3-13**] 01:10PM PT-11.1 PTT-22.0* INR(PT)-1.0
[**2192-3-13**] 01:10PM PLT SMR-VERY LOW PLT COUNT-69*
[**2192-3-13**] 11:45AM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
[**2192-3-13**] 11:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-6.0 LEUK-TR
[**2192-3-13**] 11:45AM URINE RBC->182* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**3-12**] MRI: Three markedly enlarged hemorrhagic metastases have
progressed
dramatically since the brain MR [**First Name (Titles) **] [**2192-2-4**]. The
largest of these
measures 35 mm in greatest diameter. Other small metastatic
lesions appear
unchanged.
[**3-13**] CT head: One right and two left frontal hemorrhagic lesions
with surrounding edema, concerning for metastasis. These lesions
were seen in the MRI of [**2192-3-12**], but new since the CT of
[**2192-2-3**]. No new hemorrhage. No midline shift. Prominent
bilateral extra-axial spaces, likely subdural hygromas.
[**3-13**] CXR: PRELIM Consolidation in the lingular segment of the
left lung, is
consistent with known diagnosis of lung cancer. No new pulmonary
pathology
identified.
Pathology Report Tissue: RIGHT PARIETAL LESION. Study Date of
[**2192-3-15**] White matter and blood clot. No tumor identified,
levels x3.
[**3-15**] MRI Brain- IMPRESSION: Previously noted enhancing lesions in
the brain on the MRI of [**2182-3-12**] again identified for WAND study
for surgical planning. No midline shift or hydrocephalus. No
change in the size of the lesion seen since the previous study.
[**3-15**] NCHCT: IMPRESSION: Status post right frontal craniotomy and
resection of right frontal hemorrhagic metastasis with expected
intralesional and intracranial post-surgical changes. Stable
appearance of left frontal hemorrhagic metastasis and left
parieto-occipital encephalomalacia from prior resection. Stable
bilateral subdural hygromas.
[**3-16**] ECG: FINDINGS: The patient has been extubated. Left upper
lobe consolidation has improved. This pattern is consistent with
an obstructive pneumonia consistent with known lingular mass.
There is no pleural effusion or pneumothorax. The heart size is
within normal limits.
[**3-21**] LENI's: IMPRESSION: No evidence of DVT.
Brief Hospital Course:
72 yo M with NSCLC with brain mets s/p parietal/occipital crani
for tumor resection on [**2192-2-3**], relatively new bilateral
frontal hemorrhagic mets scheduled for neurosurgical resection
next week now s/p WB XRT with progressive weakness now with
hematuria x 1 week, worsening thrombocytopenia.
On [**3-13**], The patient completed WBXRT- 3500 cGy over 14 fractions
and was sent to the Emergency Department. He presented with
hematuria,thrombocytopenia, and hemoptysis. The patient had a
Head CT which was consistent with multiple known hemorrhagic
metastases in bifrontal lobes. There was no new intracranial
hemorrhage. The patient was admitted to Oncology with plans to
prepare the patient for surgery on Friday with Dr [**Last Name (STitle) **] for a
craniotomy for resection of brain mass. The platlet level was
69.
On [**3-15**], The patient went to the Operating Room for an elective
craniotomy for resection of brain mass with Dr [**Last Name (STitle) **]. The
patient tolerated the procedure well and was recovered in the
intensive care unit. The goal systolic blood pressure was < 140.
The post operative Head Ct was consistent with expected post
operative changes. The patient was alert and oriented to person
and place at baseline the patient never knows date. He was
moving all extremities and exhibited his baseline level of left
sided weakness. The goal was to keep the patient platlets > 80
for 24 hours post surgery. A blood sample was sent to the lab
and the patient was found to be HEPARIN DEPENDENT ANTIBODIES
Positive. The patient was not started on prophylactic SQ
Heparin as a result. Venodyne boots were on at all times and
mobility was encouraged.
On [**3-16**], POD #2 the patient continued to have a production
productive cough/hemoptysis. He was able to independently raise
secretions and was using a hand held suction independently. A
CXR was performed in the afternoon which was consistent with
left upper lobe consolidation which had improved. The pattern
was consistent with an obstructive pneumonia consistent with
known lingular mass. There was no pleural effusion or
pneumothorax. The heart size was within normal limits. The
platlets were 67 and the patient was transfused with 1 pack of
platlets and post transfusion platlet count was 136. The
dexamethasone was weaned. The systolic blood pressure goal was <
160. A regular insulin sliding scale was initiated given the
dexamethasone. The patients diet wa advanced and physical
therapy and occupational therapy was ordered. The patient was
transferred to the floor.
On [**3-17**], The patient's hematocrit was 21.7 from 27 the day prior
and 2 units of Packed Red Blood Cells were administered with 10
mg IV lasix to avoid fluid volume overload. The patient
continued have hemoptysis although this was improved. The serum
potassium level was 3.8 and was repleated with 20 meq KCL. The
foley catheter remained in place to accuratly moniotr urine
output in the setting of transfusion of blood products and
adminitration of lasix. The platlets count was 63. Decadron was
weaned to 4mg [**Hospital1 **] per neurology oncology recommendations. The
post transfusion hematocrit was 31.3. The evening platlet count
was 37. On exam, the patient is primarily Greek speaking. He
exhibits improved hemotysis. The surgical dressing was removed
and the staples at the incision were intact and the incision was
well approximated. There was no drainage, erythema or edema.
The patient was alert, oriented to person and place. The pupils
5-4mm bilaterally. The patient was able to move all
extremitiesand exhibited baseline Left sided weakness. The left
deltoid strength was [**2-13**], bicep [**1-15**], tricep 4-/5, grip [**1-15**], IP
[**1-15**], quad /ham4-/5, AT/[**Last Name (un) 938**]/[**Last Name (un) **] [**2-13**] RLE full, RUE 5-/5.
HIT markedly positive no heparin.
[**Date range (1) 19033**] The patient remained neurologically stable but
physically continued to become weaker and have increased pain
throughout his body. Palliative Care was consulted and pain
medications were adjusted. Multiple family meetings were held
with the son and daughter in regards to discharge planning.
Their ultimate goal was to send the patient back to [**Country 5881**] which
delayed the patient's discharge in order to figure out how to
best make this happen.
On [**3-23**] the patient continued to appear more weak, refused to
eat and complained of pain. The palliative care team met with
the family again and they all agreed that it would be in the
patient's best interest to be made CMO. Medications except for
pain meds were d/c'd. Patient was kept comfortable and he passed
with family at the bedside on [**2192-3-23**] at 23:30
Medications on Admission:
dexamethasone 4mg [**Hospital1 **]
famotidine 20mg [**Hospital1 **]
advair
keppra 750 [**Hospital1 **]
oxycodone (not really using)
TMP-SMX
acetaminophen prn
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
NSCLCA with mets to brain
Hematuria
Thrombocytopenia
Hemoptysis
COPD
Discharge Condition:
Expired on [**2192-3-23**] at 23:30
Discharge Instructions:
Expired
Followup Instructions:
N/A
Completed by:[**2192-3-23**]
ICD9 Codes: 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3997
} | Medical Text: Admission Date: [**2163-10-17**] Discharge Date: [**2163-10-22**]
Date of Birth: [**2099-6-29**] Sex: M
Service: Trauma
HISTORY OF PRESENT ILLNESS: This is a 64-year-old male found
unconscious in a truck with multiple facial injuries
consistent of superficial lacerations and multiple visible
facial deformities. The patient was initially transferred
from [**Hospital6 302**] where the patient was intubated for
decreased mental status. There, the patient received
tetanus, oxacillin, clindamycin, and Dilantin loading with
mannitol and Solu-Medrol. The patient was nonverbal at the
outside hospital and transferred via Med-Flight. CT scan at
the outside hospital showed pneumocephalus with an occipital
fracture and a cribriform plate fracture. His vital signs
were stable on arrival and transfer. The patient was moving
all four extremities but not responding with opening eyes or
following any commands.
PAST MEDICAL HISTORY: Hypertension.
MEDICATIONS ON ADMISSION: Unknown.
ALLERGIES: Unknown.
SOCIAL HISTORY: Social history later revealed positive
tobacco use.
FAMILY HISTORY: Father with a myocardial infarction in
his 80s, brother with a myocardial infarction in his 60s.
PHYSICAL EXAMINATION ON ADMISSION: Temperature was 100,
heart rate of 99, blood pressure of 120/66, respiratory rate
of 8 intubated. The patient was confused and combative.
HEENT revealed positive ecchymosis and swelling of the
bilateral eyes, right greater than left. Tympanic membranes
were clear. Trachea was midline. Cardiovascular had a
regular rate and rhythm. Negative deformities or ecchymosis
of the chest wall. No crepitus. Breath sounds were severely
decreased in the left base. Old scar on the left thorax.
The abdomen was soft. The pelvis was stable. Rectal
revealed normal tone, guaiac-negative. Extremities had 2+
pedal pulses. No obvious deformities.
LABORATORY DATA ON ADMISSION: White blood cell count of 17,
hematocrit of 42, platelets of 235. Coagulations of PT 12.6,
PTT 24.3, and INR of 1.1. Chem-7 revealed sodium of 141,
potassium 3.1, chloride 105, bicarbonate 22, BUN 14,
creatinine 0.7, and glucose of 131. Fibrinogen of 240,
amylase of 65. His toxicology screen was negative. Lactate
was 5.9.
RADIOLOGY/IMAGING: CT scan of the head showed a left
occipital bone fracture, left axillary wall fracture,
questionable ethmoid sinus fracture, air in bilateral orbit,
and pneumocephalus.
CT scan of the cervical spine was negative.
CT scan of the abdomen and pelvis was negative.
Chest x-ray showed atelectasis with collapse of left lower
lobe.
Cervical spine was negative to C5; pelvis was negative. TLS
showed old compression fractures.
HOSPITAL COURSE: The patient was admitted to the Surgical
Intensive Care Unit for observation of his pneumocephalus.
The Neurosurgery Service was consulted, and it was
recommended that the patient have conservative management
with follow-up head CT, and the patient's follow-up head CT
showed improvement of the pneumocephalus.
The Otolaryngology Service was consulted regarding the facial
fractures, and they also recommended conservative management
for fractures.
Of note, the patient had difficult to control atrial
fibrillation that was not previously known for the patient to
have. The Cardiology Service recommended Lopressor to be
titrated for rate control, and a cardiac echocardiogram which
was performed and showed marked abnormalities. The patient
was rate controlled on 50 mg of Lopressor b.i.d. on which the
patient was sent home.
On [**10-21**] and [**10-22**], the patient was ambulating
throughout the hospital without any difficulty whatsoever and
was at his baseline per his wife. Considering the current
conservative management of all the services, the patient was
discharged home with followup.
MEDICATIONS ON DISCHARGE: Same as discharge instructions
with the addition of Lopressor 50 mg p.o. b.i.d.
DISCHARGE FOLLOWUP: The patient was to follow up with the
[**Hospital 878**] [**Hospital **] Clinic in three to four weeks
at [**Telephone/Fax (1) 1690**]. Neurologically [**Hospital 9105**] Rehabilitation
has recommended no driving or work until followup. The
patient was to follow up with Plastic Surgery as needed for
cosmetic repair of facial fractures within two to three weeks
at [**Telephone/Fax (1) **]. He was also to follow up with his personal
cardiologist closer to his home in [**Location (un) 5503**] in five to
seven days, in addition to his primary care doctor in one to
two days. The patient has been given all of these
instructions and was amenable to this plan.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 34926**]
MEDQUIST36
D: [**2163-10-22**] 11:09
T: [**2163-10-22**] 11:15
JOB#: [**Job Number 29299**]
ICD9 Codes: 5180, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3998
} | Medical Text: Admission Date: [**2132-4-8**] Discharge Date: [**2132-4-11**]
Service: MEDICINE
Allergies:
Plavix
Attending:[**First Name3 (LF) 7202**]
Chief Complaint:
Transferred from [**Hospital 100**] Rehab with acute shortness of breath
Major Surgical or Invasive Procedure:
Intubated
History of Present Illness:
[**Age over 90 **] y.o. female with hx 3VD (99% LAD, 90% LCx, 100% RCA cath in
[**2128**]), refused CABG in past, h/o NSTEMI [**9-11**], CHF (echo [**3-15**] EF
15-20%, 3+ MR, mild AR), admitted for respiratory failure for
third time in last month. Precipitating factors for her repeated
CHF exacerbations are not clear. Patient denies medication
non-compliance or dietary indiscretions. Patient denies cough,
fever, chills, progressive dyspnea, chest pain, orthopnea or PND
prior to admission. Found at [**Hospital 100**] Rehab satting 74% on RA
150/80, 82, 28, 96.8 --> 100 % on NRB RR 30. In the ambulance
received 80 mg IV Lasix, NTG 0.4 SL x3, and magnesium. In ED
found to be in fulminant pulmonary edema, pale, diaphoretic, and
clammy. Put on CPAP and nitro gtt at 40 mcg. In the ED also
received Lasix 100 mg IV once and aspirin 600 mg. Intubated for
impending respiratory distress. Admitted to CCU. Briefly on
dopamine for BP support. Extubated the following day. Weaned off
pressors. Diuresed 1.6 L over CCU stay. Transferred to [**Hospital Unit Name 196**].
The patient was just admitted [**3-25**] -[**3-28**] with similar
presentation. Treated with diuresis and Levaquin for presumed
CAP.
Past Medical History:
1. CAD: 3VD, cath [**2128**] with 99% LAD, 90% LCx, 100% RCA stenoses.
Refused CABG. NSTEMI [**9-11**], hospitalization complicated by
cardiogenic shock requiring pressors and intubation and NSVT.
2. Ischemic cardiomyopathy: echo [**3-15**] EF 15-20%; severe global
LV HK, inferior AK, 1+ AR, [**4-11**]+ MR
3. CHF: Baseline 2 pillow orthopnea, chronic intermittent LE
edema. Numerous admissions for flash pulmonary edema. Most
recently discharge [**3-28**].
4. DM type II
4. HTN
5. Hyperlipidemia
Social History:
Lives at [**Hospital 100**] Rehab. She lost her husband almost 30 years
ago, and has 2 sons. [**Name (NI) 9464**] is a health care proxy. She denies
any history of smoking or alcohol use. No IVDU.
Family History:
non-contributory
Physical Exam:
When evaluated at the time of transfer out of the CCU:
99.4 BP: 96/54 P: 68 R: 24 O2 sat 100% on 2L
Gen: awake, alert, and oriented, in no apparent distress.
Neck: supple, JVP at 8cm
Lungs: Decreased breath sounds at both bases, with sort
bibasilar crackles.
CV: regular, Nl S1S2, II/VI HSM at apex.
Abd: soft, nontender, nondistended, with normoactive bowel
sounds.
Ext: trace LE edema
Pertinent Results:
Admission Labs:
[**2132-4-8**] 09:05AM [**Year/Month/Day 3143**] WBC-12.9*# RBC-4.90# Hgb-14.2# Hct-44.3#
MCV-91 MCH-29.0 MCHC-32.1 RDW-14.2 Plt Ct-815*
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] WBC-7.8 RBC-4.45 Hgb-12.9 Hct-38.6 MCV-87
MCH-29.1 MCHC-33.5 RDW-14.2 Plt Ct-647*
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] Plt Ct-647*
[**2132-4-8**] 09:05AM [**Year/Month/Day 3143**] Neuts-56 Bands-2 Lymphs-30 Monos-1*
Eos-8* Baso-2 Atyps-1* Metas-0 Myelos-0 NRBC-1*
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] Glucose-113* UreaN-36* Creat-1.5* Na-142
K-4.1 Cl-103 HCO3-25 AnGap-18
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] Calcium-9.3 Phos-4.3 Mg-2.1
[**2132-4-9**] 02:49PM [**Year/Month/Day 3143**] %HbA1c-PND
[**2132-4-8**] 11:20AM [**Year/Month/Day 3143**] Type-ART Rates-/18 Tidal V-500 FiO2-100
pO2-253* pCO2-48* pH-7.27* calHCO3-23 Base XS--4 AADO2-413 REQ
O2-72 Intubat-INTUBATED
[**2132-4-8**] 04:27PM [**Year/Month/Day 3143**] Type-ART pO2-129* pCO2-36 pH-7.43
calHCO3-25 Base XS-0
[**2132-4-8**] 11:59AM [**Year/Month/Day 3143**] Lactate-3.6*
[**2132-4-8**] 04:27PM [**Year/Month/Day 3143**] Lactate-1.3
_________________________________
Cardiac enzymes:
[**2132-4-8**] 09:05AM [**Year/Month/Day 3143**] CK-MB-NotDone cTropnT-<0.01
[**2132-4-8**] 09:29PM [**Year/Month/Day 3143**] CK-MB-NotDone cTropnT-0.03*
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] CK-MB-NotDone cTropnT-0.02*
[**2132-4-8**] 09:05AM [**Year/Month/Day 3143**] CK(CPK)-41
[**2132-4-8**] 09:29PM [**Year/Month/Day 3143**] CK(CPK)-40
[**2132-4-9**] 04:18AM [**Year/Month/Day 3143**] CK(CPK)-39
_________________________________
Other Labs:
[**2132-4-10**] 06:40AM [**Year/Month/Day 3143**] Iron-45 calTIBC-192* Hapto-108
Ferritn-353* TRF-148*
[**2132-4-9**] 02:49PM [**Year/Month/Day 3143**] %HbA1c-6.1*
_________________________________
Labs at the time of discharge:
[**2132-4-11**] 06:55AM [**Year/Month/Day 3143**] WBC-4.6 RBC-3.36* Hgb-10.0* Hct-29.2*
MCV-87 MCH-29.8 MCHC-34.3 RDW-14.0 Plt Ct-482*
[**2132-4-11**] 06:55AM [**Year/Month/Day 3143**] Glucose-97 UreaN-39* Creat-1.3* Na-138
K-4.2 Cl-105 HCO3-27 AnGap-10
[**2132-4-11**] 06:55AM [**Year/Month/Day 3143**] Calcium-8.6 Phos-3.9 Mg-2.2
_________________________________
Microbiology:
[**Year/Month/Day **] cultures 3/1/5: NGTD
Urine culture 3/1/5: <10,000 organisms
_________________________________
EKG: rate 100, nl axis, normal intervals, no R waves in V1-3,
left intraventricular conduction delay, secondary ST-T wave
changes in I, aVL, V6, no significant changes from prior EKG
CXR [**2132-4-9**]: There has been substantial interval clearing of the
patient's pulmonary edema.
Brief Hospital Course:
1. CHF exacerbation. This presentation and admission was similar
to the patient's prior admissions for pulmonary edema. There was
not clear etiology for her CHF exacerbation. The patient ruled
out for MI (she did have a small troponin leak in setting of
CHF). CXR on admission showed frank congestive heart failure.
The patent had to be intubated for impeding respiratory distress
in the ED and then was transferred to the CCU. She was diuresed
while still in the ED, and while she was in the CCU. Her beta
blocker, Imdur and ACE inhibitor were held because of
hypotension. She was on dopamine briefly for BP support (the
hypotension was felt to be secondary to aggressive diuresis). In
the CCU she diuresed 1.6 liters negative, with acceptable ABG's
on pressure support, and so was extubated. She was slightly
hypotensive after that (systolics in the 80s) and was placed on
dopamine for a day Once the dopamine was discontinued, her
regular medications were slowly restarted. She was placed back
on her lisinopril and restarted on her carvedilol. She was
continued with Lasix prn for a goal 500 to 1000 cc negative per
day (she usually responded to Lasix 40 mg IV). Her Lisinopril
dose was increased from 2.5 mg to 5 mg po QD for afterload
reduction given the patient's severe MR. [**First Name (Titles) **] [**Last Name (Titles) **] pressures
tolerated this increased dose. Imdur was discontinued as ACE
inhibitor felt to provide greater afterload reduction. Her Lasix
dose was increased to 60 mg po bid (she came in on 40 mg po
bid). She should be on no added salt diet. The patient may be a
candidate for spironolactone if her [**Last Name (Titles) **] pressures can
tolerate.
2. CAD. Patient with 3 vessel disease. She refused CABG in the
past. She ruled out for MI during this admission. Her troponin
was mildly elevated on admission likely in the setting of CHF.
She was continued on Aspirin, Ticlid (cannot take Plavix),
simvastatin (LFTs normal in [**9-11**] and were not rechecked given
likely elevation in the setting of hepatic congestion). The
patient was monitored on telemetry and had no events.
3. Acute on chronic renal failure. Patient with baseline CRI -
1.3-1.5. Her creatinine was elevated to 1.8 on admission, and
had come down to 1.3 by discharge likely secondary to improved
forward flow/renal perfusion.
4. Thrombocytosis. Likely reactive in the setting of acute
illness. Patient with h/o elevated platelets in past to 800's
now over 1000. Platelet count came down to [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 500 on the
day of discharge.
5. Anemia. The patient has chronic anemia. Her baseline HCT is
around 30. Patient's hematocrit was 44 on admission and dropped
to 31.5 on HD #3. Hemolysis labs were checked and were negative.
Iron studies were suggestive on anemia of chronic disease with
low normal serum iron, high ferritin, low TIBC and TRF. This
precipitous drops in hematocrits happened during her last 3
admissions. It is unclear why, as the patient's hematocrit
should go up with diuresis. She was not transfused during this
admission. Her HCT was at 29 by discharge which is about her
baseline. Would recommend rechecking Hct in the next two days to
ensure it is stable.
6. Cough. Patient afebrile. WBC normal. CXR negative for
infiltrate. Likely secondary to irritation post-intubation.
Patient felt symptomatically better with Benzonatate and
guaifenescin.
7. Code status. On Ms. [**Known lastname 42105**] prior admissions here, the
patient seems to have indicated that she wanted to be a DNR/DMI,
but this was reversed while she was at [**Hospital 100**] Rehab. During this
admission the patient stated on several occasions that she does
not want to be resuscitated or intubated. She is aware that her
son [**Name (NI) 9464**] feels that she should be full code. The patient
signed DNR/DMI form and was given a bracelet at the time of
discharge.
Medications on Admission:
Ecotrin 325 mg po qd
Lipitor 80 mg po qd
Coreg 3.125 mg po bid
Colace 100 mg po bid
Lasix 40 mg po bid
Atrovent qid
Imdur 30 mg po qd
Prevacid 30 mg po qd
Levaquin (finished [**4-4**] for CAP)
Zestril 2.5 mg po qd
MVI
Ticlid 250 mg po bid
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Ticlopidine HCl 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 7 days: for cough.
Disp:*21 Capsule(s)* Refills:*0*
8. Docusate Sodium 100 mg Tablet Sig: One (1) Capsule PO BID (2
times a day).
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. 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*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
1. Congestive heart failure
2. Coronary artery disease
3. Mitral Regurgitation
4. Anemia of chronic disease
5. Thrombocytosis
6. Chronic renal insufficiency
Discharge Condition:
Maintaining oxygen sats in mid 90's on room air. Asymptomatic.
Tolerating diet and ambulation without difficulties.
Discharge Instructions:
Please continue to follow up closely with you doctors [**First Name (Titles) **] [**Last Name (Titles) 100**]
Rehab.
Please take all medications as prescribed. Please note that we
increased Lisinopril dose, stopped Imdur, and increased Lasix
dose to 60 mg po twice a day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: [**2127**] liters per day
Followup Instructions:
Please continue to follow closely with you doctors [**First Name (Titles) **] [**Last Name (Titles) 100**]
Rehab.
Completed by:[**2132-4-11**]
ICD9 Codes: 5849, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3999
} | Medical Text: Admission Date: [**2193-12-4**] Discharge Date: [**2193-12-12**]
Date of Birth: [**2130-3-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Presents for surgical resection of an esophageal and gastric
mass
Major Surgical or Invasive Procedure:
[**12-4**] Laparoscopic resection of gastric and esophageal massess
with Nissen fundoplication
History of Present Illness:
Mr. [**Known lastname **] presented to [**Hospital1 18**] on [**12-4**], for scheduled surgical
resection of his gastric and esophageal masses under the care of
Dr. [**Last Name (STitle) **].
Past Medical History:
Past Surgical History:
Hypercholestremia
Past Surgical History;
Hernia
Back surgery
Social History:
Vietnamese speaking
Family History:
Non-contributory
Pertinent Results:
Post-operative:
[**2193-12-5**] 01:25AM BLOOD WBC-11.9*# RBC-4.03* Hgb-12.7* Hct-35.6*
MCV-88 MCH-31.5 MCHC-35.6* RDW-13.2 Plt Ct-205
[**2193-12-5**] 01:25AM BLOOD Plt Ct-205
[**2193-12-5**] 01:25AM BLOOD Glucose-162* UreaN-20 Creat-0.9 Na-139
K-4.0 Cl-112* HCO3-19* AnGap-12
[**2193-12-5**] 01:25AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.7
[**2193-12-5**] 09:01AM BLOOD freeCa-1.01*
Discharge:
[**2193-12-8**] 03:55AM BLOOD WBC-9.4 RBC-4.17* Hgb-13.4* Hct-36.7*
MCV-88 MCH-32.1* MCHC-36.5* RDW-13.0 Plt Ct-199
[**2193-12-8**] 03:55AM BLOOD Plt Ct-199
[**2193-12-9**] 06:20AM BLOOD Glucose-111* UreaN-10 Creat-0.6 Na-138
K-4.2 Cl-106 HCO3-22 AnGap-14
[**2193-12-9**] 06:20AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.3
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 69455**],[**Known firstname 69456**] [**2130-3-15**] 63 Male [**-6/4772**] [**Numeric Identifier 69457**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]
SPECIMEN SUBMITTED: Gastric mass, LN for immunophenotyping.
Procedure date Tissue received Report Date Diagnosed
by
[**2193-12-4**] [**2193-12-5**] [**2193-12-12**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/stu
Previous biopsies: [**-6/4760**] GASTRIC MASS( LYMPHOMA W/U),
LYMPH NODE (PERISPLENIC),
[**-6/4472**] GE JX 40-43 cm.
[**-6/3925**] GASTRIC BX'S, 2.
DIAGNOSIS:
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING:
The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda and CD antibodies: 2,3,5,7,10,19,20,23 and 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. B cells are polyclonal and do not
express aberrant antigens. T cells express mature lineage
antigens.
INTERPRETATION:
Non-specific lymphoid profile; no phenotypic evidence of
lymphoma in specimen. Correlation with clinical findings and
morphology (see separate report) is recommended, as the H&E
sections show a probable malignant neoplasm. Flow cytometry
immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.
Note: This test was performed using analyte specific reagents
(ASRs). These ASRs have not been cleared or approved by the US
Food and Drug Administration (FDA). However, the FDA has
determined that such clearance or approval is not necessary .
This test was developed and its performance characteristics
determined by the Flow Cytometry Laboratory at [**Hospital1 771**], which is licensed by CLIA to perform
high complexity tests. This test was used for clinical
purposes; it should not be regarded as for research.
Clinical: Rule out lymphoma.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 69455**],[**Known firstname 69456**] [**2130-3-15**] 63 Male [**-6/4786**] [**Numeric Identifier 69457**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]
SPECIMEN SUBMITTED: LN for immunophenotyping
Procedure date Tissue received Report Date Diagnosed
by
[**2193-12-5**] [**2193-12-6**] [**2193-12-12**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/kg
Previous biopsies: [**-6/4772**] Gastric mass, LN for
immunophenotyping.
[**-6/4760**] GASTRIC MASS( LYMPHOMA W/U), LYMPH NODE
(PERISPLENIC),
[**-6/4472**] GE JX 40-43 cm.
[**-6/3925**] GASTRIC BX'S, 2.
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: FMC-7, Kappa,
Lambda, and CD antigens 3, 5, 10, 19, 20, 23 and 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
INTERPRETATION
Non-diagnostic study. Cell marker analysis could not be
performed in this case due to insufficient numbers of
lymphocytes for analysis. If clinically indicated, we recommend
a repeat specimen be submitted to the flow cytometry laboratory.
Please refer to surgical pathology report S06-[**Numeric Identifier 69458**] for further
details.
Note: This test was performed using analyte specific reagents
(ASRs). These ASRs have not been cleared or approved by the US
Food and Drug Administration (FDA). However, the FDA has
determined that such clearance or approval is not necessary .
This test was developed and its performance characteristics
determined by the Flow Cytometry Laboratory at [**Hospital1 771**], which is licensed by CLIA to perform
high complexity tests. This test was used for clinical
purposes; it should not be regarded as for research.
Clinical: Rule out lymphoma.
Cardiology Report ECG Study Date of [**2193-12-6**] 12:22:50 AM
Atrial fibrillation with a moderate ventricular response.
Otherwise, no
significant diagnostic abnormality. Compared to the previous
tracing
of [**2193-11-29**] atrial fibrillation is new. Clinical correlation is
suggested.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 0 84 [**Telephone/Fax (2) 69459**]6 21
Cardiology Report ECG Study Date of [**2193-12-6**] 8:59:12 AM
Sinus rhythm. ECG findings are within normal limits. Compared to
the previous
tracing of [**2193-12-6**] patient is now in sinus rhythm.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
65 186 86 [**Telephone/Fax (2) 69460**] 39
RADIOLOGY Final Report
ESOPHAGUS [**2193-12-10**] 11:49 AM
ESOPHAGUS
Reason: Evaulate for leak
Contrast: CONRAY
[**Hospital 93**] MEDICAL CONDITION:
63 year old man with esophageal and gastric mass, [**12-4**] s/p
laparoscopic resection.Please use gastrograffin for study
REASON FOR THIS EXAMINATION:
Evaulate for leak
INDICATION: 63-year-old male with esophageal and gastric mass
which were resected laparoscopically on [**2193-12-4**].
Please evaluate for extravasation.
FINDINGS: The scout images demonstrate feeding tube in the left
upper quadrant of the abdomen. There is a small left-sided
pleural effusion.
Conray followed by thin barium was used in this study. There is
prompt passage of contrast through the esophagus past the region
of anastomosis and into the small bowel. There is no evidence of
contrast extravasation. There is a small focal outpouching near
the anastomotic site which may be simply postoperative change,
or a small diverticulum. This drains promptly.
IMPRESSION: No evidence of extravasation of contrast after
esophageal and gastric mass resection.
RADIOLOGY Final Report
CAROTID SERIES COMPLETE [**2193-12-10**] 9:40 AM
CAROTID SERIES COMPLETE
Reason: R carotid bruit
[**Hospital 93**] MEDICAL CONDITION:
63 year old man needs eval of B carotids POD 6 s/p lap resection
of gastroesophageal mass, PEG, Nissen fundoplication.
REASON FOR THIS EXAMINATION:
R carotid bruit
INDICATION FOR EXAM: This is a 63-year-old man with right
carotid bruits.
RADIOLOGISTS: The exam was read by doctors [**Name5 (PTitle) 15785**] and [**Name5 (PTitle) 380**].
TECHNIQUE: Extracranial evaluation of bilateral carotids was
performed with B-mode, color and spectral Doppler modes in
ultrasound.
FINDINGS: On the right, peak systolic velocities are 65, 100,
and 75 cm/sec in the internal, common, and external carotid
arteries, respectively. The right ICA to CCA ratio is 0.65.
On the left, peak systolic velocities are 75, 94, and 75 cm/sec
in the internal, common, and external carotid arteries,
respectively. The left ICA to CCA ratio is 0.79.
Both vertebral arteries present with antegrade flow.
COMPARISON: None available.
IMPRESSION: There is no stenosis within the bilateral internal
carotid arteries.
Operative and gastric mass pathology reports: Unavailable at
time of discharge
Brief Hospital Course:
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a laparoscopic resection of an esophageal and
gastric masses with placement of PEG and Nissen fundoplication
on [**12-4**] with no intra-operative complications. Post-operatively
he was transferred to the ICU intubated, NPO, intravenous
hydration, JP drain, gastrostomy to straight drainage, foley
catheter, nasogastric tube; he was hemodynamically stable with a
hematocrit of 35, and received intravenous beta-blockade for
optimal cardio protection. On POD 1, he was extubated and was
oxygenating well on nasal cannula; he developed atrial
fibrillation which converted to sinus rhythm with increased
beta-blockade. On POD 4, he was transferred to an in-patient
nursing unit, his foley catheter and nasogastric tube were
removed; he remained afebrile with good pain control with
Morphine Sulfate. On POD 6, he [**Month/Year (2) 1834**] a Gastrografin swallow
study which was negative for a leak, his diet was advanced, and
he had +flatus. On POD 7, he had bilateral carotid ultrasounds
performed for a past history of a right carotid bruit which were
negative for stenoses. On POD 7, the JP was removed, he was
ambulating independently, tolerating soft solids, had good pain
control with Percocet elixir, and had good rate control on oral
Metoprolol. He was discharged home in good condition on [**12-12**]; he
was provided prescriptions for Percocet elixir, Metoprolol, and
Protonix. He was discharged with the gastrostomy tube clamped
and instructions for following a soft solid diet. He was to
follow-up with Dr. [**Last Name (STitle) **] in [**1-7**] weeks, and his PCP [**Last Name (NamePattern4) **] [**12-27**].
His discharge instructions were provided with the presence of
his daughter who speaks Vietnamese and provided translation.
Medications on Admission:
Multivitamin
Calcium
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*200 ML(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours: Take in morning with breakfast
And at bedtime
Change your position slowly.
Disp:*60 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation: Hold for loose stool.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Gastric and esophageal mass
Atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
Notify MD or return to the emergency department if you
experience:
*Increased or persistent pain not relieved by pain medication
*Fever > 101.5 or chills
*If incision appears red or if there is drainage
*Difficulty or inability swallowing
*Nausea, vomiting, or diarrhea
*Inability to pass gas, stool, or urine
*If gastrostomy tube is pulled out of if there is redness or
drainage around exit site
*Shortness of breath, chest pain, or palpitations
*Any other symptoms concerning to you
You may shower and wash incision with soap and water, keep dry
dressing over exit site of gastrostomy tube at all times, must
be changed after shower.
Allow white paper strips to peel away on their own
No swimming or tub baths
Discharge Instructions: What to expect when you go home:
It is normal to feel weak and tired, this will last for [**6-13**]
weeks
* You should get up out of bed every day and gradually increase
your activity each day
* You may walk and you may go up and down stairs
* Increase your activities as you can tolerate- do not do too
much right away!
It is normal to have a decreased appetite, your appetite will
return with time
* Eat small frequent meals
*Eat only SOFT FOODS for 2 weeks
What activities you can and cannot do:
* No driving, operating machinery, or alcohol use while taking
pain medication
* Increase your activities as you can tolerate- do not do too
much right away!
*No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
*You need to keep a dry dressing over the exit site of the
gastrostomy tube
* Take all medications as prescribed
You were started on a medication for your heart rate, this may
cause dizziness and/or lightheadness. Be sure to change your
position slowly
If you continue to experience dizziness, hold the dose
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**1-7**] weeks, call [**Telephone/Fax (1) 2981**] for
an appointment
Follow-up with Dr. [**First Name (STitle) **] on [**12-27**] at 10:30am, call [**Telephone/Fax (1) 69461**]
for questions or concerns
Completed by:[**2193-12-12**]
ICD9 Codes: 2720, 2859 |
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