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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4000
} | Medical Text: Admission Date: [**2175-7-17**] Discharge Date: [**2175-7-25**]
Date of Birth: [**2102-6-19**] Sex: F
Service: MEDICINE
Allergies:
Lactose / Levofloxacin
Attending:[**Last Name (NamePattern1) 9662**]
Chief Complaint:
shortness of breath, chest pain
Major Surgical or Invasive Procedure:
L PICC Line Insertion for TPN
History of Present Illness:
73 year old woman with h/o medullary and papillary thyroid CA
s/p radiation c/b esophageal strictures requiring monthly
dilations and h/o aspiration pneumonias who p/w SOB and CP. She
has been feeling more SOB with increased productive cough for
several days. Has felt warm but no objective fevers. This
morning felt a "heavy feeling" in her chest which lasted all day
so she came to the ED. She gets esophageal dilations approx
every 6 weeks and was due for one tomorrow. Has been having
increased dysphagia and subsequent poor PO intake.
.
In the ED initial VS were 99.0, 111, 139/76, 28, 80% on RA. Sats
increased to 90% on 6L, high 90s on 40% venti mask. EKG with
questionable lateral ST depressions. Labs notable for nml WBC
(but 90% PMNs), neg trop, neg lactate. VBG 7.45/41/65/29. CXR
with RLL infiltrate so patient given ceftriaxone and
azithromycin. Also ASA 325mg. Also given 1L NS at 75/hr.
Patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] had goals of care converstion with
patient in the ED. Patient has had feeding tubes in the past and
is unsure whether she would want another one. She is amenable to
temporary noninvasive ventilatory support but would not want to
be intubated or resuscitated. VS prior to transfer were 99.7,
95, 107/68, 25, 93% on 40% venti mask.
.
On arrival to the MICU, patient is wearing venti mask. Has
noticeable productive cough but states that her breathing is
slightly improved.
Past Medical History:
- Medullary and papillary thyroid CA s/p thyroidectomy and XRT
in [**1-26**] with elevated calcitonin treated with monthly octreotide
- Esophageal strictures secondary to radiation s/p esophageal
balloon dilatations approx one a month
- H/o PEG tubes
- Recurrent aspiration pneumonia
- Radiation-associated cervical myelopathy and foot drop
- Hypertension
- Lactose intolerance
- IBS
- S/p TAH
- Basal cell carcinoma face/arms
- Varicose veins s/p stripping
- Eye surgery for strabismus as a child
- Osteopenia
Social History:
Married. Has 8 kids. Worked as a receptionist/housewife
Smoking: denies
EtOH: denies
Drugs: denies
Family History:
Her father died from gastric cancer. Mom died from leukemia.
Brother had skin cancer, other brother with DM, and daughter
also had papillary thyroid cancer.
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
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
.
DISCHARGE EXAM:
VS- 98.2 BP 123/77 P87 R18 O298 RA
Gen- Thin, frail elderly lady, cachetic. 1L O2.
HEENT- trismus present, MM dry
Lungs- Course inspiratory and fine expiratory wheezes.
CV- S1S2, holosystolic murmur, no g/c/r.
Abd- Soft, nt/nd, no hepatosplenomegaly.
Ext- No c/c/e.
Neuro- A&Ox 3, no focal deficits
Pertinent Results:
ADMISSION LABS:
[**2175-7-17**] 05:45PM BLOOD WBC-9.3 RBC-4.56 Hgb-13.4 Hct-40.6 MCV-89
MCH-29.3 MCHC-32.9 RDW-13.0 Plt Ct-291
[**2175-7-17**] 05:45PM BLOOD Neuts-89.8* Lymphs-5.1* Monos-4.2 Eos-0.2
Baso-0.7
[**2175-7-17**] 05:45PM BLOOD PT-11.9 PTT-28.5 INR(PT)-1.1
[**2175-7-17**] 05:45PM BLOOD Glucose-118* UreaN-20 Creat-0.6 Na-141
K-4.3 Cl-100 HCO3-27 AnGap-18
[**2175-7-17**] 05:45PM BLOOD cTropnT-<0.01
[**2175-7-17**] 05:45PM BLOOD Calcium-8.5 Phos-2.5*# Mg-1.8
[**2175-7-17**] 05:50PM BLOOD Lactate-1.9
[**2175-7-17**] 05:50PM BLOOD Type-[**Last Name (un) **] pO2-65* pCO2-41 pH-7.45
calTCO2-29 Base XS-3 Comment-GREEN TOP
MICRO:
Sputum Cx Negative
Blood Cx Pending
Negative MRSA screen
IMAGING:
CXR [**7-17**]
IMPRESSION: Bibasilar opacities compatible with pneumonia in
the proper
clinical setting. Alternatively these could be related to
aspiration given distribution. Clinical correlation is
suggested. Repeat exam after treatment is recommended to
document resolution.
CXR [**7-21**]
IMPRESSION:
1. Increasing multifocal airspace opacities, concerning for
pneumonia.
2. New mild pulmonary edema.
3. New left upper extremity PICC, the tip of which is in the
lower SVC.
DISCHARGE LABS:
[**2175-7-25**] 06:20AM BLOOD WBC-6.2 RBC-3.57* Hgb-10.5* Hct-32.4*
MCV-91 MCH-29.4 MCHC-32.5 RDW-12.8 Plt Ct-244
[**2175-7-24**] 06:03AM BLOOD Glucose-96 UreaN-24* Creat-0.6 Na-140
K-4.6 Cl-102 HCO3-34* AnGap-9
[**2175-7-24**] 06:03AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
Brief Hospital Course:
73F with h/o medullary and papillary thyroid CA s/p radiation
c/b esophageal strictures requiring monthly dilations and h/o
aspiration pneumonias who p/w SOB, found to have RLL pneumonia.
# SOB: CXR c/w RLL pneumonia. Patient with h/o esophageal
strictures and aspiration, so likely aspiration pneumonia.
Continued ceftriaxone and azithromycin and sent sputum culture
which were negatve. Pt was stabilized in the MICU and discharged
to medicine floor a day later. Her O2 status while on the floor
improved and we gradually weaned her off oxygen, no fevers, no
WBC elevation. Respiratory was consulted to help with clearing
airway secretions. Pulmonary was consulted on the option of
suppression antibiotics, f/u appt [**Month/Day/Year 1988**].
# Chest pain: Likely in the setting of cough and pneumonia, and
has since resolved. Unlikely ACS given that it lasted all day,
two troponins negative, and no ischemic ekg changes. Given
hypoxia, PE is a possibility, though lower liklihood given
pneumonia on CXR. Pneumonia treatment as discussed above. No CP
while on the medicine floor.
# Dysphagia: Secondary to known esophageal strictures from
radation tx for thyrood CA. Overdue for dilation which she has
every 6 weeks. NPO for a few days while we determined what were
her options for nutrition. Unable to do dilation while in the
hospital (current condition, O2 req) so we decided to place L
PICC and begin TPN [**7-21**]. TPN would be a bridge until her medical
condition improved and she would be able to tolerate the
dilation. Palliative care was consulted to discuss nutrition
options and end-of-life issues.
# Medullary/Papillary thyroid CA: S/p radiation c/b esophageal
strictures. Thyroid scan on [**7-11**] showed new areas of recurrence
in the left thyroid bed. Patient is followed by Dr. [**Last Name (STitle) **]
from oncology.
# Hypertension: Started Clonidine patch since pt will be unable
to take PO pills while she waits for dilation.
#Hypothyroidism - Stable, pt to stop levothyroxine (cannot take
it PO) until after dilation per endocrinology recs. If she does
not go for dilation in 2 weeks, she may need to start IV
levothyroxine at home.
Transitional Issues- Please follow up with your PCP and
endocrinologist regarding your levothyroxine dose. Per
endocrinology, she will not receive levothyroxine until dilation
when she can take it PO. No pending labs.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - [**1-23**] HFA(s)
inhaled every 4-6 hours as needed for shortness of breath or
wheezing
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth daily at bedtime
may be crushed
LEVOTHYROXINE [LEVOXYL] - 125 mcg Tablet - 1 (One) Tablet(s) by
mouth once a day No substitution. - No Substitution
LORAZEPAM - 0.5 mg Tablet - 1-1.5 Tablet(s) by mouth nightly as
needed 90 day supply
OCTREOTIDE ACETATE [SANDOSTATIN LAR DEPOT] - 20 mg Kit - 1
injection IM monthly
SALMETEROL [SEREVENT DISKUS] - 50 mcg Disk with Device - 1 puff
inhaled once or twice daily
CALCIUM CARBONATE-VITAMIN D3 - (Prescribed by Other Provider) -
500 mg (1,250 mg)-200 unit Tablet - 1 (One) Tablet(s) by mouth
once a day with mag
CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Tablet - 1
(One) Tablet(s) by mouth daily
IBUPROFEN [MOTRIN] - (Prescribed by Other Provider) - 100 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
IMMODIUM - (OTC) - Dosage uncertain
LACTOSE-FREE FOOD WITH FIBER [ISOSOURCE 1.5 CAL] - Liquid -
one
can by mouth four times a day Give three cases
MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth
once a day
Discharge Medications:
1. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QFRI
2. Lorazepam 0.5 mg PO HS:PRN insomnia
Please place tablet under the tongue and let dissolve. DO NOT
SWALLOW TABLET.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
Primary- Aspiration Pneumonia, Esophogeal Stricture
Secondary- H/o Thyroid CA (Medullary, Papillary), HTN,
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear [**Known firstname **] [**Known lastname **],
It was a pleasure taking care of you during your stay at [**Hospital1 18**].
You were admitted for shortness of breath and chest pain. X-ray
of your chest showed that you had a pneumonia. We treated you
with antibiotics. We decided to start nutrition feeds through
the vein in order to allow you to recover from the pneumonia so
that you can tolerate the esophogeal dilation. You did well
recovering from pneumonia, and did not require any additonal
oxygen.
Your condition improved and were discharged home.
Please keep the doctor [**First Name (Titles) 4314**] [**Last Name (Titles) 1988**] and there is an
updated medication list attached.
Followup Instructions:
Dr. [**Last Name (STitle) **], Gastroenterology
[**2175-8-8**]
Completed by:[**2175-7-25**]
ICD9 Codes: 5070, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4001
} | Medical Text: Admission Date: [**2108-3-9**] Discharge Date: [**2108-3-30**]
Service: GENERAL SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
woman with a previous medical history of coronary artery
disease and hypothyroidism who presented to the Medical
Service a couple of days ago with "constipation". During
further observation and workup, the patient has been found to
have an obstructing lesion in the distal transverse colon and
presents to the Surgical Service with a massively dilated
cecum secondary to the obstructing colon lesion. The patient
was admitted to the Surgical Service for laparotomy.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypothyroidism.
PAST SURGICAL HISTORY: None.
ADMISSION MEDICATIONS:
1. Synthroid.
2. Fosamax.
3. Zoloft.
4. Lopressor.
5. Lasix.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: General: On admission to
the Surgical Service, the patient presented with a distended
abdomen and tenderness in the right part of the abdomen.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2108-3-9**] for exploration. A massively dilated cecum
secondary to an obstructing lesion in the splenic flexure was
found. Considering the patient's age and somewhat unstable
condition, it was decided to only do a cecostomy at this
procedure.
The patient underwent that procedure without complications
and had a relatively uneventful postoperative course. The
patient was then taken back to the Operating Room on [**2108-3-21**]
for a definitive procedure regarding her obstructing colon
cancer. At that procedure, a right hemicolectomy was
performed.
The patient's initial postoperative course was relatively
uneventful. Subsequently, the patient developed pulmonary
insufficiency and on postoperative day number eight, after
the right hemicolectomy, the patient's family made the
patient DNR and she expired on the following day, [**2108-3-30**].
DISCHARGE DIAGNOSIS:
1. Obstructing colon cancer.
2. Status post exploratory laparotomy and cecostomy.
3. Status post right hemicolectomy.
4. Hypothyroidism.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 49859**]
Dictated By:[**Last Name (NamePattern4) 95573**]
MEDQUIST36
D: [**2108-6-27**] 10:21
T: [**2108-7-4**] 09:54
JOB#: [**Job Number 95574**]
ICD9 Codes: 412, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4002
} | Medical Text: Admission Date: [**2131-10-31**] Discharge Date: [**2131-11-6**]
Date of Birth: [**2083-10-23**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
male with prior cardiac history significant for coronary
artery disease, history of myocardial infarction, history of
congestive heart failure, cardiomyopathy and aortic
regurgitation. The patient's aortic insufficiency has
progressed from moderate to severe over the last several
years. The patient claimed that he had a few symptoms.
However, his wife stated that he has had more dyspnea on
exertion and fatigue recently. The patient smokes
approximately one pack a day. He is overweight. The patient
denies any chest pain. The patient also has a history of
sleep apnea. A recently performed echocardiogram showed
moderate severe aortic insufficiency with ejection fraction
of approximately 25%. A repeat cardiac catheterization
performed on [**2131-9-3**] showed one vessel branch coronary artery
disease, moderate to severe aortic regurgitation, severe
global left ventricular systolic dysfunction, mild
biventricular systolic dysfunction and mild pulmonary
arterial diastolic hypertension. At the time, the left
ventricular ejection fraction was estimated to be 29%. Given
the patient's worsening symptoms, the decision was made to
proceed with an aortic valve replacement as a long term
solution.
PAST MEDICAL HISTORY:
1. [**6-24**] echocardiogram with ejection fraction of 20% to 25%
with multiple wall motion abnormalities including apical
akinesis, anteroseptal hypokinesis/akinesis, inferior
hypokinesis/akinesis as well as lateral hypokinesis/akinesis.
2. Congestive heart failure with ejection fraction of 20% to
29%. History of myocardial infarction.
3. Aortic insufficiency
4. Cardiomyopathy
5. Coronary artery disease
6. Sleep apnea
PAST SURGICAL HISTORY: No known surgical history.
MEDICATIONS:
1. Coumadin 5 mg po q day
2. Lipitor 20 mg po q day
3. Mavik 4 mg po q day
4. Lasix 40 mg po q day
5. Toprol XL 25 mg po q day
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION:
VITAL SIGNS: Afebrile, heart rate 70 and sinus rhythm, blood
pressure 130/81.
GENERAL: Alert and oriented in no apparent distress, obese
white male.
HEAD, EARS, EYES, NOSE AND THROAT: Within normal limits. No
evidence of jugular venous distention. No evidence of
bruits.
PULMONARY: Clear to auscultation bilaterally.
CARDIAC: Sinus rhythm, 2/6 systolic murmur and [**3-28**] diastolic
murmur.
ABDOMEN: Obese, soft, nontender.
EXTREMITIES: No edema, pulses present and are palpable
bilaterally.
LABORATORY STUDIES ON ADMISSION: Hematocrit 30.5, white
blood cell count 10.2, platelets 122. PTT 35.2, PT 12.2, INR
1.0. Glucose 119, BUN 14, creatinine 0.9. Sodium 136,
potassium 4.7.
IMAGING: Preoperative chest x-ray was within normal limits.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to
cardiac surgery service. Given symptomatic aortic
insufficiency and also history of congestive heart failure,
it was decided that a surgical intervention would be
appropriate. On [**2131-10-31**], the patient underwent aortic valve
replacement with a 23 mm Carbomedics mechanical valve. The
procedure was without any complications. The patient
tolerated the procedure well. Please see the full operative
note for details. The patient remained intubated and was
transferred to the Intensive Care Unit for further management
in stable condition. The patient was extubated on the same
day. His oxygenation remained good. He was making adequate
urine.
Postoperatively, the patient's arterial blood gas was pH
7.38, PCO2 of 34, PO2 of 110. His hematocrit was stable at
30.5. The patient was further diuresed. He was transferred
to the regular floor on postoperative day 1 in good
condition. The patient continued to have excellent
oxygenation on minimal supplemental oxygen. Physical therapy
was consulted which followed the patient throughout his
hospitalization and then officially cleared him to go home.
Anticoagulation with Coumadin was restarted. Given the
presence of a mechanical valve, an INR of 2.5 to 3 was set as
the goal.
The patient remained afebrile. He remained in sinus rhythm.
His lungs were clear to auscultation bilaterally. His pacing
wires were removed on postoperative day 3. His urine
catheter was removed on postoperative day 2. The patient was
also started on intravenous heparin on postoperative day 3
given slow rise in the NR level. The patient was ambulating
without assistance. The patient was continued to be diuresed
with Lasix. He had 1+ lower extremity edema bilaterally.
His incision was clean, dry and intact throughout this
hospitalization course. On the date of discharge, his INR
was 1.9. The patient was discharged to home on postoperative
day 6.
DISCHARGE CONDITION: Stable
DISCHARGE DISPOSITION: Home
DISCHARGE DIAGNOSES:
1. Severe aortic insufficiency, status post aortic valve
replacement with a 23 mm Carbomedics mechanical valve.
2. Congestive heart failure
3. Cardiomyopathy
4. Sleep apnea
DISCHARGE MEDICATIONS;
1. Lasix 20 mg po bid x14 days
2. Lipitor 20 mg po q day
3. Lopressor 50 mg po bid
4. Coumadin 7.5 mg on [**2131-11-6**] and 7.5 mg on [**2131-11-7**] (to
follow up at the [**Hospital 197**] Clinic for further dosing).
5. Potassium chloride 20 milliequivalents po bid x14 days
6. Colace 100 mg po bid
7. Percocet 1 to 2 tablets po q 4 to 6 hours prn pain
DISCHARGE INSTRUCTIONS:
1. The patient is to follow up with his surgeon, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], in approximately for weeks.
2. The patient is to follow up with Dr. [**First Name (STitle) **] Grape, who is
his primary care physician and cardiologist, in approximately
one week.
3. The patient is to follow up at the [**Hospital 197**] Clinic in two
days to have his INR levels drawn and his Coumadin levels
adjusted.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1112**] 02-229
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2131-11-6**] 11:07
T: [**2131-11-6**] 11:03
JOB#: [**Job Number 39816**]
ICD9 Codes: 4241, 4280, 4254, 4168, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4003
} | Medical Text: Admission Date: [**2122-3-12**] Discharge Date: [**2122-3-28**]
Date of Birth: [**2056-8-28**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Atraumatic Subarachnoid Hemorrhage
Major Surgical or Invasive Procedure:
angiograms
extraventricular drain
VP shunt placement
History of Present Illness:
Patient is a 65 yo woman with no PMH who was found down tonight
by family members, wedged between the bed and the wall. She was
confused, moaning and complaining of a headache. She was taken
to [**Last Name (un) 1724**] where a CT showed diffuse SAH particularly in basilar
cistern, with no vascular anomaly on CTA.
Transferred here where she continues to be confused, but awake
and alert. Currently only complaining of headache and neck
ache.
Past Medical History:
none per niece
Social History:
lives with family in 2 family. no tob/etoh.
Family History:
Heart Dz, choesterol
Physical Exam:
PHYSICAL EXAM:
O: T: na BP: 135/86 HR: 92 R 23 O2Sats 92% NC
Gen: WD/WN, comfortable, NAD.
HEENT: MMM an intact
Neck: in hard collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Confused.
Oriented to [**Hospital6 **], [**2123**], self. Language intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally. Visual fields difficult to assess.
III, IV, VI: bilateral 6th N palsies.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-2**] triceps and antigravity legs.
Sensation: Intact to light touch x 4
Reflexes: B T Br Pa Ac
Right 2 throughout
Left 2 throughout
Toes up bilaterally
Coordination: normal on finger-nose-finger
Pertinent Results:
CT: Diffuse SAH with greatest concentration at basilar cistern.
CTA [**First Name8 (NamePattern2) **] [**Last Name (un) 1724**] radiologist does not show vascular abnormalities.
[**2122-3-12**] 01:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]->1.050
[**2122-3-12**] 01:50AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2122-3-12**] 01:50AM URINE RBC-0-2 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2122-3-12**] 01:50AM PT-14.0* PTT-25.2 INR(PT)-1.2*
[**2122-3-12**] 01:50AM WBC-21.3* RBC-5.38 HGB-13.8 HCT-42.1 MCV-78*
MCH-25.7* MCHC-32.9 RDW-14.5
[**2122-3-12**] 01:50AM NEUTS-90* BANDS-0 LYMPHS-5* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2122-3-12**] 01:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2122-3-12**] 01:50AM CALCIUM-9.6 PHOSPHATE-2.7 MAGNESIUM-2.0
[**2122-3-12**] 01:50AM CK(CPK)-222*
[**2122-3-12**] 01:50AM cTropnT-0.33*
[**2122-3-12**] 01:50AM GLUCOSE-220* UREA N-19 CREAT-0.9 SODIUM-139
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-18* ANION GAP-24*
Brief Hospital Course:
Was transferred from OSH and was admitted to the ICU where she
then had an EVD placed due to hydrocephalus. She was also found
to have a small troponin leak which peaked at .37.
Hemodynamically stable. On [**3-12**] she was then intubated for a
cerebral angiogram which did not show an aneurysm. She remained
intubated due to concern for aspiration because a carrot was
seen in ETT after intubation. Later in the evening she
self-extubated and she was stable on face tent. On admission she
was found to have bilateral 6th nerve palsies which opthalmology
recommended f/u in 1 month. She failed clamping trials of her
EVD, and was taken to the OR for a VP shunt placement on [**3-23**].
Postoperatively she was transferred to the floor. She continues
to have diarrhea and is C.diff negative x 2. On [**3-28**] she was
stable for d/c to rehab. She will f/u with opthalmology in 1
month and continue on her nimodipine for 21 days. She will f/u
with Dr. [**First Name (STitle) **] in 1 month with an MRI/MRA.
Medications on Admission:
none
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed.
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
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. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6HRS
PRN () as needed for SBP > 140.
11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed).
12. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours).
13. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
subarachnoid hemorrhage
Discharge Condition:
stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need an MRI/MRA of the brain prior to your
appointment. This can be scheduled when you call to make your
office visit appointment.
Follow up with your ophthomologist within one month.
ICD9 Codes: 486, 5180, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4004
} | Medical Text: Admission Date: [**2105-3-6**] Discharge Date: [**2105-3-12**]
Date of Birth: Sex: M
Service: NEONATOLOGY
PRELIMINARY DIAGNOSIS: Upper gastrointestinal bleed,
resolved.
SECONDARY DIAGNOSIS:
1. Acute gastritis.
2. Hyperbilirubinemia, resolved.
3. Sepsis evaluation.
HISTORY OF PRESENT ILLNESS: The patient, [**Known lastname 51628**], is a 3795
gram male, born to a 33 year old, Gravida I, Para I Mom who
was admitted to the Neonatal Intensive Care Unit after bloody
emesis. Maternal prenatal laboratory studies include
hepatitis surface antigen negative, RPR nonreactive, Rubella
immune, blood type A positive and antibody negative.
Estimated date of confinement of [**2105-3-3**]. Mom had a benign
prenatal course.
She presented on [**3-6**] in spontaneous labor. Due to arrest of
descent, infant was delivered by cesarean section on [**3-6**] at
22:21. Infant required positive pressure bag-mask ventilation
for four minutes; bulb suctioned for thick secretions, none noted
to be bloody at the time of delivery. The patient was transferred
to the newborn nursery for further care. In the newborn nursery,
baby had some spits of old blood noted overnight. Neonatal
Intensive Care Unit team was contact[**Name (NI) **] at 3 p.m. on the 17th
when the infant vomited a moderate amount of dark maroon colored
blood. Vital signs always remained stable, including blood
pressure. He was brought to the Neonatal Intensive Care Unit
for further evaluation.
Mom was GBS negative. She had a low grade fever less than
100.4. Rupture of membranes five hours prior to delivery.
No meconium stained amniotic fluid.
PHYSICAL EXAMINATION: Weight was 3795 grams; head
circumference 36.5 cm; length 20 inches; blood pressure mean
48; heart rate 140's; respiratory rate 50. The patient is a
well appearing infant in no distress, responsive and pink.
Anterior fontanel soft, open and flat; normal S1 and S2, no
murmur. Breath sounds clear. Abdomen: Slightly distended yet
soft, nontender. Bowel sounds slightly decreased.
Extremities: Warm and well perfused. Tone: Normal for
gestational age.
LABORATORY DATA: Initial laboratory studies revealed a CBC
with a white count of 25,000; 70% polys, 1% bands, 1
enucleated white blood count, hematocrit of 60%; platelets
250,000. Initial PT was 21.6; PTT 36.5; INR of 3.1. KUB
showed normal gas pattern throughout. In the Neonatal
Intensive Care Unit, the patient was initially lavaged with
90 cc of normal saline, initially obtained old hemolyzed
blood, followed by small volume bright red blood, which
ultimately cleared. No blood remained.
HOSPITAL COURSE:
1. Respiratory: The patient remained on room air throughout
hospitalization.
2. Cardiovascular: The patient never experienced any
hemodynamic instability with stable blood pressures
throughout.
3. Fluids, electrolytes and nutrition: After fed once in
the newborn nursery, the patient was made n.p.o. [**Last Name (un) 37079**] was
placed to low wall suction and the patient was started on
intravenous ranitidine. 10% dextrose solution was initiated at
60 cc per kg per day. On day of life three, [**Last Name (un) 37079**] was
removed after it had no output for 24 hours. That day, the
patient was started on breast feeding with no difficulty.
By day of life four, the patient was able to breast feed ad
lib well, with initial supplementation of Enfamil 20 calorie
formula. At discharge, the patient was receiving breast
feeding only. Weight on the day of discharge was 3465 grams
which is 9% down from birth weight. On the day before
discharge, the patient was changed over to oral ranitidine. D
sticks remained stable throughout hospitalization.
Electrolytes last obtained on day of life three were within
normal limits. Sodium was 140; potassium of 4.5; chloride of
103 and bicarbonate of 24.
4. Hematology: Repeat hematocrit on day of life 2 was 36.8.
Last hematocrit on day of life 4 was 39.5. No transfusions
were given. Repeat coagulation studies showed a PT of 16.4
and a PTT of 34.8 on day of life two. No further bleeding
occurred.
5. Gastrointestinal: Phototherapy was initiated on day of
life two with a total bilirubin of 7 and a direct of 0.3.
Phototherapy was discontinued on day of life three with a
total bilirubin of 6.1 and direct of .3. Rebound bilirubin
the following day was 7.7 with a direct of .3. Liver
function tests sent on day of life one were within normal
limits.
6. Infectious disease: Ampicillin and Gentamicin were
initiated on day of life one after bloody emesis occurred.
Blood cultures remained negative and antibiotics were
discontinued after 48 hours on day of life three.
7. Routine health care maintenance: Circumcision done on
day of life five. The patient has maintained temperature in
an open crib. Hearing test was passed. Newborn screen sent.
Hepatitis B vaccine given.
PHYSICAL EXAMINATION: On discharge, weight was 3,465 grams;
anterior fontanel soft, open and flat. Palate intact. Red
reflexes present bilaterally. Clavicles intact. Clear
breath sounds bilaterally with equal air entry; regular rate
and rhythm; normal S1 and S2, with a 2/6 systolic ejection
murmur heard, loudest at left lower sternal border with no
radiation. Four extremity blood pressures were within normal
limits. 2+ femoral pulses bilaterally, warm and pink.
Abdomen soft, nondistended, with normoactive bowel sounds.
Circulation intact. Testes down bilaterally. Patent anus.
No sacral dimple. Normal tone for gestational age. Normal
moro, grasp and suck reflexes.
DIAGNOSES ON DISCHARGE:
1. Acute gastritis, resolved.
2. Hyperbilirubinemia, resolved.
3. Sepsis evaluation.
MEDICATIONS ON DISCHARGE:
1. Ranitidine 8 mg p.o. three times a day.
FOLLOW-UP:
1. Follow-up appointment with gastrointestinal clinic to be
scheduled for six weeks after discharge.
2. Pediatric appointment for the day following discharge,
followed by VNA over the weekend.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Name8 (MD) 54816**]
MEDQUIST36
D: [**2105-3-12**] 03:20
T: [**2105-3-12**] 14:45
JOB#: [**Job Number 55112**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4005
} | Medical Text: Admission Date: [**2104-5-2**] Discharge Date: [**2104-5-8**]
Date of Birth: [**2059-2-18**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
transfer from OSH for dental abscess
Major Surgical or Invasive Procedure:
1. Incision and drainage of submandibular cellulitis [**5-2**]
2. Intubation [**5-2**]
3. Extubation [**5-3**]
History of Present Illness:
45 year old male with past medical history of hypertesion and
severe obesity who has not seeked regular medical or dental care
presents to OSH with 10 day history of right lower tootache,
fever and chills. He heard a [**Doctor Last Name **] one day ago with associated
pain and progressive swelling which prompted him to go to
[**Hospital 1562**] hospital.
At [**Hospital **] hospital, CT neck showed soft tissure infection with
phlegmon in the right perimandibular region likely originating
from dental infection of tooth #7 in the right lower jaw. Labs
significant for normal WBC and HgA1c of 12%. He was started on
Vancomycin and Unasyn. He was also started on lantus 10 units
qam. He was transferred to [**Hospital1 18**] as [**Hospital 1562**] hospital does not
have OMFS service on call.
On the floor, he reports dysphagia. He also reports having few
episodes of unresponsiveness with drooping of face and slurring
of his speech over past few years. Last episode one month ago.
Past Medical History:
1. New diagnosis of diabetes mellitus
2. Hypertension
3. Severe obesity
4. Likely obstructive sleep apnea
Social History:
1 ppd. Over 50 year pack year history of smoking. Social alcohol
use. No IVDU. Lives with daughter and her husband. [**Name (NI) **] works as a
[**Doctor Last Name **]. Has four dogs at home.
Family History:
Mother diet of breast cancer. He has 13 siblings of whom four
passed away.
Physical Exam:
Admission Physical Exam
100.2 149/90 92 20 95%RA
Gen: Ill appearing obese male with right submandibular swelling
HEENT: PERRLA. EOMI. Fundoscopic normal. Poor dentition. Right
last molar is partially mandibular and mostly submandibular
space tender to palpation without any fluctuation palpable in
this area
Neck: Submandibular area is tender to palpation and progress
towards lateral clavicular area
Chest: CTAB. No crackles or wheezing noted
Heart: Regular rate and rhythm. No murmurs or gallops
appreciated
Abdomen: Soft, nontender and nondistended. NABS.
External: No edema. R shin 3 cm wound
Neuro: Alert and oriented x 3. CN 2-12 intact. [**4-17**] muscle
strength. Sensation intact
Discharge Physical Exam
Objective: 98.4 126-127/70-85 70-76 20 96-100%2LNC
181/184/235
Gen: Obese male NAD. Mild fluctuations noted around right
submandibular area
HEENT: PERRLA. EOMI. Fundoscopic normal. Poor dentition.
Chest: CTAB. No crackles or wheezing noted
Heart: Regular rate and rhythm. No murmurs or gallops
appreciated
Abdomen: Soft, nontender and nondistended. NABS.
External: 1+ edema. R shin 3 cm wound
Neuro: Alert and oriented x 3. CN 2-12 intact. [**4-17**] muscle
strength. Sensation intact
Pertinent Results:
[**2104-5-3**] 03:43AM BLOOD WBC-14.3* RBC-5.05 Hgb-14.5 Hct-43.6
MCV-86 MCH-28.7 MCHC-33.2 RDW-13.6 Plt Ct-189
[**2104-5-5**] 07:35AM BLOOD WBC-9.6 RBC-4.38* Hgb-12.6* Hct-38.2*
MCV-87 MCH-28.7 MCHC-33.0 RDW-13.5 Plt Ct-223
[**2104-5-7**] 08:00AM BLOOD WBC-10.1 RBC-4.56* Hgb-12.9* Hct-38.2*
MCV-84 MCH-28.2 MCHC-33.7 RDW-13.4 Plt Ct-343
[**2104-5-7**] 08:00AM BLOOD ESR-100*
[**2104-5-3**] 03:43AM BLOOD Glucose-311* UreaN-15 Creat-1.0 Na-131*
K-4.8 Cl-95* HCO3-26 AnGap-15
[**2104-5-4**] 04:13AM BLOOD Glucose-289* UreaN-30* Creat-1.2 Na-136
K-4.1 Cl-100 HCO3-26 AnGap-14
[**2104-5-8**] 08:31AM BLOOD Glucose-178* UreaN-10 Creat-0.9 Na-138
K-3.9 Cl-100 HCO3-29 AnGap-13
[**2104-5-3**] 03:43AM BLOOD ALT-120* AST-117* AlkPhos-99 TotBili-1.9*
[**2104-5-5**] 07:35AM BLOOD ALT-102* AST-51* AlkPhos-101
[**2104-5-5**] 07:35AM BLOOD Triglyc-382* HDL-33 CHOL/HD-6.4
LDLcalc-101
[**2104-5-5**] 07:35AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.2 Cholest-210*
[**2104-5-5**] 07:35AM BLOOD TSH-1.8
[**2104-5-7**] 08:00AM BLOOD CRP-30.7*
EKG ([**2104-5-2**])
Sinus tachycardia. Right axis deviation. Non-diagnostic
repolarization
abnormalities. No previous tracing available for comparison.
TTE ([**2104-5-2**])
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 65%). The right ventricular free wall thickness is
normal. The right ventricular cavity is dilated with focal
hypokinesis of the apical free wall. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: dilated hypocontractile right ventricle
CXR ([**2104-5-5**])
In comparison with the study of [**5-3**], cardiac silhouette is at
the
upper limits of normal. The pulmonary opacifications have
decreased,
consistent with improved vascularity. Some of this could reflect
the upright position rather than supine. Area of increased
opacification at the right base is worrisome for possible
pneumonia.
Endotracheal tube and nasogastric tubes have been removed.
CT Neck ([**2104-5-5**])
Phlegmonous changes in the right submandibular region/floor of
mouth without residual drainable fluid collection.
[**2104-5-3**] 1:43 am SWAB Site: MANDIBLE RIGHT.
GRAM STAIN (Final [**2104-5-3**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
WOUND CULTURE (Preliminary):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH OROPHARYNGEAL FLORA.
WORK UP REQUESTED PER DR. [**Last Name (STitle) **] #[**Numeric Identifier 21912**] [**2104-5-5**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SECOND MORPHOLOGY.
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. RARE GROWTH.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN IS SENSITIVE AT 0.12MCG/ML.
VIRIDANS STREPTOCOCCI. RARE GROWTH.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN IS SENSITIVE AT 0.12 MCG/ML .
Penicillin IS RESISTANT AT >=8 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STREPTOCOCCUS ANGINOSUS
(MILLERI) GROU
| | VIRIDANS
STREPTOCOCCI
| | |
CLINDAMYCIN-----------<=0.25 S S S
ERYTHROMYCIN----------<=0.25 S <=0.25 S 2 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 2 I
OXACILLIN-------------<=0.25 S
PENICILLIN G---------- <=0.06 S R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S <=1 S <=1 S
ANAEROBIC CULTURE (Preliminary):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum.
ID PER DR.[**Last Name (STitle) **] [**2104-5-5**].
PREVOTELLA SPECIES. SPARSE GROWTH. BETA LACTAMASE
NEGATIVE.
Brief Hospital Course:
45 year old male with past medical history of hypertension and
severe obesity without regular medical or dental care presents
to OSH with submandibular abscess now status post tooth
extraction.
1. Right submandibular osteomyelitis: Likely due to molar
infection. He was continued on IV unaysn/vancomcyin. He was
taken to the OR the night of admission where he had extra-oral
incision and drainage of the right submandibular space that was
connected with the right lateral pharyngeal space. Two penrose
drains were placed in right lateral pharyngeal space. After
Incision and drainage, tooth was removed that was thought to be
source.
He was continued on IV Unasyn to cover polymicrobial flora.
Infectious disease was consulted. Repeat CT neck showed no
drainable collection but there was concern for jaw
osteomyelitis. Culture from his OR specimen showed
polymicrobiol flora with coagulase negative staph, anaerobes and
gram negative rods. He was started on IV vancomycin and
continued on IV unasyn. After seven days of IV antibiotics, he
was discharged home on linezolid, ciprofloxacin and flagyl.
2. Type 2 DM: HgA1c of 12% from OSH. He was treated with
insulin lantus 15 units in the morning with sliding scale
humalog. He was discharged home on metformin 1000 mg po BID and
glyburide 10 mg in the morning and 5 mg in the afternoon. He
was started on aspirin and lisinopril. He was risk stratified
with lipids which showed dysplipidemia.
3. Hypertension: Untreated in the past per patient. He was
started on lisinopril 40 mg po qdaily and chlorthalidone 25 mg
po qdaily.
4. Smoking: Kept on nicotine 14 mg patch
Follow up for PCP
1. Weekly lab work (CBC with diff, Chem-7, ESR and CRP) to be
faxed to Dr. [**Last Name (STitle) 23**] (Fax: [**Telephone/Fax (1) 1419**])
2. He will need to have his type 2 DM regimen optimized. We
were not able to obtain a glucometer for him to monitor his
blood sugar levels.
3. Please check creatine and electrolytes at your next visit as
we started chlorthalidone and lisinopril during his hospital
stay.
Medications on Admission:
None
Discharge Medications:
1. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 21 days.
Disp:*42 Tablet(s)* Refills:*0*
2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. glyburide 5 mg Tablet Sig: One (1) Tablet PO qpm .
Disp:*30 Tablet(s)* Refills:*2*
4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*90 Tablet(s)* Refills:*2*
9. glyburide 5 mg Tablet Sig: Two (2) Tablet PO qam.
Disp:*60 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
Please check weekly CBC with differential, chemistry panel,
creatinine, ESR and CRP. Please fax it to Dr. [**Last Name (STitle) 23**] (Fax:
[**Telephone/Fax (1) 1419**])
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. R mandibular cellulitis
Secondary Diagnosis:
2. Type II Diabetes mellitus
3. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital 1562**] hospital for an infection in your
tooth and jaw. You were transferred to [**Hospital1 827**] for surgery to remove the tooth and the infected
tissue. You were intubated during the procedure and remained
intubated in the ICU for 24 hours to make sure that your airway
was stable. Two drains were placed in your mouth to help drain
any infected fluid from your jaw. Both drains were removed prior
to your discharge from the hospital.
You were then transferred to the medicine floor for antibiotic
treatment of your infection. You were treated with IV Vancomycin
and Unasyn while in the hospital. You were switched to oral
linezolid to be taken at home for 3 weeks and oral ciprofloxacin
and flagyl to be taken for 6 weeks. While you were in the
hospital, your blood pressure was high and you were treated with
lisinopril and chlorthalidone.
You were also diagnosed with type II diabetes. You were
counseled on how to change your diet and exercise to control
your diabetes. You were treated with insulin and metformin while
you were in the hospital. You were discharged with metformin and
glyburide for treatment of your diabetes at home.
Please have weekly labs drawn and faxed to Dr. [**Last Name (STitle) 23**](Fax:
[**Telephone/Fax (1) 1419**]). You should have your first week lab drawn at Dr.
[**Last Name (STitle) **] office.
FOLLOWING CHANGES WERE MADE TO YOUR MEDICATIONS:
START: Linezolid 600 mg by mouth twice per day for 3 weeks for
jaw infection
START: CIPROFLOXACIN 500 mg by mouth twice per day for 6 weeks
for jaw infection
START: FLAGYL 500 mg by mouth three times a day for 6 weeks for
jaw infection
START: METFORMIN 1000 mg by mouth twice per day for diabetes
START: Glyburide 10 mg by mouth in the morning and 5 mg by mouth
in the evening
START: Lisinopril 40 mg by mouth once per day for blood pressure
START: Chlorthalidone 25 mg by mouth once per day for blood
pressure
START: Aspirin 81 mg by mouth once per day for prevention of
heart disease
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: TUESDAY [**2104-5-13**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
*Dr. [**Last Name (STitle) **] will be your new Primary Care doctor.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2104-5-23**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 88995**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Hospital6 **] [**Location (un) 442**] of Yawkey building
[**Last Name (NamePattern1) **]. on [**2104-5-19**] @ 1pm
Dr. [**Last Name (STitle) **] (phone: [**Numeric Identifier 88999**])
ICD9 Codes: 0389, 5070, 2761, 5849, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4006
} | Medical Text: Admission Date: [**2198-3-29**] Discharge Date: [**2198-4-5**]
Date of Birth: [**2133-2-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Adhesive Tape
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
leukocytosis
Major Surgical or Invasive Procedure:
Radiation therapy
Hemodialysis
History of Present Illness:
64 M with MMP including CHF, DVT, ESRD on HD, metastatic poorly
differentiated CA, likely NSLCA. He is s/p multiple recent
admissions, most recently from [**3-7**] - [**2198-3-22**] for respiratory
failure requiring intubation, thought due to volume overload
from a missed HD session.
.
He was d/c'ed to rehab on [**3-22**]. Per the patient, he has been
improving at rehab, gaining strength. He has had continued cough
occasiionally productive of a rusty-colored sputum associated
with some dyspnea on exertion, though he is not able to quantify
the amount of exertion required. He denies rest dyspnea, and
denies orthopnea or PND. Aside from the rust-colored sputum, he
denies any frank hemoptysis. He has not had any chest pain, n/v,
f/c/s.
.
He was at [**Location (un) **] hemodialysis where he was noted to have a Hb of
7.1, and sent in to the [**Hospital1 18**] ED for evaluation.
.
In ED, he denied any symptoms including CP, SOB, LH, or fatigue.
A laboratory evaluation revealed a Hb of 7.9 and Hct 27.0 (Hct
prior to discharge appears 26-28, though last Hct 35.4 but no
evidence of transfusion). Labs also remarkable for WBC of 22
with a poly predominance. CXR showed a new left basilar opacity,
thought to represent atelectasis vs infection. He was ordered
for 2U pRBCs, vanco, levoflox, and cefepime.
.
Currently, his only complaint is his chronic neck pain, which is
less well controlled this morning because he may have missed a
dose of his pain medication.
Past Medical History:
#. Onc HX: [**12-11**] pre-renal transplant CT scan chest noted
enlarged RML nodule, w/ subcentimeter FDG avid scattered lymph
nodes. Developed neck pain and found to have C2 pathological
fracture, [**11-22**] cytology demonstrated poorly differentiated
carcinoma. Likely non-small cell lung carcinoma, with RML mass
and metastasis to the cervical and sacral spine. The only
manifestation of his disease currently is cervical neck pain,
s/p pathologic fracture and posterior cervical arthrodesis C1-C3
and palliative XRT.
#. Left Common Femoral DVT: small non-occlusive, possibly
chronic DVT and started on coumadin for a goal INR [**1-7**] in [**1-/2198**]
#. CAD s/p angioplasty D1 [**7-10**] and stents to OM2/3 in [**3-11**]
#. ESRD secondary to FSGS on HD (MWF)
#. Hypertension
#. LLE peroneal nerve palsy [**1-6**] GSW to L leg
#. Thalassemia trait
#. h/o Substance abuse (heroin/cocaine); reports none since [**2163**]
#. CHF w/ EF 35% in [**11-11**], EF 25-30% on [**Date Range 113**] [**2198-1-23**]
#. MR - 2+ on [**Month/Day/Year 113**] in [**11-11**]; now found to be 3+ MR [**First Name (Titles) **] [**Last Name (Titles) 113**]
#. Pathological C2 Fx s/p C1-3 Fusion
#. Parotiditis - [**12-12**] (levo/flagyl)
#. CDiff - [**12-12**]
#. HCV - grade 1 inflammation and stage 0 fibrosis on bx [**2-9**]
Social History:
He was discharge to rehab on [**3-22**]. Patient does not recall where
he is still at rehab, or has been discharged from rehab.
However, he does not think he has been home since. He is
married, with 2 sons. Used to work in construction, + smoker 1
PPD for many years quit recently, rare ETOH, no drugs.
Family History:
Brother with CAD, and kidney disease requiring hemodialysis
Physical Exam:
Vitals - T 98.3, BP 116/72, HR 76, RR 18, O2 sat 97% RA (MD
check)
General - chronically ill appearing male; speech is slow, but
responses are appropriate
HEENT - PERRL, EOMI, OP clr, MM dry, no JVD
CV - RRR, [**2-8**] syst mur
Chest - CTAB
Abdomen - soft, NT/ND, no g/r
Back - gluteal region with stage 2 ulcers
Extremities - Left AV fistula bandaged, c/d/i, with palpable
thrill
Neuro - Oriented to hospital ([**Hospital3 **]) and [**2198-3-6**] (did
not know date).
rectal tone absent, decreased sensation to pinprick in LEs, no
saddle anesthesia to LT. 3/5 strength in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]. R
foot internally rotated. Unable to walk. toes upgoing
bilaterally. reflexes not tested.
Pertinent Results:
[**2198-3-29**] 12:10PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2198-3-29**] 12:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2198-3-29**] 12:10PM URINE RBC-[**5-15**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**2-7**]
[**2198-3-29**] 09:35AM GLUCOSE-99 UREA N-27* CREAT-3.0* SODIUM-137
POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-30 ANION GAP-17
[**2198-3-29**] 09:35AM CALCIUM-9.2 PHOSPHATE-4.5 MAGNESIUM-1.5*
[**2198-3-29**] 09:35AM WBC-19.6* RBC-3.29* HGB-8.1* HCT-26.2*
MCV-80* MCH-24.5* MCHC-30.8* RDW-17.9*
[**2198-3-29**] 09:35AM PLT COUNT-277
[**2198-3-29**] 09:35AM PT-24.8* PTT-31.4 INR(PT)-2.4*
[**2198-3-29**] 02:19AM TYPE-ART PO2-140* PCO2-47* PH-7.50* TOTAL
CO2-38* BASE XS-12 INTUBATED-NOT INTUBA
[**2198-3-28**] 10:47PM COMMENTS-GREEN TOP
[**2198-3-28**] 10:47PM LACTATE-2.4*
[**2198-3-28**] 09:15PM GLUCOSE-94 UREA N-20 CREAT-2.3*# SODIUM-141
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-34* ANION GAP-14
[**2198-3-28**] 09:15PM estGFR-Using this
[**2198-3-28**] 09:15PM WBC-21.7* RBC-3.49* HGB-7.9*# HCT-27.0*
MCV-77* MCH-22.7* MCHC-29.3* RDW-18.1*
[**2198-3-28**] 09:15PM NEUTS-89.3* BANDS-0 LYMPHS-5.4* MONOS-2.0
EOS-3.3 BASOS-0.1
[**2198-3-28**] 09:15PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ OVALOCYT-1+ TARGET-1+
STIPPLED-1+ TEARDROP-1+
[**2198-3-28**] 09:15PM PLT SMR-NORMAL PLT COUNT-315
[**2198-3-28**] 09:15PM PT-24.1* PTT-30.7 INR(PT)-2.3*
65 year old man with high white count
REASON FOR THIS EXAMINATION:
eval for pna
INDICATION: 65-year-old male with high white count. Please
evaluate for pneumonia.
FINDINGS: Single portable upright chest radiograph is reviewed
and compared to [**2198-3-15**], and to CTA of the chest from [**2198-1-21**].
Cardiomediastinal silhouette is unchanged. Multifocal areas of
opacity scattered throughout both lungs are largely similar to
previous exam, and consistent with metastatic lung cancer.
Dominant right hilar mass is similar in appearance. There is new
streaky opacity at the left lung base, with associated volume
loss, which may represent atelectasis, although underlying
infectious process cannot be excluded. There is no pleural
effusion or pneumothorax. Radiopaque density projecting over the
upper thoracic spine is unchanged in appearance, maybe related
to prior vertebroplasty.
IMPRESSION:
1. New left basilar streaky airspace opacity and volume loss,
may represent atelectasis, although this is concerning for
underlying infection in the appropriate clinical setting.
2. Unchanged appearance of multifocal opacities consistent with
metastatic lung cancer, and dominant right hilar mass.
=======
MR L SPINE W/O CONTRAST [**2198-3-29**] 5:33 PM
MR L SPINE W/O CONTRAST
Reason: eval for cauda equina syndrome, extent of bony mets with
gad
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with bony metastases known to C,L,S spine, now
with decreased rectal tone and urinary retention
REASON FOR THIS EXAMINATION:
eval for cauda equina syndrome, extent of bony mets with
gadolinium
CONTRAINDICATIONS for IV CONTRAST: esrd, will advise renal, pt
to get dialysis post-procedure
INDICATION: 65-year-old with diffusely metastatic adenocarcinoma
and now with decreased rectal tone and urinary incontinence.
Evaluate for cauda equina syndrome.
COMPARISON: MRI of the lumbar spine, [**2197-11-15**].
TECHNIQUE: Sagittal T1, T2, and STIR as well as axial T1 and T2
images through the sacrum were obtained.
FINDINGS: There has been interval development of extensive tumor
infiltration of the sacrum since the prior exam of [**Month (only) 1096**]
[**2196**]. Previously, the patient had a capacious thecal sac
extending into the sacrum. Now there is extensive tumor
infiltration throughout the sacrum, which obliterates the spinal
canal at L5-S1 and presumably infiltrates the nerve roots below
this level. Tumor extends beyond the bony confines of the sacrum
into the posterior soft tissues (5:30). The iliac wings appear
unaffected, and the sacroiliac joints are intact. There is a
defect within the left iliac [**Doctor First Name 362**] posteriorly with T1
hypointense scar tissue extending to the skin consistent with
the patient's prior graft donor site.
The visualized portion of the lumbar spine is unremarkable with
no abnormal signal intensity within the vertebral bodies, conus,
or cauda equina. There is mild edema in the inferior endplate of
L5 and disc desiccation at L5- S1, likely degenerative. The
L5-S1 disc bulges into the sac causing mild indentation of the
thecal sac ventrally.
IMPRESSION: Extensive tumor infiltration of the sacrum with
obliteration of the thecal sac (and presumably the nerve roots)
below the L5-S1 level.
Brief Hospital Course:
64yo M with metastatic poorly differentiated CA, likely NSLCA,
CHF, DVT, ESRD on HD, here with urinary retention/UTI and
compression of sacral nerve roots [**1-6**] metastatic dz.
.
# Cauda equina syndrome. Pt. arrived on floor with sx. of
urinary retention with 1.2L upon straight cath. Further
neurologic exam revealed LE weakness, decreased sensation and
absent sphincter tone. Stat MRI showed sacral involvment of
metastasis and compression of sacral roots. Radiation Oncology
consulted who arranged for emergent radiation therapy with
planned mapping [**2-27**] AM. Decadron initiated as well. The
patient completed a course of radiation therapy by [**2198-4-5**].
Dexamethasone taper has been started on discharge.
Unfortunately, his leg weakness has persisted despite maximal
therapy.
.
# Anemia - Hct 27.0 in ED here, not clearly different from his
baseline during his recent admission. He already received 1U in
the ED. epo @ HD
- guiac neg, no signs of blood loss.
.
# Onc - poorly differentiated histology, likely NSCLC; with mets
to cervical and sacral spine. With neck pain s/p c1-c3
arthrodesis. very poor overall prognosis, but in past
discussions, pt. goals of care to be aggressive. No chemo
currently offered from onc team, but are aware.
- continue oxycodone/oxycontin for pain control
- neck brace as previously ordered - for pain relief. Neck is
otherwise stable.
- [**Year (4 digits) 653**] [**Name (NI) 2270**] [**Name (NI) 1764**] of palliative care who followed during
previous visits. Dr. [**Last Name (STitle) 5717**], his PCP and current attending
aware.
.
# CAD - with prior stenting, and evidence of prior MI by ECG
- continue [**Last Name (STitle) **], [**Last Name (STitle) **], B-blocker, ACE-I, statin, and nitrate
.
# Chronic systolic congestive heart failure - depressed EF of
25-30% in [**2198-1-5**]. The patient developed acute pain and became
hypertensive and had flash pulmonary edema necessitating
transfer to the MICU, where he received emergent hemodialysis
and avoided intubation. He was transferred to the floor where
his care was continued.
.
# HTN - currently well-controlled
- continue B-blocker, ACE-I, and nitrate
.
# ESRD - last HD on [**3-28**]
- renal diet
- nephrocaps
- hemodialysis per routine
.
# Left Common Femoral DVT. The patient had a supratherapeutic
INR and his warfarin was held, it will need to be resumed once
his INR is less than 3.
Medications on Admission:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for neck pain: leave on for 12 hours, then take off for
12 hours.
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO please
give once daily on dialysis days only. do not give on days the
patient does not have dialysis.
16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 2 weeks.
17. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection at hemodialysis.
18. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 13 days: last dose due on [**4-3**].
19. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): hold if
sedated or RR < 10.
20. Oxycodone 20 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for Pain: hold if patient is sedated or RR < 10.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) Powder in Packet PO once a day.
11. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Fentanyl Citrate (PF) 50 mcg/mL Solution Sig: Twenty Five
(25) mcg Injection q2 hours as needed for pain.
15. Dexamethasone 0.5 mg Tablet Sig: Taper as follows PO every
six (6) hours: 2mg PO q6hr for 3 days, then 1mg PO q6hr for 3
days, then 0.5mg PO q6hr for 3 days, and then discontinue.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Non-small cell lung cancer metastatic to spine with cauda equina
syndrome;
Pathological C2 fracture, s/p C1-3 Fusion;
Chronic neck pain;
ESRD on hemodialysis;
Chronic systolic congestive heart failure;
Mitral regurgitation;
Coronary artery disease;
Femoral deep venous thrombosis;
Hypertension;
Thalassemia trait;
Left lower extremity peroneal nerve palsy [**1-6**] GSW to L leg;
Recent C. difficile colitis;
Recent VRE urinary tract infection;
Chronic Hepatitis C;
Sacral decubitus ulcer.
Discharge Condition:
Stable. Decreased mobility secondary to Cauda Equina Syndrome.
Also continues with pain from spinal mets with some lethargy due
to narcotic analgesics.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Fluid Restriction: [**2189**] cc.
Please continue with your dialysis every
Monday/Wednesday/Friday.
Please tell the health-care providers at the extended care
facility if you have: shaking chills, a fever, chest pain,
difficulty breathing, abdominal pain, vomitting, blood in your
stools, if the pain in your neck/back increases or if you
experience a change in mental status. Please take your
medications as prescribed. Please make and keep all of your
follow-up appointments.
Followup Instructions:
1. Continue hemodialysis every Monday/Wednesday/Friday.
2. Please contact your Primary Care Provider ([**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],
[**Telephone/Fax (1) 250**]) and your Oncologist to arrange follow-up
appointments.
ICD9 Codes: 486, 5856, 5990, 5180, 4280, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4007
} | Medical Text: Admission Date: [**2170-7-26**] Discharge Date: [**2170-8-3**]
Date of Birth: [**2109-4-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Dyspnea with fever
Major Surgical or Invasive Procedure:
ICD extraction
History of Present Illness:
61M hx iCM EF 15-20%, CAD with AMI [**2167**], VFib arrest from IST
[**2167**] s/p ICD implantation, COPD on 2L O2 baseline, DM, [**Hospital **]
transferred from [**Hospital3 **] for ICD explantation.
.
Recently admitted to [**Hospital1 46**] from [**Date range (1) 98806**] for respiratory
failure secondary to CHF and COPD exacerbation. Patient with
chronic exertional dyspnea with mild-moderate activity,
minimally ambulatory, lives in a Nursing Home due to his medical
comorbidities. The staff at his NH noted that he was tachypneic
(RR 28) and requiring additional oxygen supplementation. His
temperature at the time was 100.2F and he was transferred to the
[**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **]. He remained febrile (temp 100.5-104F as per report)
and his SBP was noted to be 80-90s. Blood cultures were obtained
and he was given ceftazidime, vancomycin, and levofloxacin. At
[**Hospital1 46**] he grew MRSA from the bloodstream. Over the course of his
hospitalization there, his ICD pocket became erythematous, warm
and swollen. It had increased to baseball sized by the time of
transfer, and was fluctuant and warm. TEE was negative for
vegetations there, and blood cultures have since been negative
or NGTD per report (not included in OSH transfer records).
.
He was transfered to [**Hospital1 18**] for ICD explantation. On arrival, he
was in mild respiratory distress and was found to have bibasilar
crackles and a swollen ~4 inch fluctuant mass over the ICD
implant that was erythematous, warm, and tender. Vitals were T
98.2, BP 105/73, HR 87, RR 20, and SpO2 97% on 3LNC. He was
continued on Vancomycin for MRSA infection, and diuresed
overnight using Furosemide 40 mg IV followed by 5 mg/hr drip.
He had good urine output and fluid balance negative 1500 ml
overnight.
He was taken to the OR morning of [**2170-7-27**]. His ICD was removed
with purulent material in the pocket. After explantation, there
was continued oozing from the site and a drain was left in
place. He remained intubated following the procedure, and was
transferred to the PACU in stable condition.
Past Medical History:
# CAD -- h/o MI
-- ?stent thrombosis in [**2167**] with subsequent thrombectomy
-- stent placement x3 to his LAD in [**2169**]
# VFib arrest -- s/p ICD implantation in [**9-/2168**]
# Ischemic cardiomyopathy -- LVEF 15-20%
# COPD -- on 2L home oxygen
# Hypertension
# Hyperlipidemia
# Anemia -- with h/o transfusions, etiology unclear
# Chronic Kidney Disease
-- (time course unclear, Cr 0.91 in [**2170-7-9**])
Social History:
# Home: Married, lives at [**Hospital 62931**].
# Work: Former electrician.
# Tobacco: 40 pack year smoking history, quit 5 months ago
# Alcohol: Alcohol abuse history but also quit 5 months ago
# Illicit: None
Family History:
Father with MI
Physical Exam:
ADMISSION:
VS: 98.2 105/73 87 20 97%3LNC
GENERAL: Older male in NAD, intubated and sedated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple without elevated JVP .
CARDIAC: RRR, normal S1, S2. No M/R/G.
LUNGS: Synchronous on vent. CTAB without crackles, wheezes, or
rhonchi.
ABDOMEN: Soft, NT, ND. No HSM.
EXTREMITIES: No C/C/E. No femoral bruits.
SKIN: Pressure dressing over left chest ICD site C/D/I. Drain
with serosanguinous fluid.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
DISCHARGE:
VS: 98.7 81 108/73 18
GENERAL: Older male in NAD, intubated and sedated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple without elevated JVP, Large EJ.
CARDIAC: RRR, normal S1, S2. No M/R/G.
LUNGS: Decreased breath sounds over lower lung fields. No
crackles, wheezes, or rhonchi.
ABDOMEN: Distended, firm. Non-tender, +BS.
EXTREMITIES: No C/C/E. No femoral bruits. No edema.
SKIN: Dressing over pocket, with serosanguinous fluid.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION:
[**2170-7-26**] 11:27PM BLOOD WBC-10.5 RBC-2.94* Hgb-8.4* Hct-26.5*
MCV-90 MCH-28.5 MCHC-31.7 RDW-21.8* Plt Ct-153
[**2170-7-26**] 11:27PM BLOOD Neuts-87.4* Lymphs-8.2* Monos-2.6 Eos-1.3
Baso-0.5
[**2170-7-26**] 11:27PM BLOOD PT-15.3* PTT-39.1* INR(PT)-1.4*
[**2170-7-26**] 11:27PM BLOOD Glucose-92 UreaN-22* Creat-0.8 Na-130*
K-4.7 Cl-99 HCO3-26 AnGap-10
[**2170-7-26**] 11:27PM BLOOD ALT-15 AST-18 AlkPhos-119 TotBili-1.5
[**2170-7-26**] 11:27PM BLOOD Calcium-8.5 Phos-2.2* Mg-2.4
STUDIES:
(CXR [**2170-7-27**]) Moderate-to-large right greater than left pleural
effusions. The additional presence of pneumonia cannot be
excluded
.
(ECHO [**2170-7-28**]) The left atrium is moderately dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. There is severe
global left ventricular hypokinesis (LVEF = 15 %). No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve leaflets are structurally normal. No
mass or vegetation is seen on the mitral valve. Moderate (2+)
mitral regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. No vegetation/mass is seen on the tricuspid or
pulmonic valves. There is no pericardial effusion.
Brief Hospital Course:
61M with history of CAD, MI, sCHF EF 15-20%, VFib arrest s/p ICD
placement in [**2167**], COPD on 2L home O2, who presents from [**Hospital1 **] with MRSA bacteremia and ICD pocket infection.
.
# MRSA ICD INFECTION with Bacteremia: MRSA bacteremia found at
OSH, Positive growth of Staph aureus from ICD pocket, blood cx
negative since admission here. Pocket has appeared infected over
the past few days, culminating in a ~4 inch fluctuant mass that
was erythematous, warm, and tender over the ICD implant. S/P
ICD explantation and pocket washout with placement of drain. Pt
required temporary phenylephrine, and epinephrine. He had a
drain placed which was pulled on [**2170-8-2**]. He had a transient
decrease in HCT with oozing around pocket, and was 26.7 on day
of discharge. He will require monitoring of his CBC at rehab.
ID was consulted who recommended 6 weeks of Vancomycin. Pt has
PICC line in right basilic vein for Vancomycin 750mg q12 (stop
date [**2170-8-27**]).
.
# Acute on Chronic Systolic CHF: Initially hypoxic beyond
baseline (3L on admission, 2L at home) with bibasilar rales and
bilateral effusions, JVP elevation, peripheral edema. Likely
due to iatrogenic causes in setting of MRSA bacteremia and
initial presentation of sepsis. Pt initially on pressors,
weaned on the first day. [**Name (NI) 98807**], Pt was started on Lasix
drip fluid status improved and we continued PRN Lasix to goal of
-1L/day. Lisinopril and Spironolactone were initially held due
to SBPs 80s-90s, Lisinopril restarted several days prior to
discharge, and Spirolactone will need to be added on as an
outpatient with better SBPs. Pt discharged on Metop Succinate XL
25mg Daily, Lisinopril 2.5mg daily, Dig .25mg/day, and
Furosemide 80mg TID. His BPs were in the 80-90s on d/c but
patient was asymptomatic with no orthostasis on exam. In
addition, he was able to ambulate with no lightheadedness,
dizziness, SOB, or syncope.
.
# COPD: During this admissio patient was weaned to his home
baseline oxygen requirement of 2L day and night. Home 2L NC at
baseline. No cough or increased sputum to suggest COPD
exacerbation. Hypoxia/dyspnea likely related to CHF as above.
Pt did require intubation after ICD extraction for less than 24
hours. We Continued Ipratropium, Albuterol and Advair.
.
# CAD / VFib arrest: Large MI in [**2167**] with IST and VFib arrest,
s/p DESx3 to LAD. Currently CP free. ICD placement [**9-/2168**],
extracted on this admission per above. Per report no further
episodes of VFib or VTach. We continued his Aspirin and Statin
and increased Metoprolol XL to 25mg PO daily which decreased the
ectopy captured on tele.
.
# CKD: Reportedly with elevated Cr in the past (1.2 +) although
during this admission patient discharged with Cr 0.8, and range
was .8 - 1.0. Cr 1.3 on OSH admission, 0.8 prior to transfer. We
monitored renal function daily and dosed medications renally.
.
# TRANSITIONAL
- Add Spironolactone as outpatient if SBP tolerates.
- Monitor weekly Vancomycin troughs, CBC and CMP (electrolytes)
- Discussion of future ICD need
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
3. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q6h sob/wheeze
4. Thiamine 100 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Neutra-Phos 1 PKT PO DAILY
7. Digoxin 0.25 mg PO DAILY
8. Lisinopril 2.5 mg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO BID
10. Furosemide 40 mg PO BID
11. Pantoprazole 40 mg PO Q24H
12. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Digoxin 0.25 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
3. FoLIC Acid 1 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
Hold SBP< 90
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Thiamine 100 mg PO DAILY
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
9. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K > 4.5
10. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q6h sob/wheeze
11. Tiotropium Bromide 1 CAP IH DAILY
12. Vancomycin 750 mg IV Q 12H
Please give at 8am and 8pm
13. Torsemide 60 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] HealthCare/Pediatric Center at [**Location (un) 3320**]
Discharge Diagnosis:
1) Implantable cardioverter-defibrillator (ICD) Pocket Infection
2) Staph Coag positive bacteremia
3) Coronary artery disease
4) Acute on Chronic systolic congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
You were transferred from [**Hospital3 3583**] due to fevers and
elevated levels of blood cells that fight infection. It was
determined that your ICD(Implantable cardioverter-defibrillator)
was infected and we removed it to prevent the infection from
getting worse. We also started you on an antibiotic called
Vancomycin through your vein.
Followup Instructions:
.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2170-8-21**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2170-9-14**] at 11:30 AM
With: [**Name6 (MD) 27568**] [**Name8 (MD) 27569**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2170-8-14**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**Name8 (MD) 2064**] MD
Location: [**Location (un) 511**] Cardiology
Address: [**State **], [**Location (un) 2498**]
Phone: [**Telephone/Fax (1) **]
Appt: [**9-10**] at 1:50pm
ICD9 Codes: 7907, 496, 4280, 2724, 5859, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4008
} | Medical Text: Admission Date: [**2109-5-11**] Discharge Date: [**2109-5-20**]
Date of Birth: [**2044-4-8**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / Ciprofloxacin
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
pain in rt knee
Major Surgical or Invasive Procedure:
orif of rt periprosthetic distal femur fx
History of Present Illness:
65 yo f fell from standing was brought to ed and xrays showed a
rt
periprosthetic femur fx ortho was consulted and she was seen by
dr [**Last Name (STitle) **] surgery was planned she admitted to ortho and medicine
was consulted she was cleared for the or
Past Medical History:
BR>1. right hip fracture [**2-23**] s/p ORIF
2. hx. LGIB secondary to hemorrhoids
3. hx of DVT
4. HTN
5. Presumed NASH Cirrhosis with grade II varices on [**9-/2108**]-
followed by Dr. [**Last Name (STitle) 7962**]
6. Ulcerative Colitis
7. Fibromyalgia
8. OSA
9. MGUS
10. thrombocytopenia
11. Restless leg syndrome
12. anxiety and depression
13. Diabetes type 2- hgbA1C = 5.4 in [**1-/2109**]
14. s/p bilateral Total knee replacements
Social History:
She lives alone in an apartment complex for the elderly. Elder
services on [**Location (un) 448**] at all time. Housekeeper 3x per week.
Home VNA 1/month since mother was doing well. She has three
adult children. Her son, [**Name (NI) **], is quite responsible and
active in her care. He handles all of her finances since [**Doctor Last Name 1356**]-
daughter stole money from her mother. Receives an allowance and
is able to balance her finances. [**Doctor Last Name 501**] and [**Doctor Last Name **] do the
shopping. Assitance with showering but otherwise able to dress,
clean her appt. Her daughter exhibits drug-seeking behavior,
with a history of stealing mother's pain medications. She has
never smoked, used ETOH or illicit drugs. Her previous work was
in the Cafeteria Department at [**University/College **] [**Location (un) **], as a
"checker." At baseline able to walk w/o walker. No recent
deficits in memory noted.
HCP- [**Name (NI) **] [**Telephone/Fax (1) 40051**]
Family History:
Her mother and father died from MI: at age 70 and 57, resp. No
known cancers.
Physical Exam:
heent wnl
chest clear
[**Last Name (un) **] rrr no mrg
abd sft ntnd
ortho rt knee pain with rom sensation intact dp/tp +
neuro non focal
Pertinent Results:
[**2109-5-14**] 06:53AM BLOOD WBC-9.3 RBC-2.09*# Hgb-7.3* Hct-21.0*
MCV-100* MCH-34.8* MCHC-34.8 RDW-17.9* Plt Ct-85*
[**2109-5-14**] 06:53AM BLOOD WBC-9.3 RBC-2.09*# Hgb-7.3* Hct-21.0*
MCV-100* MCH-34.8* MCHC-34.8 RDW-17.9* Plt Ct-85*
[**2109-5-13**] 02:45AM BLOOD WBC-9.6 RBC-2.79* Hgb-9.6* Hct-28.0*
MCV-100* MCH-34.3* MCHC-34.2 RDW-18.1* Plt Ct-87*
[**2109-5-12**] 07:30PM BLOOD WBC-7.5 RBC-2.87* Hgb-10.0* Hct-28.9*
MCV-101* MCH-34.9* MCHC-34.6 RDW-17.9* Plt Ct-76*
[**2109-5-12**] 05:40AM BLOOD WBC-7.1# RBC-3.06* Hgb-10.9* Hct-32.8*
MCV-107* MCH-35.6* MCHC-33.2 RDW-15.1 Plt Ct-104*
[**2109-5-11**] 04:10PM BLOOD WBC-4.0 RBC-3.49* Hgb-12.6 Hct-37.5
MCV-107* MCH-36.1* MCHC-33.6 RDW-15.0 Plt Ct-73*
[**2109-5-11**] 04:10PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Pencil-OCCASIONAL
[**2109-5-14**] 06:53AM BLOOD Plt Ct-85*
[**2109-5-14**] 06:53AM BLOOD PT-26.8* INR(PT)-2.7*
[**2109-5-13**] 02:45AM BLOOD Plt Ct-87*
[**2109-5-13**] 02:45AM BLOOD PT-16.6* PTT-34.4 INR(PT)-1.5*
[**2109-5-12**] 07:30PM BLOOD Plt Smr-VERY LOW Plt Ct-76*
[**2109-5-12**] 07:30PM BLOOD PT-17.6* PTT-36.1* INR(PT)-1.6*
[**2109-5-12**] 07:30PM BLOOD Plt Smr-VERY LOW Plt Ct-76*
[**2109-5-12**] 07:30PM BLOOD PT-17.6* PTT-36.1* INR(PT)-1.6*
[**2109-5-12**] 05:40AM BLOOD Plt Ct-104*
[**2109-5-12**] 05:40AM BLOOD PT-15.4* INR(PT)-1.4*
[**2109-5-11**] 04:10PM BLOOD Plt Ct-73*
[**2109-5-11**] 04:10PM BLOOD PT-16.8* PTT-31.9 INR(PT)-1.6*
[**2109-5-14**] 06:53AM BLOOD Glucose-119* UreaN-22* Creat-0.8 Na-135
K-4.3 Cl-105 HCO3-26 AnGap-8
[**2109-5-14**] 06:53AM BLOOD Glucose-119* UreaN-22* Creat-0.8 Na-135
K-4.3 Cl-105 HCO3-26 AnGap-8
[**2109-5-13**] 02:45AM BLOOD Glucose-160* UreaN-17 Creat-0.8 Na-137
K-4.2 Cl-107 HCO3-23 AnGap-11
[**2109-5-12**] 07:30PM BLOOD Glucose-117* UreaN-14 Creat-1.0 Na-139
K-5.2* Cl-109* HCO3-22 AnGap-13
[**2109-5-12**] 05:40AM BLOOD Glucose-105 UreaN-11 Creat-0.8 Na-140
K-3.9 Cl-107 HCO3-27 AnGap-10
[**2109-5-11**] 04:10PM BLOOD Glucose-121* UreaN-10 Creat-0.9 Na-139
K-4.2 Cl-107 HCO3-24 AnGap-12
[**2109-5-14**] 06:53AM BLOOD Calcium-7.7* Phos-2.2* Mg-1.6
[**2109-5-13**] 02:45AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.9
[**2109-5-12**] 07:30PM BLOOD Calcium-7.3* Phos-3.6 Mg-1.5*
[**2109-5-11**] 04:10PM BLOOD RedHold-HOLD
[**2109-5-13**] 02:59AM BLOOD Type-ART pO2-175* pCO2-37 pH-7.40
calHCO3-24 Base XS-0
[**2109-5-12**] 07:35PM BLOOD Type-ART pO2-235* pCO2-44 pH-7.36
calHCO3-26 Base XS-0
[**2109-5-12**] 06:07PM BLOOD Type-ART pO2-286* pCO2-35 pH-7.48*
calHCO3-27 Base XS-3
[**2109-5-12**] 06:07PM BLOOD Glucose-103 Lactate-2.9* Na-136 K-3.9
Cl-108
[**2109-5-12**] 06:07PM BLOOD Hgb-8.9* calcHCT-27
[**2109-5-13**] 02:59AM BLOOD freeCa-1.11*
[**2109-5-12**] 07:35PM BLOOD freeCa-1.10*
[**2109-5-12**] 06:07PM BLOOD freeCa-1.03*
Brief Hospital Course:
on [**2109-5-12**] was taken to the or and underwent orif of rt femur
see op note for details
transfered to pacu stable and then to the micu for ebl of 1300
she was stable over nite and came to cc6 she was started on
coumadin and lovenox bridge because of her hx of dvt her inr was
2.7 and she was dc off the lovneox her hct was 28 abd it
dropped to 21 and she recieved 1unit of prbc and her hct rose
to 27.7 . her inr was elevated at 3.3 it was then 3.9 and in
recheck the day of transfer it was 3.6 the goal inr for her was
2-2.5 due to her hx of dvt she developed wheezing and was
started on on neb treatments her urine was checked because of
dysuria and it came back positive and had a 3 day course of
bactrim ds because of her multiple medical issues and difficulty
in physical rx case management was consulted and screening was
started and she was ready for dc her inr and coumadin would be
managed at the rehab and they were aware of this
Medications on Admission:
alendronate
citopram
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection every
4-6 hours as needed for break thru pain.
9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
12. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
PRN (as needed) as needed for constipation.
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
16. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q6H (every
6 hours) as needed.
17. Promethazine 25 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed.
18. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: goal
inr is 2-2.5 for hx of dvt.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care
Discharge Diagnosis:
rt periprosthetic femur fx of distal femur
postop anemia
s/p blood transfusion
uti
Discharge Condition:
good to rehab
Discharge Instructions:
dc to rehab
keep wound clean and dry
non weight bearing rt leg
take dc meds as ordered
call dr [**Last Name (STitle) **] for temp over 101 and if any drainge ocurrs [**Telephone/Fax (1) 40054**]
follow up with dr [**Last Name (STitle) **] in 2 weeks call [**Numeric Identifier 40055**] for
appointment
Physical Therapy:
Activity: Out of bed w/ assist
Right lower extremity: Non weight bearing
Treatments Frequency:
Site: right leg
Type: Surgical
dsd daily
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1228**] Call to schedule
appointment
Completed by:[**2109-5-20**]
ICD9 Codes: 5715, 2875, 5990, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4009
} | Medical Text: Admission Date: [**2118-7-4**] Discharge Date: [**2118-7-8**]
Date of Birth: [**2065-6-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hematemasis
Major Surgical or Invasive Procedure:
EGD ([**7-6**])
Intubation ([**7-5**])
Dialysis (started on [**7-6**])
Central line in left IJ (started on [**7-5**])
History of Present Illness:
This is a 53 yo male with a history of alcoholic cirrhosis and
type 2 DM presenting with vomiting dark brown material for 1
week. The patient reports that 7 days prior to admission that
he vomiting dark coffee colored emesis, followed by diarrhea of
with dark red stool the following day. He also develop
epigastric/RUQ abdominal 6 days prior to admission. He was
admitted to an OSH at that time, but left AMA (unclear what
day). After arriving home he continued to have intermittent
abdominal pain, dark brown emesis, but denies having stools for
the past 2-3 days. He continued to vomit so he returned to
[**Location 111781**] General, who gave him protonix 80mg, 25grams of
25%albuin, vancomycin 1 gram, ctx 1gram, 2mg of PO lorazepam,
1mg of IV ativan vitamin K 10mg IV x 1 dose. Basic labs were
also obtained (see records for details) and transferred him to
[**Hospital1 18**] for further management.
In the ED, initial VS were: 106 129/55 20 100% The patient was
started on an octreotide gtt. A CBC reveal a Hct of 29 (down
from 32 at OSH) and the patient was admitted to the MICU for
further management.
After arrival to MICU, the patient vomited coffee ground emesis.
Past Medical History:
Alcohol abuse
Cirrhosis
Type 2 DM
Social History:
- Tobacco: 1 [**11-29**] pack x 20-30 years
- Alcohol: heavy drinker, told to stop > 1 year ago, last drink
2 weeks ago
- Illicits: mj, denies IVDA:
Family History:
Non-contributory
Physical Exam:
Vitals: T 97.2 BP 121/36 HR 101 RR 30 SpO2 97% RA
General: Alert, oriented, jauncided
HEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Tense, distended, non-tender, bowel sounds present, no
organomegaly
Skin: Jaundice, spider angiomas
Ext: warm, well perfused, palmar eythema, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred,
Discharge Exam:
Deceased
Pertinent Results:
IMAGING:
EGD ([**2118-7-6**]):
No esophageal varices. Diffuse portal hypertensive gastropathy.
Coffee ground material seen in the stomach, no ulcers or
erosions, no gastric varices. No signs of active bleeding.
Otherwise normal EGD to second part of the duodenum.
EKG ([**2118-7-5**]):
Sinus tachycardia. Compared to the previous tracing of [**2118-7-4**]
there is now
marked ST segment depression in leads I, II, III and aVF and
V3-V6,
downsloping in appearance. These findings are consistent with
global ischemic process. Rule out myocardial infarction.
Followup and clinical correlation are suggested.
Rate PR QRS QT/QTc P QRS T
108 130 104 376/460 71 60 -26
Abdominal x-ray ([**2118-7-5**])
CLINICAL HISTORY: 53-year-old man with concern for ischemic
bowel. Evaluate for acute intra-abdominal process.
COMPARISON: None.
FINDINGS: Single portable supine view of the abdomen is
provided. There are gas filled loops of small and large bowel
throughout the abdomen ,NG tube tip within the stomach.
Underlying bony structures are unremarkable.
Imp: non-specific pattern, no definite ileus or obstruction.
Abdominal ultrasound ([**2118-7-5**])
1. Findings of cirrhosis with some variation in size of liver
nodularity.
Liver MRI or multi-phasic CT is recommended for further
evaluation.
2. Gallbladder sludge without evidence of cholelithiasis or
cholecystitis.
3. Small amount of intraperitoneal ascites and splenomegaly.
4. Normal Doppler evaluation of the hepatic vasculature.
ADMISSION LABS:
[**2118-7-4**] 06:13PM BLOOD WBC-26.7* RBC-2.68* Hgb-9.2* Hct-29.0*
MCV-108* MCH-34.4* MCHC-31.7 RDW-15.3 Plt Ct-213
[**2118-7-4**] 06:13PM BLOOD Neuts-80* Bands-6* Lymphs-7* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2118-7-4**] 06:13PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-1+ Polychr-1+ Burr-1+
[**2118-7-4**] 06:13PM BLOOD PT-38.0* PTT-50.5* INR(PT)-3.7*
[**2118-7-4**] 09:53PM BLOOD
[**2118-7-4**] 06:13PM BLOOD Glucose-98 UreaN-55* Creat-4.5* Na-130*
K-5.7* Cl-87* HCO3-13* AnGap-36*
[**2118-7-4**] 09:53PM BLOOD ALT-75* AST-162* LD(LDH)-353* AlkPhos-104
TotBili-4.2*
[**2118-7-4**] 09:53PM BLOOD Albumin-2.7* Calcium-7.1* Phos-9.4*
Mg-2.1
[**2118-7-4**] 11:07PM URINE Color-GREEN Appear-Cloudy Sp [**Last Name (un) **]-1.019
[**2118-7-4**] 11:07PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-TR Ketone-10 Bilirub-LG Urobiln-NEG pH-5.0 Leuks-MOD
[**2118-7-4**] 11:07PM URINE RBC-2 WBC-7* Bacteri-FEW Yeast-NONE Epi-1
[**2118-7-4**] 11:07PM URINE CastHy-3*
[**2118-7-4**] 11:07PM URINE Mucous-RARE
[**2118-7-4**] 11:07PM URINE
[**2118-7-4**] 10:30PM ASCITES WBC-161* RBC-112* Polys-4* Lymphs-3*
Monos-0 Eos-3* Mesothe-16* Macroph-74*
[**2118-7-4**] 10:30PM ASCITES TotPro-0.5 Albumin-LESS THAN
RELEVENT LABS:
[**2118-7-5**] 02:26AM BLOOD CK-MB-4 cTropnT-0.03*
[**2118-7-5**] 10:21AM BLOOD CK-MB-8 cTropnT-0.16*
[**2118-7-4**] 09:53PM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE
[**2118-7-4**] 09:53PM BLOOD HCV Ab-NEGATIVE
[**2118-7-4**] 09:53PM BLOOD AFP-3.6
[**2118-7-5**] 05:07AM BLOOD Type-[**Last Name (un) **] Temp-36.4 O2 Flow-2 pO2-55*
pCO2-22* pH-7.21* calTCO2-9* Base XS--17 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2118-7-5**] 05:07AM BLOOD Lactate-14.1*
Brief Hospital Course:
Mr. [**Known lastname **] is a 53 yo male with h/o alcoholic cirrhosis who
presented to [**Hospital1 18**] with coffee ground emesis and a hematocrit
drop to 25. On admission he was talking but subequently went
into acute liver failure, acute tubular necrosis renal failure
and respiratory failure. He was intubated and was started on
CVVH to correct his worsening electrolytes. EGD was performed
during the first 24 hour which showed no ulcers, erosions or
varices. He was coagulopathic and was transfused 5 units of prBC
and 5 units of FFP with slight increase of his hematocrit. He
was stablized over a couple of days. On [**7-7**] he developed melena,
increased Fio2 requirement and his CVVH stopped functioning. He
developed a lactic acidosis. During this time his liver
function worsened and his Bilirubin increased to 35, and he was
not a transplant candidate. Given his grave prognosis, goals of
care were discussed with his HCP in light of his worsening
clinical status and it was decided to make the patient CMO. He
was terminally extubated and time of death owas 1650 on [**2118-7-8**].
Medications on Admission:
None
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Alcohol cirrhosis
Discharge Condition:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5845, 2851, 4589, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4010
} | Medical Text: Unit No: [**Numeric Identifier 74427**]
Admission Date: [**2106-9-16**]
Discharge Date: [**2106-9-29**]
Date of Birth: [**2106-9-16**]
Sex: F
Service: NB
HISTORY: Baby girl twin [**Initials (NamePattern4) **] [**Known lastname 122**] is an 1810 gram product of
a 33-5/7 weeks gestation pregnancy, born to a 29-year-old,
gravida 6, para 0-2 mother. Maternal history notable for
positive PPD, treated with INH, but stopped during pregnancy.
Prenatal screen O-, antibody negative, hepatitis B surface
antigen negative, RPR nonreactive, rubella immune, GBS
unknown. Mother received RhoGAM. The review of systems was
otherwise negative. Mother had a cerclage placed, but
developed preterm labor. The twins were delivered by
cesarean section. Rupture of membranes at delivery. Twin B
emerged vigorous with good cry, Apgars 7 and 9. She was
transferred to the NICU for prematurity.
PHYSICAL EXAMINATION:
Weight 1810 grams (25th to 50th %), length 45.5 cm (50th to 75th
%), head circumference 30.5 cm (25th to 50th %)
T 97.9, P 150, RR 30, BP 66/39(48), O2 Sat 94% on RA
HEENT: Anterior fontanelle open and flat. Palate intact.
Chest: Clavicle intact. Clear breath sounds with mild
retraction.
Heart: Regular rate and rhythm. No murmur. Good femoral pulses.
Abdomen: Soft, nondistended, with no hepatosplenomegaly.
GU: Normal female. Patent anus.
Neurologic: Good tone.
Skin: Collodion like with diffuse thickened, shiny,
erythematous skin.
Discharge measurements:
Weight 2020g Length 45cm Head circumference 31.5cm
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory. The baby has always been on room air,
never needed respiratory support. She never had any
apnea of prematurity.
2. Cardiovascular. The baby was has no murmur.
Blood pressures were stable. She never needed
any boluses or pressors.
3. Fluids, electrolytes, nutrition. [**Known lastname 2951**] was started on
IV fluids and n.p.o. She was started on feeds on day of
life 2, which were advanced as tolerated. She currently
is on ad lib feeds of breast milk 24 with EnfaCare.
4. GI. [**Known lastname 2951**] was found to have a hyperbilirubinemia
with peak of 9.1 over 0.3 on day of life 4. She had
phototherapy for 24 hours which was
discontinued. Her most recent bilirubin was on [**9-24**] or
day of life 8, which was 6.9/0.2. She continues to
be slightly jaundiced with no treatment necessary.
5. Hematology. Upon admission, a CBC was done which showed
a hematocrit of 50.6 and platelets of 246,000. No
further issues.
6. Infectious disease. On admission, the baby's white
count was 10.4 with 16 polys and 1 band. A blood
culture was also drawn, which was ultimately negative.
She was started on ampicillin and gentamicin for a 48-
hour rule out. On repeat CBC on day of life 1,
secondary to a low ANC, the baby's white count was 10.2
with 65 polys and 1 band. No further CBCs were needed.
7. Neurology. The baby was started off in an isolette and
was taken out of the isolette on day of life 11 and has
had a stable temperature since that time. Otherwise,
she had a normal neurologic exam.
8. Dermatology. The baby was found to be collodion at
birth. There was a dermatology consult by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of
[**Hospital3 1810**] [**Location (un) 86**] who assessed the
baby at 4 days of life. They found diffuse dry, scaly,
erythematous skin with fissures consistent with the
findings of a collodion baby. Collodion membranes are
nonspecific and can be seen in many different
conditions, including congenital ichthyotic disorders.
Her mother has a history of ichthyosis vulgaris and the
patient may very well have ichthyosis vulgaris
presenting as a collodion. Other causes include
idiopathic collodion, lamellar ichthyosis, ichthyosis
vulgaris and X-linked ichthyosis. They recommend
liberal emollients which we are using Aquaphor Cream
twice a day to the entire skin surface to prevent
further fissuring that could predispose the patient to
infection and sepsis and a follow-up appointment with
dermatology, which is scheduled for [**10-11**].
9. Sensory.
a. Audiology. A hearing screen was performed with
automated auditory brain stem responses on [**2106-9-28**],
which the baby passed.
b. Ophthalmology. Eyes were not examined in this
baby secondary to her gestational age of 33-
5/7 weeks gestational age.
CONDITION AT DISCHARGE: Excellent.
DISCHARGE DISPOSITION: Home.
PRIMARY CARE PEDIATRICIAN: Dr. [**Last Name (STitle) 42176**] at [**Hospital 1426**]
Pediatrics, Phone #([**Telephone/Fax (1) 56268**]
CARE RECOMMENDATIONS:
1. Feeds at discharge. Please continue the baby on breast
milk 24 kilocalories with EnfaCare. Mother gets her
feeds through [**Name (NI) **] and a prescription has been provided
to them for the EnfaCare.
2. Medications. Aquaphor Cream to entire body twice a day. She
is also on Iron supplementation 2 mg/kg/day.
3. Iron and vitamin D supplementation.
a. Iron supplementation is recommended for preterm
and low birth weight infants until 12 months corrected
age.
b. All infants fed predominately breast milk should
receive vitamin D supplementation at 200 international
units (may be provided as a multivitamin preparation)
daily until 12 months corrected age.
4. Car seat position screening was done on this infant and
she passed.
5. State newborn screening status. The baby has had 2
state newborn screens done, the second is still
pending.
6. Immunizations received. The baby received hepatitis B
immunization on [**2106-9-27**].
7. Immunizations recommended.
a. Synagis RSV prophylaxis should be considered
from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of
the following 4 criteria: 1) Born at less than 32 weeks. 2)
Born between 32 and 35 weeks with 2 of the following:
day care during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school-
age siblings, chronic lung disease, hemodynamically
significant congenital heart disease.
b. 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.
c. This infant has not received rotavirus vaccine.
The American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable and at least 6 weeks, but fewer than 12 weeks of
age.
8. Follow-up appointments scheduled:
a. An appointment has been made with Dr. [**Last Name (STitle) 42176**] at
[**Hospital 1426**] Pediatrics for Friday, [**2106-10-1**].
b. A follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the
dermatology clinic has been made for [**2106-10-11**].
c. VNA will be visiting the household on Friday,
[**2106-9-30**].
DISCHARGE DIAGNOSIS:
1. Prematurity at 33 5/7 weeks.
2. Twin gestation.
3. Rule out sepsis, resolved.
4. Collodion baby/ichthyosis.
5. Hyperbilirubinemia, resolved
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 69933**]
MEDQUIST36
D: [**2106-9-29**] 07:30:16
T: [**2106-9-29**] 09:50:13
Job#: [**Job Number 74428**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4011
} | Medical Text: Unit No: [**Numeric Identifier 78077**]
Admission Date: [**2189-3-4**]
Discharge Date: [**2189-5-4**]
Date of Birth: [**2189-3-4**]
Sex: F
Service: Neonatology
HISTORY: Baby girl [**Known lastname 62243**] was born at 705 grams at 28 and 5
weeks gestation to a 32-year-old G2 P0-1 mom. The pregnancy
was complicated by oligohydramnios and pregnancy induced
hypertension. This patient also had intrauterine growth
restriction. In addition, the patient was complicated by
proteinuria at 13 weeks and progressive elevations of blood
pressure. The patient had decreased fetal growth during 22-26
weeks of fetal life. On the day prior to delivery, the mom
was treated with magnesium sulfate for worsening
preeclampsia. She was also given betamethasone and
antibiotics for concern of premature preterm rupture of
membranes.
This patient was taken to C section because of nonreassuring
fetal heart tracing and because of worsening preeclampsia in
the mother. The patient emerged limp and apneic with a low
heart rate that responded to bag and mask ventilation. The
patient was intubated in the delivery room and Apgars were 2,
5 and 7. The patient was brought to the NICU for further
intensive care. The patient remained hospitalized at the [**Hospital1 1444**] NICU until the patient will
reach 37-3/7 corrected gestational age.
PHYSICAL EXAMINATION: On discharge, weight was 2.165 kg,
length 44.5 cms, and HC 32 cms on [**2189-5-1**]. Generally
the patient was well appearing and alert. HEENT is
significant for anterior fontanel open, soft and flat. Ears
are normal set. There are no clefts. The patient has no
dysmorphic facies. The patient has a supple neck. Lungs
sounds are clear bilaterally. There is good aeration.
Cardiovascular: The patient has a normal S1, S2. No murmur
was appreciated upon discharge. The patient intermittently
has a mottled color. This mottling has been present for
multiple weeks in the hospital. The mottling is believe to be
the patient's baseline. The patient has equal femoral pulses
bilaterally. The patient's abdominal exam is consistent for
normal active bowel sounds. The abdomen is soft, nondistended
and nontender with no palpable masses. A small umbilical
hernia is present which is soft and easily reducible. GU exam
is consistent with normal female genitalia with no hernias
noted. The patient's extremities are warm and well perfused.
Neurologically, this patient has a normal such and Moro
reflex. The patient has normal tone for her gestational age.
The patient has obvious sensation to stimulation by examiner.
The patient has no hip clunks or clicks. The patient has a
patent anus and no sacral [**Hospital1 **] or dimples were noted.
HOSPITAL COURSE:
1. Respiratory: This patient was initially intubated and
put on conventional ventilation. The patient received
surfactant x 1 on the first day of life and was
extubated to CPAP by day of life #2. The patient
remained on CPAP until day of life 6. The patient was
then placed in room air and remained in room air or
minimal amounts of nasal cannula until day of life 24.
From day of life 24 until discharge, the patient
remained stable in room air. The patient did have apnea
of prematurity. The patient was initially placed on
caffeine. The caffeine was discontinued at day of life
43 at approximately 35-0/7 weeks corrected. The patient
has not had spells since [**2189-4-24**]. The patient has
had no concerning signs of apnea of prematurity for
approximately a week prior to discharge.
2. Cardiovascular: This patient has had no appreciable
murmur in the first week of life. This patient was never
evaluated for a patent ductus arteriosis. This patient
never received indomethacin and never had an
echocardiogram. Other than a baseline
mottled appearance, this patient has had no other
concerning factors in the cardiovascular portion of her
hospital course.
3. Fluids, electrolytes and nutrition: As mentioned before,
this patient's birth weight was 705 grams and the
patient was initially placed on total parenteral
nutrition. Feedings were started on day of life 4 with
breast milk. This patient achieved maximum feeds at day
of life 16. The patient was advanced on feedings until
the patient received a maximum of 130 cc per kilo per
day of breast milk fortified with 32 kcal per ounce. The
patient continued to grow well on that. At discharge,
the patient will be sent home with breast milk 26 kcal per
ounce. The breast milk is fortified with EnfaCare powder.
The patient will also be sent home with supplemented iron
and multivitamin.
4. GI: The patient received phototherapy for an elevated
indirect bilirubin (for infant's size). Peak level was
5.4/0.3. Last bilirubin level off phototherapy was
1.8/0.4 on day of life 8.
Although the infant's growth restriction was likely due to
mom's persistent pregnancy induced hypertension, a small
workup was performed. The newborn screen for toxoplasma
was negative. Mom had no history of Herpes lesions. A
urine CMV was sent and was negative. These findings made
the neonatology team less convinced of TORCH infection as
a possible etiology for the intrauterine growth
retardation.
5. Hematology: This patient's initial CBC had a white count
of 9.6. This patient was placed on ampicillin and
gentamicin for rule out sepsis workup related to preterm
labor for the first two days of life. This patient has
had no further antibiotics during the rest of her
hospital course. The last hemoglobin and hematocrit that
were performed was on [**4-27**]. At this time, the
hematocrit was 26 and reticulocyte count was 2.9%. The
patient remains on high doses of iron at 4 mg/kilo/day of
elemental iron for anemia of prematurity.
6. Infectious disease: As previously mentioned, this
patient received ampicillin and gentamicin only for a 48
hour rule out at birth related to preterm birth and
labor.
7. Neurology: This patient did have several head
ultrasounds related to prematurity at birth. Head
ultrasound was performed on [**3-11**], [**4-1**], and
[**2189-5-4**] which were all normal and showed no
significant intracranial hemorrhages or PVL.
8. Sensory: This patient passed her hearing screen prior
to discharge. This patient has been followed by
ophthalmology for retinopathy of prematurity. This
patient had two exams thus far. On [**2189-4-7**], this
patient had immature retina in zone 2. On [**2189-4-21**],
this patient had immature retina now in zone 3, with
recommended followup in three weeks. This patient will
need to have an outpatient ophthalmology eye exam to
follow for retinopathy of prematurity in mid-[**Month (only) 547**]. Our
next scheduled date was [**2189-5-11**]. We have asked the
parents to make this followup appointment.
9. Psychosocial: The parents of this child are intact. Mom
is a pediatric hematology/oncology attending who works at
[**Hospital3 328**].
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Home.
PRIMARY CARE PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 60051**] of [**Hospital 620**]
Pediatrics. The address of [**Hospital 620**] Pediatrics is [**Last Name (NamePattern1) 76136**], [**Location (un) 620**], [**Numeric Identifier **]. Phone number of
[**Hospital 620**] Pediatrics is [**Telephone/Fax (1) 37814**].
CARE AND RECOMMENDATIONS:
1. Feedings at discharge: Breast milk 26 k-calorie/ounce made
with EnfaCare formula.
2. Medications: Ferrous Sulfate 0.4 mL PO daily
(Concentration of drops 25 mg/mL; dose = ~ 4 mg/kilo/day).
Goldline multivitamin 1.0 ml p.o. daily.
Iron and Vitamin D supplementation: Iron supplementation is
recommended for preterm and low birth weight infants until
12 months corrected age. All infants fed predominantly
breast milk should receive vitamin D supplementation at 200
International Units (may be provided as a multi-vitamin
preparation) daily until 12 months corrected age.
3. Due to the infant's low birth weight, she is being
discharged in a car bed.
4. Newborn state screens have been performed during her
hospitalization on [**2189-3-7**], [**2189-3-18**], and [**2189-4-15**]. The
last screen was without any abnormal results.
5. Immunizations received: 2 month immunizations including
Pediarix, HIB, Pneumococcal 7-valent Conjugate vaccine and
Synagis [**2189-4-30**].
Immunizations recommended: Synagis
RSV prophylaxis should be considered from [**Month (only) **] through
[**Month (only) 958**] for infants who meet any of the following four
criteria: Born at less than or equal to 32 weeks. Born
between 32 and 35-0/7 weeks with two of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings. Chronic lung disease. Hemodynamically
significant congenital heart disease.
Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for all household contacts and out-of-home
caregivers.
This infant has not received rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following discharge
from the hospital if they are clinically stable and at
least 6 weeks or fewer than 12 weeks of age.
FOLLOWUP APPOINTMENTS SCHEDULED/RECOMMENDED:
1. Primary care pediatrician follow up 1- 2 days following
discharge to follow weight.
2. Pediatric ophthalmology followup for retinopathy of
prematurity near or around [**2189-5-11**].
3. Referral made to the infant followup clinic and Early
Intervention.
DISCHARGE DIAGNOSES:
1. Premature birth at 28 weeks.
2. Intrauterine growth restriction.
3. Respiratory distress syndrome, resolved.
4. Apnea of prematurity, resolved.
5. Rule-out sepsis, ruled-out.
6. Anemia of prematurity.
7. Hyperbilirubinemia, resolved.
8. Small umbilical hernia.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern4) 75901**]
MEDQUIST36
D: [**2189-5-1**] 16:51:42
T: [**2189-5-1**] 18:26:02
Job#: [**Job Number 78078**]
ICD9 Codes: 7742, 769 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4012
} | Medical Text: Admission Date: [**2130-1-6**] Discharge Date:[**2130-2-21**]
Date of Birth: [**2061-12-10**] Sex: M
Service: Coronary Care Unit
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 21892**] is a 68 year old
man with a history of severe peripheral vascular disease,
coronary artery disease, status post coronary artery bypass
grafting, Type 2 diabetes, status post bilateral above the
knee amputations as well as many other comorbid conditions,
who is transferred from [**Hospital6 2910**] for
management of congestive heart failure and cardiac
catheterization. The patient was recently admitted to the
[**Hospital 1774**] Hospital for congestive heart failure exacerbation and
received an automatic implanted cardioverter defibrillator on
[**12-9**]. He was diuresed during that admission and
transferred to the [**Hospital3 3583**] for rehabilitation. He
was readmitted to [**Hospital6 2910**] on [**12-29**],
for placement of a Swan-Ganz catheter and cardiac
catheterization via brachial approach to assess graft patency
and his remaining native vasculature. His catheterization
was complicated by inaccessible vessels, although a left
circumflex artery with an 80% occlusion was identified for
possible intervention.
PAST MEDICAL HISTORY: 1. Congestive heart failure with a 5
to 10% ejection fraction. 2. Bilateral above the knee
amputations. 3. Type 2 diabetes mellitus. 4.
Hypercholesterolemia. 5. Status post coronary artery bypass
grafting in [**2125**] which was performed in [**State 4565**] with right
internal mammary artery and left internal mammary artery to
left anterior descending as well as saphenous vein grafts to
diagonal 1. 6. Chronic renal insufficiency, baseline
creatinine 1.8 to 2. 7. Status post automatic implanted
cardioverter defibrillator placement on [**2129-12-9**].
8. History of ischemic colitis. 9. Hypertension. 10.
Gout.
ALLERGIES: No known drug allergies
MEDICATIONS ON TRANSFER:
1. Plavix 75 mg p.o. q.d.
2. Carvedilol 25 mg p.o. b.i.d.
3. Enteric coated acetaminophen 325 mg p.o. q.d.
4. Protonix 40 mg p.o. q. day
5. Digoxin 0.125 mg p.o. q. day
6. Nitropaste ?????? inch t.i.d.
7. Senokot prn
8. Tylenol prn
9. Tigan 200 mg p.o. prn
10. Ambien 5 mg p.o. q.h.s.
SOCIAL HISTORY: The patient has a remote history of tobacco
use. He denies alcohol or drug use.
FAMILY HISTORY: Non-contributory.
PHYSICAL EXAMINATION: The patient was afebrile with a
heartrate of 98, blood pressure 107/70, respiratory rate 24
and oxygen saturation 100% on a 100% face mask. In general
the patient was alert in moderate respiratory distress.
Head, eyes, ears, nose and throat examination revealed
normocephalic, atraumatic. Extraocular muscles were intact.
Pupils were equal, round, and reactive to light. Oral mucosa
was moist. The neck was supple with no jugulovenous
distension. Chest examination indicated the presence of
bibasilar rales. There were no wheezes or rhonchi.
Cardiovascular examination indicated regular rhythm, normal
S1 and S2, no murmurs, gallops or rubs. The abdomen was
distended, soft, nontender with normal bowel sounds. On
extremity examination the patient had bilateral above the
knee amputations with well healed surgical scars. He had 1+
edema in the bilateral upper extremities. Neurologically the
patient was alert and oriented times three. He was moving
his upper extremities.
LABORATORY DATA: Initial laboratory studies indicated a
white blood cell count of 5.1, hematocrit 27.0, platelets
186, chem-7 was remarkable for a BUN of 40 and creatinine
2.0. Electrocardiogram indicated normal sinus rhythm at 90
with prolonged PR intervals, Q waves in AVR, AVL, V1 and V2
with left anterior vesicular block.
HOSPITAL COURSE: The patient underwent cardiac
catheterization on hospital day #1 via left brachial access.
PA pressure was 63/34 with a wedge pressure of 33 and an RV
pressure of 65/18. The saphenous vein graft to obtuse
marginal 1 was occluded. The left anterior descending artery
had a 95% proximal occlusion. The left circumflex artery had
an 80% proximal occlusion. During the catheterization the
right internal mammary artery graft was not able to become
engaged due to complicated anatomy. Following
catheterization the patient was started on a Dobutamine drip
as well as Lasix to improve his volume overload. While on
the Dobutamine drip his cardiac index improved to 2.6. The
patient was continued on Aspirin and Plavix as well as a
nitroglycerin drip. On hospital day #2 the patient received
transfusion of ?????? a bag of packed red blood cells which was
complicated by the developmental of flash of pulmonary edema
with improvement in oxygen saturation following the
administration of intravenous Lasix. On hospital day #3 the
patient became acutely agitated with hallucinations. This
was thought to be secondary to the administration of Ambien
the evening prior and these hallucinations resolved over the
course of the day. The patient was sent back to the
Catheterization Laboratory on hospital day #4 for possible
intervention of his left circumflex lesion. At that time the
patient demonstrated a 100% proximal right coronary artery
lesion, 70% left circumflex, 90% left anterior descending
lesion. The right internal mammary artery to posterior
descending artery graft was patent with an 80% right
posterior descending artery lesion which was stented.
Following catheterization the patient was placed on
Integrilin drip. The patient received approximately 400 cc
of Di-load during this second catheterization. Subsequently
he developed acute renal failure which was felt to be due to
the Di-load. His mental status worsened which was thought
secondary to uremia. He also became anuric. The Renal
Service was consulted and on hospital day #6 the patient
received emergent hemodialysis for worsening pulmonary edema
in the setting of anuria. The patient also developed
generalized seizures times three which again was thought
secondary to his uremia and slight hyponatremia. Following
hemodialysis, the patient's seizures resolved, however,
neurology was consulted to rule out further etiologies. The
patient was started on Dilantin. Head computerized
tomography scan was negative. The patient was scheduled for
an electroencephalogram but was unable to comply with the
procedure secondary to agitation. On hospital day #6 the
patient received another 1 unit transfusion of packed red
blood cells. This transfusion was complicated by mismatched
minor antigens, however, hemolysis labs were sent and were
negative. On hospital day #6 Digoxin was held secondary to
an increase in Digoxin levels in the setting of renal
failure. The patient was maintained on hemodialysis for
volume control with a slow restitution of urine output to
approximately 200 cc per day. His mental status continued to
improve with dialysis but not to his preadmission baseline.
Dobutamine was weaned as the patient was titrated up on
Hydralazine and Isordil. His Carvedilol was restarted and
the patient was transferred to the floor for further
management. On hospital day #8, the patient experienced an
episode of 17 seconds of third degree heartblock during his
Dilantin load. This was thought secondary to the loading
process and resolved spontaneously. The patient had no
further episodes of heartblock during his hospital stay. His
automatic implanted cardioverter defibrillator was
interrogated following this episode and was found to be
functioning normally. While on Dilantin therapy the patient
developed an elevated alkaline phosphatase and GGT with
normal transaminases and total bilirubin. A abdominal
ultrasound was performed which indicated a contracted
gallbladder with stones but no evidence of biliary tree
dilatation. Neurology Service believed that the isolated
alkaline phosphatase elevation could be attributed to
Dilantin use and recommended continuing Dilantin as the
elevated alkaline phosphatase did not appear to be
problem[**Name (NI) 115**].
On hospital day #16 the patient had an episode of bright red
blood per rectum. His hematocrit remained stable and he had
no further episodes of rectal bleeding. Subsequent stool
samples were found to be guaiac negative and no further
workup was felt to be necessary.
On hospital day #20 the patient was again sent for cardiac
catheterization for potential intervention of his left
anterior descending, results are pending at the time of this
dictation.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-641
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2130-1-26**] 16:36
T: [**2130-1-26**] 16:49
JOB#: [**Job Number 29295**]
ICD9 Codes: 4280, 5990, 5849, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4013
} | Medical Text: Admission Date: [**2175-7-12**] Discharge Date: [**2175-7-16**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Motor Vehicle Collision
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
On [**2175-7-12**] the patient was the restrained driver in a head-on
motor vehicle collision. He reportedly fell asleep at the wheel
of his car. The driver of the other vehicle involved died
secondary to intra-cranial bleeding. The patient was taken from
the scene of the accident to [**Hospital **] Hospital ED, where CT of
the chest revealed a large thoracic aortic aneurysm. He was
subsequently transferred to [**Hospital1 18**] for further evaluation and
monitoring.
Past Medical History:
Glaucoma, Hypertension
Social History:
The patient is married and lives at home independently with his
wife. [**Name (NI) **] is a non-smoker.
Family History:
Non-contributory.
Physical Exam:
Vital Signs: T98.7 HR92 BP107/58 RR25 POx95% Non-Rebreather
General: AA&Ox3, very hard of hearing, no acute distress
HEENT: Right TM clear, left TM not visualized, right periorbital
ecchymosis
Respiratory: Good breath sounds bilaterally
Chest: No crepitus, sternum stable, tender to palpation over the
manubrium
Abdomen: Soft, non-tender, non-distended
Pelvis: Stable
Rectum: Good tone, no gross blood
Pulses: Upper and lower extremity 2+ bilaterally
Spine: No stepoffs or deformities, no tenderness
Pertinent Results:
[**2175-7-12**] 10:00PM BLOOD WBC-10.5 RBC-4.74 Hgb-15.3 Hct-45.9
MCV-97 MCH-32.3* MCHC-33.3 RDW-12.6 Plt Ct-222
[**2175-7-13**] 02:48AM BLOOD WBC-10.3 RBC-4.15* Hgb-13.7* Hct-39.6*
MCV-95 MCH-33.0* MCHC-34.6 RDW-13.0 Plt Ct-157
[**2175-7-12**] 10:00PM BLOOD PT-14.0* PTT-27.7 INR(PT)-1.2*
[**2175-7-12**] 10:00PM BLOOD Plt Ct-222
[**2175-7-13**] 02:48AM BLOOD Plt Ct-157
[**2175-7-12**] 10:00PM BLOOD UreaN-20 Creat-1.3*
[**2175-7-13**] 02:48AM BLOOD Glucose-131* UreaN-19 Creat-1.1 Na-139
K-4.6 Cl-102 HCO3-28 AnGap-14
[**2175-7-13**] 02:48AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1
[**2175-7-12**] 10:09PM BLOOD Glucose-140* Lactate-1.6 Na-143 K-5.5*
Cl-98* calHCO3-30
[**2175-7-12**] Portable AP Chest [**Known lastname **]: Worsening right greater than
left upper pulmonary contusions. Apparent right apical pleural
thickening, which may reflect presence of a pleural cap.
[**2175-7-13**] Chest [**Known lastname **]: Compared to the prior study from [**2175-7-12**], there is an increase in the right upper lobe opacity as
well as increased bibasilar opacities accompanied by pleural
effusions. This most likely represents worsening of the
pulmonary contusion as well as new bibasal aspiration
accompanied by pleural effusion. There is left retrocardiac
opacity consistent with atelectasis giving the new left
mediastinal shift. There is no pneumothorax.
[**2175-7-15**]: In comparison with the study of [**7-13**], there has been
substantial
clearing of the opacifications involving both upper lung zones,
most likely representing resolution of pulmonary contusion. The
density about the right apex, representing a pleural cap, has
also decreased. Blunting of the costophrenic angle is seen,
consistent with some fluid in the pleural space. Similar
changes are seen at the left base, also consistent with pleural
fluid. Mild basilar atelectatic changes are seen bilaterally. No
evidence of pneumothorax.
[**2175-7-13**] ECG: Sinus rhythm with first degree A-V delay, varying
P-R interval, probable nonconducted atrial premature complex
with junctional escape beat followed by what appear to be more
marked first degree A-V delay or possible transient junctional
rhythm. Left atrial abnormality. Right bundle branch block.
Left anterior fascicular block. Q-Tc interval appears prolonged
but is difficult to measure
[**2175-7-13**] Echocardiogram: The left atrium is mildly dilated.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild regional
left ventricular systolic dysfunction with inferior and
inferolateral hypokinsis. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Right ventricular chamber
size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
markedly dilated The aortic valve leaflets (3) are mildly
thickened. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to increased stroke
volume due to aortic regurgitation. Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Large ascending aortic aneurysm. Mild inferior and
inferolateral left ventricular focal dysfunction. Moderate
aortic regurgitation
[**2175-7-14**] Carotid Series: Duplex evaluation was performed of both
carotid arteries. Minimal plaque was identified. On the right,
peak systolic velocities are 66, 52, 55 in the ICA, CCA, and ECA
respectively. The ICA to CCA ratio is 1.2. This is consistent
with no stenosis. On the left, peak systolic velocities are 57,
64, 77 in the ICA, CCA, and ECA
respectively. The ICA to CCA ratio is 0.9. This is consistent
with no
stenosis. There is antegrade flow in both vertebral arteries. Of
note, the diastolic velocities throughout the carotid system are
diminished bilaterally, which can be consistent with an
intracranial carotid artery
occlusive disease
Brief Hospital Course:
The patient is an 88 year-old man who was admitted to the Trauma
Surgical Service on [**2175-7-12**] for management of suspected
pulmonary contusions & low oxygen saturation and for monitoring
of his 7cm thoracic aortic aneurysm, which was incidentally
discovered, after his motor vehicle collision. He was initally
admitted to the TSICU for his requirement of a non-rebreather.
RESPIRATORY: The patient was able to transition from
non-rebreather to oxygen via nasal cannula during the course of
his admission. He was able to maintain saturations of 93% on
room air while seated but dropped to 88% with ambulation. He
was asymptomatic during these episodes. He was discharged with
home oxygen.
CARDIAC: The patient was evaulated by the Cardiothoracic Surgery
Service for his stable, asymptomatic aortic aneurysm. After
evaluation by ECG, echocardiogram and carotid duplex the
decision was made to recommend starting a beta-blocker for
protection, and outpatient angiogram and follow-up for possible
elective repair.
GI: The patient was discharged on a regular diet.
GENERAL: The patient was voiding and ambulating without
difficulty, and his pain was under good control with oral
medication.
Medications on Admission:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Discharge Medications:
1. Finasteride 5 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. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
status post motor vehicle collision.
Discharge Condition:
Stable.
Discharge Instructions:
You came to [**Hospital1 69**] for care after
your motor vehicle accident
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back
* 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.
Followup Instructions:
Please follow up with your primary care physician this week for
evaluation and for removal of your skin staples.
Please also call to make an appointment for outpatient cardiac
catheterization prior to your appointment with Dr. [**Last Name (STitle) 914**]
[**2175-7-28**].
Completed by:[**2175-8-2**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4014
} | Medical Text: Admission Date: [**2131-12-29**] Discharge Date: [**2132-1-30**]
Date of Birth: [**2074-11-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
ICD firing
Major Surgical or Invasive Procedure:
Pacer interrogation
Cardiac catheterization (no intervention)
Central venous line placement in Coronary Care Unit
History of Present Illness:
57 yo M with non-ischemic dilated CMP (EF 20% in [**2-10**] with 4+
MR) secondary to Chagas disease, s/p PPM-ICD for cardiac arrest
[**2127**], multiple ED evaluations for orthostasis, presenting s/p
ICD discharges on [**12-27**] and [**12-29**]. Both shocks were preceded by
prodrome of dizziness without chest pain, palpitations, or SOB,
or syncopal event, and was shocked once. EP evaluation on [**12-27**]
revealed appropriate VT therapy on both occasions. On [**12-27**],
amiodarone was increased from 200 mg QD to 400 mg [**Hospital1 **] x2 weeks
for reloading. EP also adjusted anti-tachycardia pacing
threshold and RV pacing output (given increase in threshold).
Has not had ICD firing prior to these events since implant, but
has had ? regular fast palpitations in chest over past 2 weeks.
On ROS, only other symptom noted was recent URI, for which he
started started Zithromax on [**2131-12-28**].
Past Medical History:
1. Heart failure (EF 20%, 4+ MR) primary cardiologist Dr. [**First Name (STitle) 437**]
2. Chagas disease (travel history in [**Country 3992**], SE [**Female First Name (un) 8489**], S.
America)
3. TB exposure (in travel), +PPD s/p INH.
4. multiple ED evaluations for orthostasis in setting of
medications
Social History:
Does not smoke, drink, or use drugs. Previously worked as
sniper/anti-narcotics [**Doctor Last Name 360**] in [**University/College **], [**Country **], and [**Country 3992**].
Born in [**Country 35188**]. Past exposure to TB in colleagues, never had
active TB, was treated with INH x 12 months
Family History:
No history of CAD. Mother died of diabetes complications. Father
died from prostate CA
Physical Exam:
PE: VS: 100.2 (100.6) | 106/67 | 79 | 24 | 95% on RA; Wt. 205
lbs.
gen: NAD, resting comfortably in bed.
HEENT: PERRL/EOM intact, OP clear, MMM, no JVD, no carotid
bruit.
neck: no masses, no LAD.
CV: RRR, nl s1s2, no murmurs.
chest: CTA b/l, no crackles or wheezes.
abd: soft, nt/nd, +bs, no organomegaly.
extr: warm well perfused, 2+ dp pulses, no cyanosis, no LE
edema.
neuro: a&ox3, cn ii-xii intact; motor, sensory, coordination,
and language grossly non-focal
Pertinent Results:
Admission Labs:
===============
[**2131-12-29**] WBC-8.8 RBC-4.43* Hgb-13.6* Hct-39.8* MCV-90 Plt
Ct-211
[**2131-12-29**] PT-12.8 PTT-21.9* INR(PT)-1.1
[**2131-12-29**] Glucose-64* UreaN-21* Creat-1.5* Na-140 K-4.7 Cl-105
HCO3-25
[**2131-12-29**] Calcium-9.7 Phos-3.5 Mg-2.0
[**2131-12-29**] TSH-0.47
[**2131-12-29**] Digoxin-0.5*
.
Cardiac Enzymes:
===============
[**2131-12-29**] 06:30AM CK-MB-4 cTropnT-<0.01
[**2131-12-29**] 05:00PM CK-MB-4 cTropnT-<0.01
[**2131-12-29**] 09:00PM CK-MB-3 cTropnT-<0.01
[**2131-12-31**] 04:48AM CK-MB-4 cTropnT-<0.01
[**2131-12-29**] 12:00AM CK(CPK)-195
[**2131-12-29**] 06:30AM CK(CPK)-183
[**2131-12-29**] 05:00PM CK(CPK)-165
.
ECHO [**2131-12-31**]-
Conclusions:
===========
1. The left atrium is elongated. LA 6.6 cm.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated (diastolic dimension
8.9cm). Overall left ventricular systolic function is severely
depressed (EF 15-20%). Resting regional wall motion
abnormalities include lateral, inferolateral and apical
akinesis. The remaining left ventricular segments are
hypokinetic.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The mitral valve leaflets are mildly thickened. Severe (4+)
mitral
regurgitation is seen.
5.There is mild pulmonary artery systolic hypertension.
6.There is no pericardial effusion.
7. There is an echogenic density in the right ventricle
consistent with an AICD.
.
CXR [**2131-12-30**]
===========
There is a dual lead left-sided pacemaker, unchanged in
position. There is a new right-sided IJ central venous catheter
with the distal tip in the proximal right atrium. No
pneumothoraces are identified. There is marked cardiomegaly
which is unchanged. There has been interval increase in the
pulmonary vascular markings consistent with edema. There is
again seen a linear density within the right mid lung zone which
may represent atelectasis or scarring. This is unchanged. The
left CP angle has been cut off from the study. There is some
mild elevation of the right hemi-diaphragm and blunting of the
right CP angle which may be secondary to atelectasis, scarring,
or pleural fluid
.
CATH [**2132-1-2**]:
INDICATIONS FOR CATHETERIZATION:
1. Ventricular tachycardia
2. Dilated cardiomyopathy.
3. Severe mitral regurgitation
4. Pre-operative evaluation.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.11 m2
HEMOGLOBIN: 33.3 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 19/17/15
RIGHT VENTRICLE {s/ed} 67/19
PULMONARY ARTERY {s/d/m} 67/37/49
PULMONARY WEDGE {a/v/m} 32/38/30
LEFT VENTRICLE {s/ed} 98/32
AORTA {s/d/m} 98/50/69
**CARDIAC OUTPUT
HEART RATE {beats/min} 80
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 70
CARD. OP/IND FICK {l/mn/m2} 3.8/1.8
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1137
PULMONARY VASC. RESISTANCE 400
**% SATURATION DATA (NL)
SVC LOW 50
PA MAIN 52
AO 95
**ARTERIAL BLOOD GAS
INSPIRED O2 CONCENTR'N 24
pO2 72
pCO2 50
pH 7.4
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DIFFUSELY DISEASED 10
2) MID RCA DIFFUSELY DISEASED 10
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA DIFFUSELY DISEASED 10
4) R-PDA DIFFUSELY DISEASED 10
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DIFFUSELY DISEASED 20
6) PROXIMAL LAD DIFFUSELY DISEASED 10
6A) SEPTAL-1 NORMAL
7) MID-LAD DIFFUSELY DISEASED 10
8) DISTAL LAD DIFFUSELY DISEASED 10
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 NORMAL
12) PROXIMAL CX DIFFUSELY DISEASED 10
13) MID CX DIFFUSELY DISEASED 10
13A) DISTAL CX DIFFUSELY DISEASED 10
14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED 10
15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED 10
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
minimal luminal irregularities. The LMCA had mild plaquing up to
20%.
The LAD had minimal luminal irregularities with a distal
myocardial
"bridge" with systolic compression. The apical LAD wrapped well
around
the apex. The LCx had minimal luminal irregularities. The RCA
had
minimal luminal irregularities, it had a twin distal system with
rPDA
and RPL.
2. Hemodynamics demonstrated severely elevated left and right
heart
filling pressures, severely elevated pulmonary artery pressures
and
large V waves on the pulmonary capillary wedge pressure. Cardiac
index
was depressed. The arterial waveform demonstrated narrow pulse
pressure
with low normal systolic systemic arterial pressure. There was
no
gradient across the aortic valve on pull-back of the catheter
from the
LV to the aorta.
3. Left ventriculography was not done as the filling pressures
were too
elevated.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Severe mitral regurgitation.
3. Severe systolic and diastolic ventricular dysfunction.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2131-12-29**] andk initially
underwent device interrogation by EP, followed by IV amiodarone
loading over 24 hours. He subsequently experienced two episodes
of VT/VF the night during amiodarone loading at 12:30, then
subsequently at 7:30 the following morning, 30 min after IV
amiodarone was completed. Anti-tachycardia pacing failed on both
attempts and he was shocked into SR. Lidocaine was initiated
with 100mg bolus and 1mg/min maintenance infusion. He was
transitioned to oral mexilitine. One hour following mexilitine
dose, pt was found by care assistant c/o SOB, nausea, dizzy and
"looking poorly." Nurse found pt to be hypotensive, diaphoretic,
and non-verbally responsive, lidocaine infusion turned off, no
events noted on telemetry. Upon finding pt, vitals noted to be
BP 70/50s HR 70s. Code blue was initiated, pt was able to speak
minimally with femoral pulses present. BS 123. Placed on NRB
with good sats. Received atropine 1 mg and 1L NS without effect,
and was started on levophed gtt 1.0 mcg/kg/min, with improvement
in bp to MAP 60s. ABG noted 7.39/41/230, lactate 1.0. Pt was
tranferred to CCU for pressor management.
On [**12-30**], the patient was transferred to the CCU. Upon arrival to
CCU, all 3 peripheral IV access was lost, thus Levophed drip
held and pts MAP remained > 60 with no further symptoms. He was
transferred back to ther cardiology service the following day.
Amiodarone and Mexilitine were continued and he had no further
episodes of VT/VF. He did have episodes of lightheadedness and
nausea following mexilitine doses but no further hypotensive
episodes.
Patient went to cardiac catheterization and EP study on [**2132-1-2**]
for VT ablation and right and left heart catheterization for
pre-operative preparation for MVR, but EPS could not isolate
endocardial source. EP recommendation at that time was to treat
HF as a possible trigger of VT, discontinue mexilitine and
re-load amiodarone. At that time, his right-heart hemodynamics
revealed severe congestion, mitral regurgitation, and
cardiogenic shock [Fick CO=3.78/1.8, RA 15, RV 67/19, PA 67/37
(49), PCW 29, LV 98/32]. Cardiac surgery was consulted for
possible MVR given persistent HF in setting of MR, and preferred
minimally invasive MVR, without epicardial VT ablation (per EP).
Patient was transferred back to CCU post-procedure. Overnight on
[**1-2**], the patient had another episode of 30 beat NVST without
ICD firing. The patient was maintained on amiodarone and
diuretics for hypervolemic status. He was diuresed and evaluated
for surgery. On [**1-7**], the patient experienced an 18 beat run of
VT followed by ATP pacing and successful conversion to NSR. On
the morning on [**1-8**], the patient had recurrent VT and failed VT
therapy ATP and required external cardioversion by single 30J
shock. The patient was transferred back to the CCU on [**1-8**] and
remained asymptomatic in preparation for cardiac surgery.
On [**2132-1-11**], the patient was taken to the operating room, where he
underwent mitral valve repair with 28mm annuloplasty ring.
Please see operative note for full details. The patient
tolerated this procedure, and was taken to the cardiac surgery
recovery unit on epinephrine, levophed, vasopressin and
lidocaine drips. On post-op day #1, the patient was able to
self-extubate, and required emergent re-intubation. His
lidocaine drip was stopped, and his epinepherine drip was
increased. On post-op day #3, the patient experienced another 27
beat run of VT. An amiodarone drip was initiated, and his
pitressin drip was titrated up for hypotension. On post-op day
#4, the patient was briefly extubated, but was re-intubated for
hypercarbic respiratory failure. On post-op day #5, a palpable
cord was noted on the patient's left arm from an infiltrated IV
site. IV vancomycin was started. Blood cultures were drawn,
which resulted in one set positive for coag(-) staph. Subsequent
blood cultures were all negative. On post-op day #6, the patient
was diuresed with lasix, and tube feeding was initiated. On
post-op day #8, the patient suffered recurrent runs of VT with
unsuccessful ATP x2 along with one unsuccessful attempt at
external shock with 30J before final control with a second
external shock. A lidocaine drip was re-initiated. On post-op
day #9, heparin sc was started, and the patient was extubated.
EPS recommendations were to start PO amiodarone 400mg QD along
with mexilitine 200mg PO Q8h. Shortly after initiating these
changes, the patient again suffered VT, and the amiodarone and
lidocaine drips were restarted. Though the patient was
considered for ablation, these interventions were felt to be too
risky. Based on EPS recommendations, the lidocaine drip was
stopped. On POD#11, an infectious diseases consult was obtained
for ongoing fevers to 101.5F. His antibiotic coverage was
broadened, and he was pan-cultured, though these all failed to
show any causative organism. The patient was re-intubated for
respiratory failure, and he patient suffered another episode of
VT requiring defibrillation. On post-op day #12, his amiodarone
drip was increased, and his LFT's were checked. This revealed
normal transaminases but an amylase of 587. The patient was made
NPO. This was rechecked on post-op day #13 and was found to be
526. A right-upper quadrant ultrasound was performed, but failed
to visualize the gallbladder. No common bile duct dilation was
noticed. The patient's medication regimen was reviewed, and all
non-essential drugs with possible hepatotoxicity were stopped.
On post-op day #15, the amylasemia continued to rise to 724 with
a lipase of 827. A CT scan was performed, but this failed to
show any evidence of pancreatitis. The patient remained
clinically benign. On post-op day #16, a clear liquid diet was
initiated. On post-op day #17, the amylase and lipase continued
to rise slightly, and a GI consult was obtained. No specific
etiology was noted, and the patient was again made NPO. On
post-op day 18, the patient again suffered 3 rounds of VT. The
amylase and lipase continued to rise to the 800's and 1000's
respectively. He remained NPO. On post op day 19 his amylase
remained elevated at 780. GI medicine recommmended beginning the
[**Last Name (un) **] diet when the diet is restarted and t/c discontining the
NGT. He was transferred to [**Hospital1 2025**] for transplant consideration.
Medications on Admission:
1. Carvedilol 3.125 mg [**Hospital1 **]
2. Lasix 20 mg QOD
3. Aldactone 50 QD
4. Amiodarone 200 mg QD changed to 400 mg daily [**12-27**]
5. Digoxin 0.1 mg QHS
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Lidocaine in D5W 4 mg/mL Parenteral Solution Sig: One (1)
ml/min Intravenous INFUSION (continuous infusion).
3. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous Q 24H (Every 24 Hours).
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: Five (5) cc PO BID
(2 times a day). cc
6. Amiodarone 50 mg/mL Solution Sig: One (1) mg/kg/min
Intravenous INFUSION (continuous infusion).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q6H (every 6 hours).
10. Bumetanide 0.25 mg/mL Solution Sig: One (1) mg Injection [**Hospital1 **]
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1129**]
Discharge Diagnosis:
Non-ischemic dilated cardiomyopathy, Chagas disease
VT with AICD
Cardiogenic shock
Discharge Condition:
Good
Discharge Instructions:
Please report chest pain, palpitations, AICD firing, shortness
of breath or other concerning symptoms to your primary
physician.
You have been started on two new medications called Amiodarone
and Mexilitine. Please continue to take these as scheduled until
otherwise directed by your cardiologist. Please follow-up with
Dr. [**First Name (STitle) 437**] as scheduled below.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2132-1-7**]
1:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2132-1-9**]
9:00
Completed by:[**2132-1-30**]
ICD9 Codes: 4271, 5185, 7907, 486, 4240, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4015
} | Medical Text: Admission Date: [**2165-1-10**] Discharge Date: [**2165-1-13**]
Date of Birth: [**2115-10-11**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
transferred to the [**Hospital1 18**]
when discovered to have a pituitary hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient recalls the onset of head discomfort three months
ago. At that time he noticed a "fullness" located on the medial
frontal region above the bridge of the nose. The discomfort was
non-radiating. There was no clear trigger. Bending over
exacerbated the discomfort, while standing upright alleviated
the
discomfort to some degree. The headache would last for "hours."
.
In the one to two months prior to presentation, the head pain
increased in intensity and duration. For the syndrome, he
presented to the CVS minute clinic. At first alleve was
recommended. He returned to the clinic when alleve provided no
relief. On the second visit he was given antibiotics for a
presumed sinus infection. He had an allergic reaction to the
antibiotics. He presented to his PCP who prescribed [**Name Initial (PRE) **] different
antibiotic. When the antibiotics failed to provide relief, he
was given abortic migraine therapy (he thinks imitrex) and
firoricet about 1.5 weeks prior to admission.
.
In about the two weeks prior to presentation, the headache again
intensified and became constant. He describes the current
syndrome as a "pulsing" that involves the bifrontal (L>R)
region.
At its worst, the pain rates [**10-12**]. There was no clear trigger.
Lights, noise, and head movement exacerbate the discomfort, as
does exertion (eg coughing and sneezing). Although the headache
is not positional, it has awakened him from sleep. Alleve,
excedrin, antibiotics, imitrex, and fioricet have failed to
provide relief. Associated symptoms include nausea,
lightheadedness, and seconds of vertigo with quick head
movements. He denies similar episodes in the past. Prior to the
onset of the headache months ago, he experienced occasional
headaches completely responsive to tylenol.
.
Concerned by the intensity and persistence of symptoms, the
patient presented to the [**Location (un) 47**] [**Hospital1 1281**] ED. There, an MRI of
the brain revealed a pituitary hemorrhage. He was transferred
to
the [**Hospital1 18**] for further evaluation and care.
Past Medical History:
right knee injury (patellar fracture?) in setting of MVC, s/p
surgical repair
Social History:
- lives with wife and two children
- works as a programmer
Family History:
- positive for migraine
- negative for stroke, seizure
Physical Exam:
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: Alert. Able to relate history without
difficulty.
* Orientation: Oriented to person, place, day, month, year,
situation
* Attention: Attentive. Able to name [**Doctor Last Name 1841**] backwards without
difficulty.
* Memory: Pt able to repeat 3 words immediately and recall [**4-4**]
unassisted at 30-seconds and 5-minutes.
* Language: Language is fluent without evidence of paraphasic
errors. Repetition is intact. Comprehension appears intact; pt
able to correctly follow midline and appendicular commands.
Prosody is normal. Pt able to name high (pen) and low frequency
objects (knuckles) without difficulty.
* Calculation: Pt able to calculate number of quarters in $1.50
* Neglect: No evidence of neglect.
* Praxis: No evidence of apraxia.
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 3 to 2mm and brisk. Bitemporal (L>R, superior
quadrant>inferior quadrant) when eyes tested individually with
red pin. Fundi not well-visualized.
* III, IV, VI: EOMI without nystagmus.
* V: Facial sensation intact to light touch in the V1, V2, V3
distributions.
* VII: No facial droop, facial musculature symmetric.
* VIII: Hearing intact to finger-rub bilaterally.
* IX, X: Palate elevates symmetrically.
* [**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally.
* XII: Tongue protrudes in midline.
Motor:
* Bulk: No evidence of atrophy.
* Tone: increased in the bilateral lower extremities.
* Drift: No pronator drift bilaterally.
* Adventitious Movements: No tremor or asterixis noted.
Strength:
* Left Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Right Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Left Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
* Right Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
Reflexes:
* Left: brisk (3) throughout Biceps, Triceps, Bracheoradialis,
3+ to 4 Patellar, difficult to elicit Achilles
* Right: brisk (3) thoughout Biceps, Triceps, Bracheoradialis,
3+
to four Patellar, difficult to elicit Achilles
* Babinski: extensor bilaterally
Sensation:
* Light Touch: intact bilaterally in lower extremities, upper
extremities, trunk, face
* Pinprick: intact bilaterally in lower extremities, upper
extremities, trunk, face
* Temperature: intact to cold sensation throughout
* Vibration: intact bilaterally at level of great toe
* Proprioception: intact bilaterally at level of great toe
* Extinction: No extinction to double simultaneous stimulation
Coordination
* Finger-to-nose: intact bilaterally
* Rapid Alternating Movements: No evidence of dysdiadochokinesia
Gait:
* Description: Good initiation. Narrow-based with normal-length
stride and symmetric arm-swing
* Tandem: unable to tandem walk without difficulty
* Romberg: negative
Pertinent Results:
[**2165-1-10**] 04:47PM GLUCOSE-109* UREA N-17 CREAT-1.0 SODIUM-138
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-23 ANION GAP-12
[**2165-1-10**] 04:47PM CK-MB-2 cTropnT-<0.01
[**2165-1-10**] 04:47PM WBC-8.5 RBC-4.30* HGB-12.6* HCT-36.5* MCV-85
MCH-29.3 MCHC-34.5 RDW-12.9
[**2165-1-10**] 04:00PM ALBUMIN-4.2
[**2165-1-10**] 04:00PM TESTOSTER-87* SHBG-12* calcFT-26*
[**2165-1-10**] 06:55AM CORTISOL-17.5
[**2165-1-9**] 07:20PM PT-13.0 PTT-26.5 INR(PT)-1.1
[**2165-1-9**] 07:20PM WBC-11.2* RBC-4.58* HGB-14.1 HCT-39.6* MCV-87
MCH-30.8 MCHC-35.6* RDW-12.8
[**2165-1-9**] 07:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2165-1-9**] 07:20PM T4-8.2
[**2165-1-9**] 07:20PM FSH-3.4 LH-1.1* TSH-3.0
[**2165-1-9**] 07:20PM CALCIUM-10.0 PHOSPHATE-3.0 MAGNESIUM-2.1
Brief Hospital Course:
In ED, he was given dilaudid for pain and was noted to have
slight visual field defecits per ED note, but patient did not
notice any vision problems himself. Neurology and neurosurgery
were consulted. Per neuro note "Bitemporal (L>R, superior
quadrant>inferior quadrant) when eyes tested individually with
red pin" on exam, but neurosurgery felt "Visual fields are full
to confrontation". The recommendation was to observe him until
the blood resolves in ~2 weeks prior to any surgery for possible
adenoma.
.
He was admitted to the neurology service and while on the floor
he had an event in which he became bradycardic to 38s, BP
dropped
to 88/66 and very symptomatic with dizzyness and diaphoresis.
This was thought to be due to adrenal crisis and he was given
100
mg hydrocortisone. However, prior to giving this, his BP
resolved with IV fluids. When reviewing the telemetry, he had
bradycardia with 5s pause, 2 beats of a junctional escape, then
return to sinus rhythm.
He had no further episodes of bradycardia or hypotension. He was
transferred to the floor and then discharged on [**2165-1-13**] with
follow up scheduled for neurosurgery. Endocrinology was able to
see the patient and felt that his adrenal were working
correctly.
Follow-up appointments were made in neurology and in
endocrinology.
Medications on Admission:
none
Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO daily.
Disp:*30 Tablet(s)* Refills:*2*
2. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours for 1 weeks.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pituitary Hemorrhage
Discharge Condition:
Improved; he has normal mental status, cranial nerves, normal
strengh and sensory exam
Discharge Instructions:
You were admitted with headaches and your brain imaging showed a
pituitary hemorrhage.
You should take prednisone 5mg per day and follow-up your
consults.
If you develop worsening headches, confusion, dizziness you
should call the neurology resident on call or come to ER.
You should have a repeat brain MRI in [**5-8**] weeks.
Followup Instructions:
Endocrinology: please, schedule an appoitment with Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 88376**]
Neurology: please, schedule an appoitment along with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 19825**] and Dr. [**First Name (STitle) 1726**]: [**Telephone/Fax (1) 31415**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
Completed by:[**2165-1-15**]
ICD9 Codes: 5849, 5859, 2859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4016
} | Medical Text: Admission Date: [**2159-8-22**] Discharge Date: [**2159-9-25**]
Date of Birth: [**2114-10-21**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old
woman brought to the [**Hospital6 256**]
status post gunshot wound to the head with entry point to the
right medial canthus of the right eye with no exit wound.
The patient had no pupillary reaction on the right. Left
move the left arm and leg to noxious stimulation but had a
right hemiparesis.
CT demonstrated a large left temporal hematoma about 8 cm.
There was air in the lateral ventricle system, third
ventricle, foreign body bullet adjacent to the left petrous
temporal bone with significant communication. There was
cerebral edema.
The case was discussed with the patient's family, and they
opted for emergent craniotomy for evacuation of the hematoma.
On [**2159-8-22**], the patient underwent left temporal
craniotomy for temporal lobectomy and evacuation of the
cranial hemorrhage and removal of the intracranial foreign
body of the bullet and reconstruction of the left skull base.
There were no intraoperative complications.
Postoperatively the patient was monitored in the Surgical
Intensive Care Unit. She was seen by Ophthalmology. On
[**2159-8-22**], at 11 p.m. the patient was taken to the
Operating Room by the Ophthalmology Service for ruptured
right globe and repair of right ruptured globe. There were
no intraoperative complications, and again the patient was
transferred to the SICU for close monitoring.
On postoperative day #1, the patient opened eyes to pain.
She moved all four extremities, left greater than right. She
had a temperature of 101??????. Her left pupil was equal and
reactive. The left pupil was reactive at 3 down to 2. Her
left temporal incision was clean, dry and intact. Her right
orbit was bandaged. Neck was supple. Chest was clear to
auscultation. Abdomen was soft. Extremities with no
clubbing, cyanosis or edema. The patient remained intubated.
The patient has a past medical history of depression and
alcohol abuse. She was reportedly in an abusive relationship
prior to incident. Initially on admission it was unclear
whether this injury was self-inflicted or not. At this time
it has been determined that this was a self-inflicted injury.
On [**2159-8-23**], the patient developed CSF rhinorrhea.
Ophthalmology continued to follow the patient post globe
reformation. The patient had no signs of infection, although
was given a poor prognosis for regaining vision in that eye.
The patient had a [**Doctor Last Name **] shield in placed over the right eye and
was receiving Tobradex ointment for that right eye three
times a day.
On [**2159-8-23**], the patient had a cerebral arteriogram to
rule out carotid cavernous fistula or pseudoaneurysm both of
which were ruled out. On [**2159-8-24**], the patient had a
repeat head CT which showed no discreet abscess, unchanged
midline shift with left ventricular compression, decreased
pneumocephalus. The patient opened eyes spontaneously. The
patient had movement of the left side more than the right side.
The right side localizes to pain. The patient had a lumbar drain
placement on [**2159-8-26**], for CSF rhinorrhea. The drain was
in place for 5-7 days.
The patient was followed by the Oromaxillofacial Service for
the right medial canthus entry site of her gunshot wound.
There was no bony injury to the orbit. On [**2159-8-27**],
the patient spiked a temperature to 101.5??????. She was fully
cultured. She was given one single dose of Zithromax and
Flagyl. On [**2159-8-26**], the patient grew out
gram-positive cocci in blood culture. The patient was
started on Vancomycin. On [**2159-8-28**], the patient
spiked to 103.8??????. Blood cultures came back positive for
gram-positive cocci. Sputum had gram-positive cocci. The
patient was continued on Vancomycin and started on Cipro,
Flagyl, and Ceftriaxone.
The patient again had cultures sent on [**2159-8-27**]; four
out of four bottles grew gram-negative rods. CSF was
negative, and urine culture was pending. The patient was
covered with triple antibiotics in the form of Cipro,
Ceftriaxone, Vancomycin, and Flagyl. Infectious Disease was
consulted on [**2159-8-28**].
On [**8-27**], the patient's urine culture came back with
greater than 100,000 yeast. Sputum was with multiple
organisms and greater than 10 epis. Blood cultures grew out
coag-negative staph and gram-negative rods. Sputum was with
gram-positive cocci and sparse Neisseria meningitidis. CSF
had no PMNs and no growth.
Chest x-ray on [**2159-8-27**], showed rapidly improving
atelectasis in the right lower lobe with middle lobe
atelectasis and small left pleural effusion. [**8-26**],
chest x-ray showed right lower lobe collapse. Head CT on
[**8-24**] showed discreet pneumocephalus, no evidence of
intracranial abscess, continuing bubble of air in the
surgical bed in the region of the temporal bone with mass
affect and shift.
The patient had repeat head CT on [**2159-8-29**], which showed
no evidence of intracranial abscess, and CSF gram stain has been
negative to date. Final speciation for blood cultures was
Enterobacter. Infectious Disease recommended discontinuing
Flagyl and Vancomycin and Ceftazidime. She continued on
Ciprofloxacin for a two-week course for the Enterobacter
bacteremia, and Vancomycin was discontinued.
The patient was doing well, opening her eyes, began following
commands, moving her left side greater than right, and was
extubated on [**2159-8-30**]. The patient had a swallow
study on [**8-30**], for which she was not awake enough to
swallow appropriately, so the patient was kept NPO.
The patient was also followed by the Psychiatry Service.
Psychiatry found the patient to be more impulsive and
required a 1:1 sitter, which she had until [**2159-9-20**].
Her impulsivity has slowly improved to the point where she is
no longer in need of a 1:1 sitter. Psychiatry also felt that
the patient would require a neurocognitive rehabilitation
rather than a psychiatry admission due to her head injury.
On [**2159-8-31**], the patient was transferred to the
regular floor and out of the Intensive Care Unit. The
patient was followed by Physical Therapy and Occupational
Therapy and found to require acute rehabilitation for
neurocognitive rehabilitation prior to discharge home.
On [**2159-9-2**], the patient spike a temperature to 103??????
and then to 104??????. The patient's line was discontinued, and
the tip was sent for culture. Blood cultures, urine, and
catheter tip were all sent for culture. The patient was
started on Ceftriaxone and Fluconazole and continued on
Ciprofloxacin. The Infectious Disease Service was
reconsulted. On [**2159-9-3**], the patient had a head CT
which showed no evidence of acute abscess and also showed
resolving hematoma with paranasal sinus opacification. On
[**2159-9-2**], the patient's blood cultures grew 2 out of
4 bottles with yeast. The patient was started on Fluconazole
400 mg IV q.d. for two-week therapy for fungal septicemia.
The patient had a repeat swallow study on [**2159-9-5**],
and the patient was able to take p.o. with supervision and
aspiration precautions. The yeast was speciated to [**Female First Name (un) 564**]
albicans and therefore susceptible to Fluconazole; therefore,
the patient was kept on a two-week course. Positive catheter
tip confirmed the line as the source of fungemia yeast. The
Ciprofloxacin was discontinued.
On [**2159-9-6**], the patient was found to have a large
red, warm infected area in the left side of neck, thought to
be infected clot from her previous central line placement.
The patient was sent for ultrasound which confirmed the clot
in her left IJ and left subclavian vein. The patient was
continued on intravenous Fluconazole for two more days, and
then despite Fluconazole treatment, the patient continued to
spike temperatures. The patient was therefore switched to
Amphotericin.
The patient was started on TPN due to her poor calorie counts
and inability to have PEG or PICC line placement due to her
fungal infection. On [**2159-9-14**], the patient went for
repeat arteriogram which showed a 3-4 mm left posterior
communicating aneurysm and thrombosis of the left internal
jugular vein. Vascular Service was consulted in relation to the
left IJ thrombus. Because the patient is unable to be fully
anticoagulated, the Vascular Service felt that it was not
possible to perform a thrombectomy on that clot.
On [**2159-9-16**], the patient had LFTs sent which were
elevated. The patient also developed cellulitis in the IV
site and was started on Oxacillin. When her LFTs became
elevated, the Oxacillin was discontinued, and the patient was
placed on Keflex. On [**2159-9-18**], the patient's left
forearm thrombophlebitis had not improved on Kefzol. The
patient's Kefzol was discontinued, and she was started on
Vancomycin 1 g IV q.12 hours for a 7-day course. Also due to
the increasing LFTs, the patient had a scan of her abdomen to
rule out liver and spleen involvement and had a TEE to rule
out [**Female First Name (un) 564**] endocarditis which was ruled out. Abdominal CT
was negative.
On [**2159-9-19**], the patient had a PICC line placed. The
patient developed injection of the left eye which was
followed by Ophthalmology who just recommended antibiotic
ointment for her left eye.
The patient has a follow-up appointment in the Infectious
Disease Service on [**10-3**], at 1:30 p.m., in the [**Doctor Last Name 780**]
Building on the [**Location (un) 895**] for follow-up for her Amphotericin
B treatment. The patient should continue on Amphotericin B
until that appointment.
On [**2159-9-21**], it was felt that the possible cause for
increase LFTs was Dilantin. The Dilantin was discontinued,
and the patient's LFTs were coming back down to normal. On
[**9-21**], the patient's AST was 128, ALT 333, alkaline
phosphatase 226, total bilirubin 0.3. Vancomycin was
discontinued on [**2159-9-24**], and she was continued on
Amphotericin B IV for her fungal septicemia.
The patient had her potassium checked daily secondary to
potassium wasting due to the Amphotericin B. Her potassium
levels and magnesium levels should be checked daily.
Ophthalmology recommended Lacrilube t.i.d. to both eyes,
follow-up in two weeks to the Eye Clinic.
The patient is currently afebrile. Her vitals signs are
stable. She was awake and alert, oriented times three,
moving everything strongly, but still with residual
right-sided weakness. She is being discharged to
rehabilitation today. She is in stable condition.
DISCHARGE MEDICATIONS: Cyclogyl 1% one drop to the right eye
b.i.d., Zantac 150 mg p.o. b.i.d., Lacrilube O.U. t.i.d.,
Benadryl 25 mg p.o. 30 min before Amphotericin B dosing, 1 drop
O.U. q.i.d., Amphotericin B 50 mg IV q.24 hours, the patient
should be prehydrated with 250 cc of normal saline and post
hydrated with 250 cc of saline, Ibuprofen 200 mg p.o. 30 min
before Amphotericin B dose, Pred Forte 1% eye drop 1 drop q.2
hours to the right eye while awake.
FOLLOW-UP: The patient will follow-up in the [**Hospital 8183**]
Clinic in two weeks prior to discharge. She will follow-up
with Dr. [**Last Name (STitle) 1132**] in [**1-21**] weeks with a head CT. She will
follow-up with the Infectious Disease Service on [**10-3**],
and with Ophthalmology in two weeks.
CONDITION ON DISCHARGE: Stable. She is afebrile, and vitals
signs are stable.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2159-9-25**] 10:35
T: [**2159-9-25**] 10:50
JOB#: [**Job Number 35713**]
ICD9 Codes: 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4017
} | Medical Text: Admission Date: [**2113-3-27**] Discharge Date: [**2113-3-30**]
Date of Birth: [**2042-9-10**] Sex: F
Service: MEDICINE
Allergies:
Alprazolam / Acetaminophen
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Lethargy, confusion
Major Surgical or Invasive Procedure:
Arterial line
Right IJ central line
History of Present Illness:
70F with history of thyroid cancer, COPD, [**Hospital 66942**] nursing home
resident, found by [**Hospital1 1501**] staff to be lethargic this AM. O2 sat 84%
on RA. EMS was called. No further details available at time of
this note.
.
In the ED, initial vs were: T98.2 75 65/34 16 99% on NRB. Awake
but confused. Foley placed and looked like pus. Labs notable for
leukocytosis to 15K, creatinine 3.9, K 6.3, lactate 1.7,
troponin 0.09. UA positive for WBCs. ECG with ST depressions in
precordium. Patient was given vancomycin, levofloxacin,
ceftriaxone, and getting 3rd liter NS. CVL placed and
repositioned to 3 cm outside neck.
.
In the [**Hospital Unit Name 153**], patient lethargic but easily arousable, seems to be
a poor historian but denied headache, abdominal pain, chest
pain, shortness of breath.
Past Medical History:
- COPD - details unknown
- Chronic kidney disease, stage 3 - baseline creatinine unknown
- Thyroid cancer s/p thyroidectomy, now hypothyroid
- Bipolar disorder/schizoaffective disorder
- Coginitive impairment, likely secondary to mental illness ([**Name8 (MD) **]
NP, patient A&O at baseline, able to dress and feed herself,
though non-ambulatory)
- Hyperlipidemia
- Esophageal stricture
- Osteoarthritis
- Hypertension
- Peripheral vascular disease
- Peptic ulcer disease
- s/p Subdural hematoma
- s/p cholecystectomy
Social History:
Resident at [**Hospital3 **] facility. Does not make own
medical decisions at baseline (son [**Name (NI) 2259**] [**Name (NI) **] is HCP). Has
four children - two sons and two daughters. [**Name (NI) **] [**Name (NI) 2259**] (HCP) is
youngest. Is not ambulatory (?volitional), but can feed and
clothe herself.
Family History:
Non-contributory
Physical Exam:
(On admission)
General: lethargic and easily arousable, and speech mostly
confused but at times appropriate, answers simple questions.
HEENT: Sclera anicteric, PERRL (resists eye opening), MM dry and
resists further opening mouth.
Neck: obese, CVL in place, JVD unable to appreciate given body
habitus.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi appreciated, overall somewhat distant sounds.
CV: Regular rate and rhythm, S1 + S2, [**3-11**] SM at R and LUSB, some
radiation to carotids.
Abdomen: soft, obese, bowel sounds present, denies TTP though
appears uncomfortable to palpation.
Ext: slightly cool on pressors, palpable DP pulses, no clubbing,
cyanosis or edema
Neuro: Moving all extremities though some difficulty getting her
to follow strength commands. Unable to assess orientation, can
say full name.
Skin: no posterior decubs, though some skin breakdown with
fissuring under bilateral breasts.
Pertinent Results:
Admission labs
[**2113-3-27**] 10:12AM BLOOD WBC-15.0* RBC-3.55* Hgb-11.5* Hct-34.9*
MCV-98 MCH-32.4* MCHC-33.0 RDW-14.6 Plt Ct-383
[**2113-3-27**] 10:12AM BLOOD Neuts-82.4* Lymphs-11.2* Monos-4.4
Eos-1.7 Baso-0.3
[**2113-3-27**] 10:12AM BLOOD PT-13.6* PTT-27.0 INR(PT)-1.2*
[**2113-3-27**] 10:12AM BLOOD Glucose-126* UreaN-67* Creat-3.9* Na-140
K-6.3* Cl-107 HCO3-21* AnGap-18
[**2113-3-27**] 10:12AM BLOOD ALT-17 AST-23 CK(CPK)-100 AlkPhos-75
TotBili-0.3
[**2113-3-27**] 10:12AM BLOOD Lipase-39
[**2113-3-27**] 04:34PM BLOOD CK-MB-3 cTropnT-0.06*
[**2113-3-28**] 04:02AM BLOOD CK-MB-4 cTropnT-0.05*
[**2113-3-27**] 10:12AM BLOOD Albumin-3.2* Calcium-8.8 Phos-5.3* Mg-2.4
[**2113-3-27**] 10:17AM BLOOD Glucose-122* Lactate-1.7 Na-142 K-6.0*
Imaging and studies
[**2113-3-27**] - AP CXR - IMPRESSION: Markedly limited study without
gross signs of pneumonia or CHF.
[**2113-3-27**] ECG - Normal sinus rhythm. Leftward axis at minus 14
degrees. Increased R wave in the right precordial leads. ST-T
wave changes in leads I, II, aVL and V2-V6. No previous tracing
available for comparison. While non-specific these ST segment
depressions are suggestive of myocardial ischemia.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
81 138 106 392/428 53 -14 141
[**2113-3-28**] - Transthoracic ECHO - The left atrium is mildly
dilated. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF 70%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Brief Hospital Course:
A 70 year old woman with COPD and hypothyroidism s/p
thyroidectomy for thyroid cancer who presented from her [**Hospital1 1501**] with
lethargy and was found to be hypoxic, hypotensive, and have a
UTI.
.
# Septic shock/Urinary tract infection. The urinary source was
suspected. She had clearly positive UA in [**Hospital1 1501**] patient; urine
culture grew out Strep viridans, an unusual urinary pathogen.
She had no evidence of pneumonia. She had no recent antibiotic
exposure or diarrhea to suggest C.diff. Blood cultures remained
negative. ECHO was negative without evidence of vegetation
(Strep viridans is more associated with endocarditits than UTI).
Pressors were quickly weaned off and patient's mental status
improved. She was initially treated with vancomycin,
ceftriaxone, and ciprofloxacin ([**3-27**]) but continued only on
ceftriaxone when urine culture grew out Strep viridans. She will
continue to receive Ceftriaxone at her nursening home for 3 days
and then oral antibiotics (Amoxicillin) for full course. Her
home blood pressure medications were initially held, she
received several IVF boluses, and metoprolol was restarted on
[**3-29**]. We did not restart nifedpine, HCTZ, or [**Last Name (un) **] on discharge.
These medications can be restarted when her kidney function
normalizes. She SHOULD NOT RECEIVE HCTZ AT SUCH HIGH DOSE (50
mg) as this will results in numerous side effects without
significant reduction in blood pressure. If her GFR decreases,
she should not receive HCTZ at all, and Lasix can be used
instead for hypervolemia. If she develops bacteremia from Strep
viridans, TEE and colonoscopy ( colon cancer) should be
considered.
.
# Acute on chronic renal failure. Patient has a history of
stage 3 ARF on CKD. She was prerenal on admission from volume
depletion and creatine improved with IVFs. She may have also had
some component of ATN from ischemia/hypotension. No reason for
postobstructive process.
.
# Atrial fibrillation. No documented history of Afib. She had
Afib on morning of [**3-28**] after receiving norepinephrine and 500
ml of LR for hypotension. Afib resolved spontaneously after
about half hour and likely caused by atrial distention from
fluid bolus. Given her lack of history of a fib and quick
conversion, anticoagulation was felt to not be indicated. She
laready receives ASA and Plavix for unclear reasons (other than
? H/O CAD/PVD from NH notes)
.
# AMS. She was lethargic at nursing home, in [**Hospital1 18**] ED, and upon
admission to MICU. There was nothing focal on exam to suggest
focal CNS process. She is an elderly woman with polypharmacy on
a number of sedating meds which may be affected by renal
failure. Her mental status rapidly improved over the 2 day ICU
stay and was back to normal on discharge. ICU team held sedating
medications during ICU stay (depakote, risperidone, wellbutrin,
trazadone). Upon leaving ICU, wellbutrin and depakote were
restarted.
.
# Anemia. Hct drop likely dilutional in the setting of receiving
IVFs for septic shock. No signs of bleeding on exam, guiac
negative.
.
# Hyperkalemia. In ED patient had K of 6.3. Likely combination
of ARF, K supplementation at [**Hospital1 1501**] in this setting, and [**Last Name (un) **] use. K
improved rapidly with with improvement in urine output and was
down to 3.1 by morning of [**3-29**].
.
# Polypharmacy: This elderly woman with polypharmacy on a number
of sedating medications and CKD. Her medications should be
reconsidered by her PCP and some should be discontinued. No
clear indication for DAPT (dual antipatelet therapy) in this
woman, and this combination should be reconsidered. Her BP
medications and diuretics should also be reconsidered (see
above).
.
# total discharge time 45 minutes.
Medications on Admission:
KCl 20 meq [**Hospital1 **]
Metoprolol 50 mg [**Hospital1 **]
ASA 325 mg daily
plavix 75 mg daily
simvastatin 40 mg daily
Benicar 40 mg daily
nifedipine XL 30 mg daily
HCTZ 50 mg daily
Levothyroxine 50 mcg daily
Combivent inhaler 2 puffs QID
spiriva 18 mcg daily
guiafenesin 10 ml HS
famotidine 40 mg HS
fluticasone nasal HS
wellbutrin 150 mg [**Hospital1 **] / 75 mg [**Hospital1 **] per oupt records
Risperidone 1 mg HS / 0.5 mg QHS per outpt records
depakote 250 mg [**Hospital1 **]
trazodone 75 mg HS
Actonel 35 mg once weekly.
colace 100 mg daily
oxycodone 5 mg at HS and Q4H prn pain (last dose yesterday HS)
// 5 mg [**Hospital1 **] per outpt records
lidoderm patch to low back daily
MVI
Caco3 500 mg [**Hospital1 **]
Vitamin D 800 units daily
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for under breast excoriation/yeast.
12. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-4**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheeze or
dyspnea.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
15. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
16. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
19. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
20. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 3 days.
22. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO twice a
day for 7 days: Please start once she finishs Ceftriaxone. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4657**] - [**Location 1268**]
Discharge Diagnosis:
VIRIDANS STREPTOCOCCI urinary tract infection
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 had VIRIDANS STREPTOCOCCI isolated in your urine which is
uncommon bacteria to cause urinary tract infection. However, you
had a quick recovery with IV antibiotics. If you develop blood
infection with this bacteria, you will need more tests such as
an echocardiogram through the esophagus and colonoscopy.
Followup Instructions:
follow up with your PCP at the rehab facility
ICD9 Codes: 5990, 5849, 2930, 2762, 496, 2724, 4439, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4018
} | Medical Text: Admission Date: [**2159-10-25**] Discharge Date: [**2159-11-5**]
Date of Birth: [**2076-11-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
acute Non STEMI
Major Surgical or Invasive Procedure:
coronary artery bypass grafts
x4(LIMA-LAD,SVG-OM1-OM2,SVG-dg)[**2159-10-26**]
left and right heart catheterization [**2159-10-25**]
History of Present Illness:
Mr. [**Known lastname **] is an 82 year old malewith prior MI who has refused
catheterization. This morning of admission he developed chest
pressure which was located in the mid-epigastrum , with
indigestion. The sensation was similar in quality to the chest
pressure he had when he presented in 9/[**2159**]. Did not take
anything for the pain. Of note, the patient presented to his
outpatient cardiologist 1 week after his prior discharge and was
still having indigestion type chest pain at that time and was
started on Imdur with some relief.
.
The patient presented initially to [**Hospital3 1280**] Hospital where a
CXR showed pulmonary edema vs. consolidation. He received lasix,
BiPAP, morphine, levaquin and ceftriaxone and nitro paste.
Troponins initially were 0.01. He was transferred to [**Hospital1 18**].
Past Medical History:
Hyperlipidemia
hypertension
Asthma
Bronchitits
obstructive sleep apnea
noninsulin dependent diabetes mellitus
Renal calculi
Social History:
Mr. [**Known lastname **] worked as policeman for many years. He is now retired,
working at a car auction two days weekly. He denies smoking,
alcohol use, and illicit drugs.
Family History:
No family history of early myocardial infarction, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
On Admission:
VS: 98.6 150/77 81 20 100%3L
GENERAL: Lying in bed in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Good air entry b/l. Mild wheezing throughout lung fields.
Mild-moderate crackles at bases.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Conclusions
PRE-BYPASS:
-No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No spontaneous echo
contrast is seen in the body of the right atrium.
-No atrial septal defect is seen by 2D or color Doppler.
-Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 %) with normal free wall contractility.
-There are simple atheroma in the descending thoracic aorta.
-The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no aortic valve stenosis. No
aortic regurgitation is seen.
-The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
-There is no pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results at the time of the study.
POSTBYPASS:
The patient is A-paced on low dose phenyleprhrine infusion.
Right ventricularr function is maintained. Left ventricular
function is mildly decreased from baseline, EF 35-40% with
cardiac output of 4.48. Mitral regurgitation is now moderate.
The remaining valves remain unchanged. The aorta remains intact.
[**2159-11-5**] 05:30AM BLOOD WBC-11.5* RBC-3.70* Hgb-10.4* Hct-32.3*
MCV-87 MCH-28.1 MCHC-32.1 RDW-13.6 Plt Ct-276
[**2159-11-4**] 06:00AM BLOOD WBC-14.0*
[**2159-11-3**] 09:25AM BLOOD WBC-10.8 RBC-3.93* Hgb-11.3* Hct-34.3*
MCV-87 MCH-28.8 MCHC-33.1 RDW-13.6 Plt Ct-280
[**2159-11-5**] 05:30AM BLOOD Glucose-101* UreaN-36* Creat-2.1* Na-142
K-4.2 Cl-105 HCO3-28 AnGap-13
[**2159-11-4**] 06:00AM BLOOD UreaN-36* Creat-2.7* Na-144 K-4.0 Cl-103
Brief Hospital Course:
Following transfer he ruled in with positive troponins. He had
continued angina and underwent catheterization to revealed
triple vessel diseae. He went the following morning for urgent
revascularization. See operative note for details. He weaned
from bypass on Neo Synephrine and Propofol. He weaned from the
ventilator and was extubated on POD 1. Beta blockade was started
and he was diuresed towards his preoperative weight. Diuresis
was increased due to persistent left effusion which was present
pre-operatively. His foley was removed and he was able to void
in small amounts with an 850cc residual- foley was replaced and
will need a repeat voiding trial. Physical Therapy worked with
him for strength and mobility. Chest tubes and temporary pacing
wires were removed according to protocol. He was placed on
antibiotics for sternal drainage. He was discharged to [**First Name8 (NamePattern2) 1495**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] for futher recovery prior to returning home.
Appointments for follow up were arranged and medications were as
listed.
Medications on Admission:
1. Levemir 100 unit/mL Solution Sig: Fourteen (14) units
Subcutaneous at bedtime.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
5. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO three times a day.
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
7. Asmanex Twisthaler 220 mcg (30 doses) Aerosol Powdr Breath
Activated Sig: One (1) Inhalation twice a day.
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
13. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for constipation.
15. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: start
[**10-3**].
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*
16. IMDUR 30mg Daily
17. MVI
Discharge Medications:
1. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
15. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day.
16. cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a
day for 7 days.
17. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: per sliding scale.
19. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 20 Units Glargine with breakfast.
20. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
21. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 25499**] [**Hospital 731**] - [**Location (un) 47**]
Discharge Diagnosis:
Non STEMI with unstable angina
s/p coronary artery bypass grafts
coronary artery disease
hypertension
Asthma
Bronchitits
obstructive sleep apnea
noninsulin dependent diabetes mellitus
Renal calculi
hyperlipidemia
s/p left nephrectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait and assist of one
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema/ serosang drainage
Leg Left - healing well, no erythema or drainage.
Edema 2+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2159-12-3**] 1:15pm in the
[**Hospital **] medical office building [**Hospital Unit Name **].
Cardiologist: Dr. [**Last Name (STitle) 25500**] on [**11-30**] at 1:30pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6051**]([**Telephone/Fax (1) 25493**]) in [**4-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2159-11-5**]
ICD9 Codes: 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4019
} | Medical Text: Admission Date: [**2115-10-23**] Discharge Date: [**2115-11-4**]
Date of Birth: [**2087-12-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Motor vehicle collision w tree
Major Surgical or Invasive Procedure:
[**10-27**] -- Percutaneous tracheostomy and percutaneous endoscopic
gastrostomy
[**10-28**] -- Closed reduction with placement of intermaxillary
fixation
History of Present Illness:
27M restrained driver motor vehicle crash vs tree. Intubated at
scene. Per [**Location (un) 7622**], decerebrate posturing in field with GCS4 &
Cushingoid reflex. On arrival to ED, was GCS4T, intubated, and
received vec/succ for intubation. +Gag. Blood in L ear &
oropharynx.
Past Medical History:
PMH: None
PSH: Right Inguinal Hernia Repair
Medications: None
Allergies: NKDA; (allergy to shrimp, anaphylax)
Social History:
Lives alone, attending college in prep for Law school, active
full time air force national guard, avid hiker/mountaineer. He
was recently hiking in [**Location (un) 3844**] mountains last weekend. No
other recent travel. Never smoker, drinks wine on occasion, no
h/o heavy ETOH use, no known Illicit or IV drug use.
Family History:
Maternal Grandparents-both with CAD, died in their 90's. Parents
both healthy. No FH of blood clots, connective tissue disease or
autoimmune diseases.
Physical Exam:
Upon admission:
Vitals: T 98, BP 117/80, HR 77, R 18 on CPAP, sat 100%
Gen- critically ill, intubated and sedated
HEENT- NC, scattered small abrasions on face, OP clear, MMM
Neck- no carotid bruits.
CV- Distant sounds, RRR, no MRG
Pulm- CTA B
Abd- soft, ND, no HSM, BS+
Extrem- multiple abrasions, no CCE, 2+ DP, PT pulses bilat.
NEUROLOGIC EXAM:
MS- does not follow commands. localizes with left arm to sternal
rub.
CN- pupils miotic 1mm and appear unreactive to light, unable to
view fundi, slow roving eye movements, unable to test dolls as
pt
in C-collar, intact gag, intact corneals bilaterally.
Motor- winces to noxious on the left arm and leg, withdraws left
arm, internally rotates left leg to noxious.
Sensory- intact to noxious.
Reflexes- 2+ on left [**Hospital1 **], tri, braciorad, patellar, 3+ on right
[**Hospital1 **], tri, patellar
Plantar response is upgoing on the right, down on the left
Pertinent Results:
[**2115-10-23**] 03:00AM BLOOD WBC-14.2* RBC-4.77 Hgb-15.1 Hct-42.2
MCV-88 MCH-31.6 MCHC-35.7* RDW-13.2 Plt Ct-281
[**2115-10-23**] 03:00AM BLOOD PT-13.2 PTT-22.6 INR(PT)-1.1
[**2115-10-23**] 06:53AM BLOOD Glucose-78 UreaN-14 Creat-1.0 Na-142
K-4.0 Cl-99 HCO3-29 AnGap-18
[**2115-10-23**] 06:53AM BLOOD Calcium-8.9 Phos-5.2* Mg-2.2
CHEST SINGLE VIEW ON [**2115-11-2**]
FINDINGS: There has been interval decrease in the amount of
intra-abdominal free air. Tracheostomy tube is unchanged in
location. There is a small amount of volume loss versus an early
infiltrate in the left lower lung. Otherwise, the lungs are
clear.
[**2115-10-25**]
EXAMINATION: Non-contrast head CT.
COMPARISONS: Comparison to non-contrast head CT from [**2115-10-24**],
dating back to CTA of the head from [**2115-10-23**].
IMPRESSION:
1. Stable pattern of hemorrhage consistent with diffuse axonal
injury.
Dominant area of hemorrhage within the left subinsular region
with stable
associated mass effect and effacement of the left lateral
ventricle. Areas of
intraventricular hemorrhage stable. No evidence for new
hemorrhage.
2. Multiple fractures of the mandible and right
zygomaticomaxillary complex
fracture which are better evaluated on dedicated CT of the
facial bones from
[**2115-10-23**]. Please refer to CT facial bone report for further
characterization
and recommendations.
[**2115-10-23**]
Cerebral Angiogram
IMPRESSION: The patient underwent cerebral arteriography which
revealed no
evidence of arteriovenous malformations, AVMs or aneurysm, which
could be
responsible for his left putaminal hemorrhage
Brief Hospital Course:
[**2115-10-23**] Medflighted to [**Hospital1 18**] from scene. GCS4. Imaging shows
Diffuse Axonal Injury w/ multiple intraparenchymal hemorrhages
(largest L temporal); Right orbital and mandibular fractures
(body + R ramus). Neurosurgery consulted; bolt placed for ICP
monitoring. Mannitol and Dilantin started. His cervical spine
imaging was negative for any fractures or malalignment; disc
protrusion was noted at C4/5 and Neurosurgery spine recommended
to keep the cervical collar on until follow up in 4 weeks.
[**10-24**] Repeat head CT showed no interval change of intracranial
hematoma. Angio neg for AVM, good flow. ICP pressures <15. TF
started.
[**10-25**] Bolt removed. Post bolt CT: no new hemorrhage. ICPs [**2-6**];
Mannitol dose decreased. Slightly improved mental status, moving
all extremities. Sedation being weaned. U/S performed on right
inguinal area hematoma; showed hematoma with no pseudoaneurysm
or AV fistula.
[**10-26**] Febrile--urine, blood and sputum cultures sent. Imaging
shows LLL pneumonia. Vanc, Cipro, Zosyn started. Mannitol d/ced.
Neurosurgery signs off. Speech consulted for Passy Muir valve
for which he tolerated. Physical and Occupational therapy
consulted. Social work closely following.
[**10-27**] Percutaneous tracheostomy and percutaneous endoscopic
gastrostomy at bedside performed.
[**10-28**] Taken to the operating room by OMFS for closed reduction
with placement of intermaxillary fixation. His jaws were wired
shut. SQH started.
[**10-29**] Ventilator weaning initiated.
[**10-30**] On trach mask. Sputum culture grew pan sensitive staph,
Hflu. Vanco and Zosyn stopped. Continued Cipro for an additional
7 day course. Physical and Occupational therapy consulted.
[**10-31**] Transferred to the regular nursing unit floor. Remains
hemodynamically stable.
[**11-1**] Case management continuing screening for acute rehab
placement.
[**11-3**] Febrile up to 101.8; he was pan cultured, chest xray still
showing a LLL infiltrate and so Vancomycin and Zosyn were
started. His WBC was 19.6 at that time. He does have a
productive cough with copious secretions. Final culture results
are pending but he is currently being treated empirically.
Discussions whether to perform an LP took place between the
trauma team and Neurosurgery.
[**11-4**] WBC down to 14 and temp 100.8. Discussed with neurosurgery
whether they still wanted to do the LP; given that he was
clinically improving the decision was made to hold off as the
infection source was likely from his lungs. His sodium was
intermittently elevated, as high as 155 with ranges from
147-155. He was given free water boluses and his IV fluids were
increased; Na level on [**11-4**] was 152. he was discharged to rehab
facility.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**3-3**]
hours as needed for fever or pain.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
3. Senna 8.8 mg/5 mL Syrup Sig: Ten (10) ML's PO at bedtime as
needed for constipation.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection [**Hospital1 **] (2 times a day).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Dilantin-125 125 mg/5 mL Suspension Sig: Six (6) ML's PO
three times a day for 4 weeks.
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) DOSE
Injection four times a day as needed for sliding scale: see
attached sliding scale.
9. Vancomycin 1000 mg IV Q 12H
10. Piperacillin-Tazobactam Na 4.5 g IV Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 25750**]
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
Diffuse Axonal Injury w/ multiple intraparenchymal hemorrhages
Right orbital fractures
Mandibular fractures (body + R ramus)
Respiratory Failure
Malnutrition
Hypernatremia
Pneumonia
Discharge Condition:
Hemodynamcially stable
Followup Instructions:
Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Neurosurgery. Call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will
need a repeat head CT scan for this appointment.
Follow up with Dr. [**First Name (STitle) **], OMFS in Surgical [**Hospital 81546**] Clinic
in 2 weeks, call [**Telephone/Fax (1) 55393**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery. Call
[**Telephone/Fax (1) 600**] for an appointment.
If there are any difficulties scheduling any of the above
appointments please call [**First Name8 (NamePattern2) 17148**] [**Last Name (NamePattern1) 2819**], NP, Trauma Surgery at
[**Telephone/Fax (1) 67547**].
Completed by:[**2115-11-13**]
ICD9 Codes: 2760, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4020
} | Medical Text: Unit No: [**Numeric Identifier 70000**]
Admission Date: [**2164-1-26**]
Discharge Date: [**2164-1-28**]
Date of Birth: [**2083-8-23**]
Sex: M
Service: VSU
PRINCIPAL DIAGNOSIS: Abdominal aortic aneurysm, 6.2 x 6.3 x
9.6 cm from the infrarenal to the aortic bifurcation seen on
CTA on [**2164-1-5**].
PROCEDURES:
1. Abdominal aortic aneurysm repair with tube graft via
retroperitoneal approach on [**2164-1-26**].
2. Emergency laparotomy on [**2164-1-27**], with resection
of necrotic large bowel.
PAST MEDICAL HISTORY:
1. Hypertension.
2. History of atrial fibrillation and flutter.
3. History of right inguinal hernia.
4. History of right radical neck resection for squamous cell
carcinoma.
5. Right thoracotomy.
6. Right knee surgery.
MEDICATIONS:
1. Coumadin.
2. Lovastatin.
BRIEF HOSPITAL COURSE: Mr. [**Known lastname 47777**] is an 80-year-old
gentleman who was admitted on [**2164-1-26**] to [**Doctor First Name **]-
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for elective repair of
retroperitoneal abdominal aortic aneurysm for a 6.2 x 6.3 x
9.6 cm aneurysm. He was taken to the operating room on
[**2164-1-26**], and had a retroperitoneal approach for his
abdominal aortic aneurysm repair with tube graft from the
infrarenal side to his aortic bifurcation. Postoperatively he
was noted to be hypotensive and was started on Neo-
Synephrine. Over the course of the evening he had a rising
lactate and increasing pressor requirement. There was concern
of some ischemic episode and he was taken emergently to the
operating room on [**2164-1-27**], for exploratory
laparotomy. At this point his large bowel and his colon was
noted to be green and necrotic. He had a total abdominal
colectomy with ileostomy done emergently. His abdomen was
left open with I-band and Broca to the bag. He was taken back
now to the surgical intensive care unit where he stabilized,
still requiring pressors and IV fluids throughout the
evening.
On [**2164-1-28**], his pressor requirement continued to go
up and he had a Swan in place which showed elevation of PA
numbers. He was maxed out on Levophed and Neo-Synephrine at
this point as well as vasopressor 1.2 per hour. At this point
because of his increasing PA pressures, there was a concern
that he may be having a cardiac dysfunction. His lactate
remained elevated at 4, however it did not rise. A second
look was done at the bedside serially of his abdominal
contents to see if there are any signs of small bowel
ischemia, however upon inspection there were no clear signs
of small bowel ischemia. He also had a stat echo done to
evaluate for cardiac function because of his increasing
pressor requirement and hypotension.
Upon evaluation of his cardiac echo he was noted to have
significant left ventricular dysfunction with very poor
ejection fraction indicating that he had a myocardial event.
At this point we discussed with the family that there is
significant change in his overall status in that in addition
to having some septic physiology he likely was in a
cardiogenic shock as well. He went into rapid atrial
fibrillation requiring synchronized cardioversion because of
hypotension. He was cardioverted twice and went into
asystole. Chest compressions were immediately started. He
received boluses of epinephrine. He was noted then to be in
ventricular tachycardia and again hypotensive. He was
cardioverted. He was coded for approximately 30 minutes.
A lengthy discussion was carried out with the family as to
how they would like to proceed. During this time he had
somewhat stabilized, however was still hypotensive requiring
maximal pressors and was on epinephrine drip. The family,
after a lengthy discussion, felt that he would not want to
proceed with any further care and he was made CMO.
The patient expired shortly thereafter at 6:20 p.m. Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] was informed of the patient's status this
entire time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Name8 (MD) 57264**]
MEDQUIST36
D: [**2164-1-29**] 06:00:46
T: [**2164-1-29**] 14:13:35
Job#: [**Job Number 70001**]
ICD9 Codes: 0389, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4021
} | Medical Text: Admission Date: [**2170-12-18**] Discharge Date: [**2171-2-5**]
Date of Birth: [**2170-12-8**] Sex: M
Service: NBB
HISTORY: Baby [**Name (NI) **] [**Known lastname **] #2 was admitted at 10 days of age to
the [**Hospital1 69**] Neonatal Intensive
Care Unit following transfer from [**Hospital3 1810**],
[**Location (un) 86**]. He was a former 34-2/7 week gestation twin who was
born at [**Hospital1 69**] to a 35 year-old
gravida I, para 0, now II mother with prenatal screens of
blood type A positive, antibody negative, hepatitis B surface
antigen negative, RPR nonreactive, rubella immune, and group
B strep status unknown. The pregnancy had been complicated by
poor fetal growth of this twin which prompted early delivery.
He was delivered by cesarean section as he was in breech
position. He did well at delivery with Apgars of 8 and 9. He
was noted on initial examination to have an imperforate anus
so he was transferred to [**Hospital3 1810**], [**Location (un) 86**] for
surgical management. There he received a colostomy and did
well on his postoperative course so that he was transferred
back to the [**Hospital1 69**] Neonatal
Intensive Care Unit for continued care.
His hospital course at [**Hospital3 1810**] was notable for:
1. Respiratory: Baby [**Name (NI) **] [**Known lastname **] #2 was briefly intubated for
his surgical procedure and postoperatively. He was then
retransitioned to room air and has had no episodes of
apnea of prematurity.
2. Cardiology: Baby [**Name (NI) **] [**Known lastname **] #2 had an initial
echocardiogram done at [**Hospital1 64489**] prior to transfer to [**Hospital1 **] which was normal.
3. Fluid, electrolytes and nutrition - gastrointestinal: A
colostomy was performed for Baby [**Name (NI) **] [**Known lastname **] #2's
imperforate anus. He was initially maintained on
intravenous fluids. He started feedings on his second
postoperative day.
4. Genitourinary: Baby [**Name (NI) **] [**Known lastname **] #2's initial renal
ultrasound was suggestive of hydronephrosis. His
subsequent study was normal. A VCUG revealed mild
obstruction from posterior urethral valves.
5. Infectious disease: Baby [**Name (NI) **] [**Known lastname **] #2 received a 48 hour
course of ampicillin and gentamicin, then was switched to
amoxicillin prophylaxis.
6. Neurology/neurosurgery: Baby [**Name (NI) **] [**Known lastname **] #2's initial head
ultrasound was concern for periventricular echogenicity,
but a follow up head ultrasound 2 days later was normal.
He had a normal ophthalmologic examination. A spine
ultrasound revealed a tethered cord.
7. Plastics: Baby [**Name (NI) **] [**Known lastname **] #2 has a cleft palate for which
he was followed by the plastic service of [**Hospital1 62374**]. He feeds with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 38296**] nipple.
8. Genetics: Genetics was consulted in light of Baby [**Name (NI) **]
[**Known lastname **] #2's multiple congenital anomalies. No syndrome has
yet been identified.
9. Hematology: Baby [**Name (NI) **] [**Known lastname **] #2 had mild hyperbilirubinemia
requiring some phototherapy. This is now resolved.
10. Orthopedics: Baby [**Name (NI) **] [**Known lastname **] #2 was noted to have a
hypoplastic sacrum and a right clavicular anomaly. He had
a hip ultrasound at [**Hospital3 1810**] which was normal.
Baby [**Name (NI) **] [**Known lastname **] #2 has had multiple consultations including
cardiology, genetics (Dr. [**First Name4 (NamePattern1) 622**] [**Last Name (NamePattern1) 36467**]), neurosurgery
(Drs. [**Last Name (STitle) 64490**] and [**Name5 (PTitle) 64491**]), plastic surgery (Drs. [**Last Name (STitle) 7474**] and
[**Name5 (PTitle) 54464**]), orthopedics (Drs. [**Last Name (STitle) 38906**] and [**Name5 (PTitle) **]), and urology
(Dr. [**Last Name (STitle) 3060**].
PHYSICAL EXAMINATION ON ADMISSION: Weight on admission was
1845 grams. Birth weight had been 1875 grams (25th to 50th
percentile), birth length 43.5 cm (25th to 50th percentile),
and birth head circumference 28 cm (less than 10th
percentile). In general Baby [**Name (NI) **] [**Known lastname **] #2 was a mildly
premature infant resting comfortably on a radiant warmer.
Head, eyes, ears, nose and throat examination revealed an
anterior fontanelle that was soft and flat, low set ears, and
a cleft palate. His neck was supple. His lungs were clear to
auscultation bilaterally and had equal breath sounds.
Cardiovascular examination revealed a regular rate and rhythm
with no murmur and 2+ femoral pulses. His abdomen was soft
with bowel sounds present and a colostomy bag intact.
Genitourinary examination was significant for a normal
phallus with testes descended bilaterally and an imperforate
anus. He had a sacral dimple. His hip examination was normal.
His extremities were pink and well perfused. He was noted to
have clinodactyly.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: Baby [**Name (NI) **] [**Known lastname **] #2 has remained stable in room
air throughout his hospitalization at [**Hospital3 **]. He has
never had any episodes of apnea of prematurity.
2. CARDIOVASCULAR: Baby [**Name (NI) **] [**Known lastname **] #2 previously had a
normal echocardiogram. He has remained hemodynamically
stable throughout his hospitalization. He did have a few
premature atrial contractions noted on cardiovascular
monitoring [**1-15**] and 18. An electrocardiogram at
that time was normal. Electrolytes including calcium were
also normal at that time. He has had no further
cardiovascular issues.
3. FLUIDS, ELECTROLYTES, NUTRITION/GASTROINTESTINAL: On
re-admission to [**Hospital1 69**], Baby
[**Name (NI) **] [**Known lastname **] #2 was taking nasogastric feedings of NeoSure 24
calories per ounce. He was changed to Premature Enfamil
26 calories per ounce, then at term corrected gestation
to Enfamil 26 calories per ounce. On day of life 39,
[**1-16**], he was increased to Enfamil 28 calories per
ounce for poor growth. He had difficulty reaching full
oral feedings, but did so by the end of [**Month (only) 404**]. His
calories were increased secondary to slow weight gain
during the first week of [**Month (only) 956**]. He is currently
receiving enfamil with 30 kcal/oz (6 cal/oz by
concentration and 4 cal/oz by MCT oil). His discharge
weight is 3130 grams.
[**First Name8 (NamePattern2) 40699**] [**Last Name (NamePattern1) **] of the [**Hospital3 1810**] plastics team
saw him to determine any contribution of his cleft palate
to the feeding issues. He was also followed by [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 7635**] of the [**Hospital3 1810**] feeding team. They
recommended feeding with the [**Last Name (un) 38296**] nipple. Baby [**Name (NI) **]
[**Known lastname **] #2 had undergone colostomy at [**Hospital3 1810**] by
Dr. [**Last Name (STitle) 64492**]. He has stooled well through his ostomy
drain during his hospitalization. He is also known to
have a rectourethral fistula. The plan is for a staged
repair of this fistula and his imperforate anus with a
colostomy take down in several steps over the first year
of his life. He has surgery follow-up scheduled with Dr.
[**Last Name (STitle) 64492**] [**2-6**] 9:15 on [**Last Name (un) 9795**] [**Location (un) **] of [**Hospital1 64493**]. Her phone number is [**Telephone/Fax (1) 64494**].
4. GENITOURINARY: Baby [**Name (NI) **] [**Known lastname **] #2 had had a renal
ultrasound on [**12-11**] at [**Hospital3 1810**] which
revealed mild bilateral hydronephrosis. A follow up renal
ultrasound 2 days later on [**12-13**] was normal. A VCUG
on [**12-17**] at [**Hospital3 1810**] was negative for
reflux but did show mild obstruction secondary to
posterior urethral valves. Baby [**Name (NI) **] [**Known lastname **] underwent
urodynamic testing on [**12-26**] with Dr. [**Last Name (STitle) 3060**]. This
was normal except for a lack of an anal wink reflex. Dr.
[**Last Name (STitle) 3060**] then performed cystoscopy on [**1-16**] for
ablation of the posterior urethral valves. Baby [**Name (NI) **] [**Known lastname **]
#2 tolerated this well but was found on screening urine
culture from that procedure to grow Klebsiella in his
urine. Please see infectious disease section for further
details. His urologic plan is for follow up urodynamic
testing in early to mid [**Month (only) 958**] and possible EMG of his
anal sphincter at 6 months of age. The urodynamics
department at [**Hospital3 1810**] is to contact the
family with this appointment. Repeat cath urine from [**1-31**]
after the antibiotic course grew coag negative staph,
thought to be a contaminant. Repeat urine from [**2171-2-4**] is
pending at the time of discharge. Pediatrician will be
notified if this culture turns positive. He remains on
bactrim prophylaxis for his colonic urethral fistula.
5. INFECTIOUS DISEASE: Baby [**Name (NI) **] [**Known lastname **] #2 received a 48 hour
sepsis rule out with ampicillin and gentamicin at
[**Hospital3 1810**] immediately after birth. He was then
switched to amoxicillin prophylaxis in light of his
rectourethral fistula. After his cystoscopy on [**1-16**]
a routine urine culture sent during that procedure grew
greater than 100,000 colonies of Klebsiella. This was not
sensitive to amoxicillin but was sensitive to meropenem
and Bactrim. A repeat catheterized urine culture was sent
prior to initiation of antibiotics at [**Hospital3 **]. This
greater than 100,000 colonies of E coli. The E coli was
also not sensitive to amoxicillin but was sensitive to
meropenem and Bactrim. The infectious disease team
[**Hospital3 1810**] was consulted at that time and
recommended 3 days of therapy with IV meropenem followed
by 7 days of therapy with treatment doses of oral
Bactrim, which he completed.
He is currently on 2 mg per kilogram per day of bactrim
once daily for prophylaxis. A G6PD screen was sent prior
to initiation of Bactrim and was normal. He will need to
have a CBC followed every other week to rule out bone
marrow suppression. His wbc on [**1-31**] was 12.4 and his
platelets were 516.
6. NEUROLOGIC/NEUROSURGICAL: Baby [**Name (NI) **] [**Known lastname **] #2 was noted to
have a sacral dimple. Ultrasound at [**Hospital3 1810**]
revealed a tethered cord. He is followed by Drs. [**Last Name (STitle) 64490**]
and [**Name5 (PTitle) 64491**] at [**Hospital3 1810**] for this. Their phone
number is [**Telephone/Fax (1) 56723**]. He needs to have an MRI of his
spine for follow up at 3 months of life. This is
scheduled for [**2171-3-11**]. He will be admitted
overnight for observation following sedation from his
MRI.
Neurology was also consulted during this hospitalization
for Baby [**Name (NI) **] [**Known lastname **] #2's history of microcephaly and poor
feeding. A head ultrasound at [**Hospital3 1810**] on
[**12-11**] had revealed some periventricular
echogenicity, but follow up head ultrasound on [**12-13**] was completely normal. Baby [**Name (NI) **] [**Known lastname **] #2 was found to
have a normal examination by neurology except for
slightly decreased axial tone. They requested a brain MRI.
This brain MRI is to be done on the same day as his spine
MRI, [**2171-3-11**]. He is to follow up with the
neonatology neurology clinic on [**2170-4-3**] at 3:10
P.M. on [**Last Name (un) 9795**] 11 at [**Hospital3 1810**]. The phone number
for that clinic is [**Telephone/Fax (1) 36468**].
7. PLASTICS: Baby [**Name (NI) **] [**Known lastname **] #2 was noted to have a cleft
palate. He has been followed by Drs. [**Last Name (STitle) 7474**] and [**Name5 (PTitle) 52380**]
at [**Hospital3 1810**] for this issue. Their phone
number is [**Telephone/Fax (1) 64495**]. He is to follow up with them in
[**Month (only) 956**]. His current plan is for repair at 8 to 10
months of age. He is fed with the [**Last Name (un) 38296**] nipple.
8. GENETICS: Baby [**Name (NI) **] [**Known lastname **] #2 received a genetics consult at
[**Hospital3 1810**] secondary to his multiple congenital
anomalies. They recommended karyotype which was performed
and was normal. They also recommended signature chip
testing which was normal. Finally they recommended an eye
examination and this was also normal. The phone number
for Dr. [**Last Name (STitle) 36467**] is [**Telephone/Fax (1) 64496**].
9. HEMATOLOGIC: Baby [**Name (NI) **] [**Known lastname **] #2 had no hematologic issues
during this hospitalization. His hematocrit was 57.4%
with a reticulocyte count of 1.2% on [**12-21**]. His most
recent hematocrit was 28.6% with a reticulocyte count of 3
.4% on [**1-31**]. He will need a screening CBC every other week
while he remains on Bactrim prophylaxis. He should have
this drawn through a pediatrican's visit during the week
of [**2-11**] when he has thyroid studies re-sent as well as
his 2 month immunizations. He is on iron supplementation
for a total of 4 mg/kg/day (2 in formula concentrate, 2
mg/kg extra given orally).
10. ORTHOPEDICS: Baby [**Name (NI) **] [**Known lastname **] #2 was found to have a right
clavicular anomaly and hypoplastic sacrum. This
clavicular anomaly is likely pseudoarthrosis and does not
denote any functional concerns. He had a normal hip
ultrasound while he was at [**Hospital3 1810**]. He is to
follow up with Drs. [**Last Name (STitle) 38906**] and [**Name5 (PTitle) **] at [**Hospital1 62374**] on [**Last Name (un) 9795**] 2 on [**2-12**] at 2 P.M. The phone
number for these doctors [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 38453**].
11. ENDOCRINE: Baby [**Name (NI) **] [**Known lastname **] #2 was found to have
hypothyroidism on his state screen. He began on Synthroid
therapy on [**12-22**]. Thyroid function tests have been
followed every 2 weeks with escalating doses to try to
normalize the thyroid function. His thyroid function
tests on [**1-18**] revealed a free T4 of 1.4 with a TSH
of 11. At that time his endocrine team recommended an
increase in his Synthroid dose to 37.5 micrograms daily.
His most recent TSH was 2.2 and his free T4 1.9 on
[**1-31**]. Endocrine recommended keeping him on his
current dose with follow-up TFTs in 2 weeks. He is to be
followed by the endocrine clinic, Dr. [**Last Name (STitle) 64497**]. Her phone
number is [**Telephone/Fax (1) 37116**]. Parents should call to make an
appointment shortly after discharge for his
hypothyroidism. The endocrine fellow should be paged
with result of TFTs drawn as an outpatient during the
week of [**2-11**]. Call page operator at [**Hospital1 **] ([**Telephone/Fax (1) 64498**] and ask for endocrine fellow to be paged. Dr.
[**Name (NI) 64499**] office can be notified of the results if
endocrine fellow is not aware of [**Doctor Last Name 64500**] history.
12. SENSORY: Baby [**Name (NI) **] [**Known lastname **] #2 has failed his hearing screen.
He is to have follow up with audiology at [**Hospital1 62374**], [**Hospital1 64501**] on the [**Location (un) 10043**], on
[**2171-2-28**] at 10:30 in the morning. The phone number
for this clinic is [**Telephone/Fax (1) 48318**]. Baby [**Name (NI) **] [**Known lastname **] #2 has had
a normal ophthalmological examination at [**Hospital1 62374**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home with both parents and a car
seat.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 47116**] [**Name (STitle) 3394**] in [**Location (un) 4047**].
Phone number is [**0-0-**]. Fax number is [**Telephone/Fax (1) 64502**].
CARE/RECOMMENDATIONS: At discharge Baby [**Name (NI) **] [**Known lastname **] #2 is
taking Enfamil 30 calories per ounce. His medications include:
1. Synthroid 37.5 mcg p.o. daily
2. Bactrim 6 mg daily (2mg/kg)
3. Ferrous Sulfate (25 mg/ml) 0.24ml po daily
Baby [**Name (NI) **] [**Known lastname **] #2 underwent car seat position screening and
passed. Baby [**Name (NI) **] [**Known lastname **] #2 has had state screenings which were
positive for hypothyroidism but were otherwise normal. Baby
[**Name (NI) **] [**Known lastname **] #2 had his hepatitis B vaccination on [**12-29**].
He will be due for his 2 month vaccinations on [**2-8**].
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following 3
criteria: 1) born at less than 32 weeks; 2) born between 32
and 35 weeks with 2 of the following: Day care during RSV
season, smoker in the household, neuromuscular disease,
airway abnormalities, or school age children; or 3) With
chronic lung disease. Influenza immunization is recommended
annually in the fall for all infants once they reach 6 months
of age. Before this age (and for the first 24 months of the
child's life) immunization against influenza is recommended
for household contact and out of home care-givers.
FOLLOW UP APPOINTMENTS:
1. Neonatal [**Hospital 878**] Clinic at [**Hospital3 1810**] on [**Last Name (un) 9795**]
11 on [**2171-4-3**] at 3:10 P.M. ([**Telephone/Fax (1) 37121**].
2. Genetics, Dr. [**Last Name (STitle) 36467**] will see [**Doctor Last Name 7306**] and his parents prior
to discharge [**2-5**] with additional follow up to be
determined by her.
3. Plastics, Drs. [**Last Name (STitle) 7474**] [**Name5 (PTitle) **] [**Name5 (PTitle) 54464**]. The parents have been
called at home about this appointment.
4. Neurosurgery, Drs. [**Last Name (STitle) 64490**] and [**Name5 (PTitle) 64491**]. The parents have
been called at home with this appointment. Baby [**Name (NI) **] [**Known lastname **]
#2 is also scheduled for a brain and spine MRI on [**3-11**], [**2170**].
5. Orthopedics, Drs. [**Last Name (STitle) 38906**] and [**Name5 (PTitle) **] on [**2-12**] at 2
P.M. at [**Hospital3 1810**] on [**Last Name (un) 16254**] 2.
6. Urology, Dr. [**Last Name (STitle) 3060**] in early to mid [**Month (only) 958**] for urodynamic
studies. The family will be contact[**Name (NI) **] by the urodynamics
laboratory with this appointment.
7. Endocrine, Dr. [**Last Name (STitle) 64497**]. Parents to call clinic for
appointment ([**Telephone/Fax (1) 52424**].
8. Surgery, Dr. [**Last Name (STitle) 64492**] [**2-6**] 9:15, [**Last Name (un) 9795**] 3.
9. Audiology at [**Hospital3 1810**] at [**Hospital1 64501**]
on the [**Location (un) 470**] on [**2171-2-28**] at 10:30 A.M.
10. Referral to Early Intervention [**Location (un) 1121**] Infant and
Toddler Development Program ([**Telephone/Fax (1) 64503**]
11. Referral to [**Hospital 269**] home health 1-[**Telephone/Fax (1) 43855**], they are to
follow feedings and weights on a weekly basis.
12. Referral to Infant Follow up Progam at [**Hospital3 1810**]
([**Telephone/Fax (1) 43625**]. Parents will be contact[**Name (NI) **] about
appointment.
DISCHARGE DIAGNOSES:
1. Prematurity at 34-2/7 weeks gestation.
2. Imperforate anus with diverting colostomy.
3. Cleft palate.
4. Hypothyroidism.
5. Urinary tract infection with Klebsiella and E coli.
6. Hypoplastic sacrum and tethered spinal cord.
7. Right clavicular anomaly.
8. Rectourethral fistula.
9. Posterior urethral valves - resolved.
10. Microcephaly.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD/[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 64504**]
Dictated By:[**Last Name (un) 64505**]
MEDQUIST36
D: [**2171-1-25**] 15:04:23
T: [**2171-1-25**] 17:21:05
Job#: [**Job Number 64506**]
cc:[**Hospital3 64507**]
Neonatal [**Hospital 878**] Clinic
[**Hospital 64508**] Hospital
Genetics: Dr. [**First Name4 (NamePattern1) 622**] [**Last Name (NamePattern1) 36467**]
[**Hospital3 1810**], [**Location (un) 86**]
Plastics - Drs. [**Last Name (STitle) 7474**] and [**Name5 (PTitle) 54464**]
[**Hospital3 1810**], [**Location (un) 86**]
Neurosurgery -Dr. [**Last Name (STitle) 64509**] and [**Hospital 64491**]
[**Hospital3 1810**], [**Location (un) 86**]
Orthopedics - Dr. [**Last Name (STitle) 38906**] and [**Doctor Last Name **]
[**Hospital3 1810**], [**Location (un) 86**]
Urology - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**]
[**Hospital3 1810**], [**Location (un) 86**]
General Surgery - Dr. [**First Name8 (NamePattern2) 11705**] [**Last Name (NamePattern1) 64492**]
[**Hospital3 1810**], [**Location (un) 86**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4022
} | Medical Text: Admission Date: [**2152-5-3**] Discharge Date: [**2152-5-11**]
Date of Birth: [**2082-11-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Endotracheal intubation
Chest Tube Placement complicated by subcutaneous emphysema
Bronchoscopy
History of Present Illness:
Briefly, 69 yo M with severe COPD on home O2 who orginally c/p
SOB x 24hrs in addition to L sided chest pain. He used nebs
without relief, did have a productive cough and was hypertensive
to 190s. EMS was called, and vitals on arrival were the
following: 190/90, HR 120, RR 24, O2 sat 90% with unclear amt of
oxygen.
.
At the [**Hospital1 18**] ED, his vitals were T99.0, P 136, BP 214/126, RR
35, and O2 sat 89% on unclr amt of O2. NIPV was tried, but did
not relieve resp distress. CXR showed L sided PTX. CT was placed
by ED, then was c/b kinking and SQ emphysema, the pt developed
extensive subcutaneous air over his chest, neck, and down into
his scrotum. He c/o increasing shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] the
decision was made to intubate him. Intubation was difficult and
c/b hypotension with sedation. IP replaced chest tube. The
patient was intubated and sedated and xferred to MICU For futher
care.
.
MICU course:
A line was placed. CT to suction was initiated, but IP not
following. Patient quickly weaned off the vent with tx for COPD
exacerbation and was extubated. He was maintained on steroids.
Hypotension resolved. L sided chest pain was controlled with
lidocaine patches and fentanyl. Original PTX thought to be due
to ruptured bleb due to patient's COPD. The patient maintained
Sats in the 90s on 6L nasal cannula. He maintained to have a
small amount of hemoptysis that was attributed to traumatic
intubation. Abx were continued empirically as well as
theophylline and inhalers as part of tx for COPD exacerbation.
Chest tube leaked persisted and there was a concern raised for
bronchopleural fistula
Past Medical History:
COPD [FEV1 of 0.67 liters, which is 27% of predicted]. is on
2-3L oxygen at home.
H/O treated TB
Hypertension
Glomerular nephritis
Hyperchol
Social History:
Positive tobacco history; he quit 15 years ago.
Worked in dowel manufacturing and was exposed to wood dust.
No alcohol or IV drug abuse.
Family History:
nc
Physical Exam:
Gen: comfortable, not tanchypneic
Skin: crepitus on L side from neck to scrotum
HEENT: NC in place, PERRLA, EOMI, no cervical LAD
Lungs: coarse [**First Name3 (LF) 1440**] sounds bilaterally, decreased BS and bases.
tenter at the chest tube site.
CV: RRR, no m/r/g
Abd: soft, nt/nd, +bs
Ext: no edema
+scrotal edema/SQ emphysema. Foley catheter is in.
Pertinent Results:
CHEST (PORTABLE AP)
The left chest tube has been repositioned and is now in the left
upper chest. The left lung appears better aerated and expanded.
An endotracheal tube is in place, approximately 7.5 cm above the
carina.
The endotracheal tube balloon cuff is overdistended, and should
be deflated slightly.
A massive amount of subcutaneous emphysema now covers both sides
of the chest wall and the neck, obscuring evaluation of the
underlying lung fields. Mediastinal air is also present.
.
CHEST (PORTABLE AP) [**2152-5-9**] 4:19 PM
INDICATION: Chest tube removal after pneumothorax.
CHEST, ONE VIEW: Comparison with [**2152-5-8**]. Left chest tube
has been removed. No residual pneumothorax is seen. Volume loss
on the left is slightly less in degree than the previous exam;
there is residual opacity over the left mid lung and left lower
lobe, which can represent consolidation, atelectasis, or
asymmetric edema. Right lung appears relatively clear, though
right lung basilar opacity is unchanged. Bilateral subcutaneous
emphysema is still present.
[**2152-5-11**] 06:05AM BLOOD WBC-9.8 RBC-3.36* Hgb-10.9* Hct-32.0*
MCV-95 MCH-32.6* MCHC-34.2 RDW-14.5 Plt Ct-194
[**2152-5-3**] 10:45AM BLOOD WBC-20.3*# RBC-4.35* Hgb-14.2 Hct-40.7
MCV-94 MCH-32.6* MCHC-34.9 RDW-14.0 Plt Ct-287
[**2152-5-3**] 10:45AM BLOOD Neuts-82.8* Lymphs-13.4* Monos-2.8
Eos-0.8 Baso-0.2
[**2152-5-10**] 06:55AM BLOOD Glucose-135* UreaN-24* Creat-0.8 Na-144
K-3.6 Cl-106 HCO3-29 AnGap-13
[**2152-5-4**] 01:06AM BLOOD CK-MB-22* MB Indx-0.9 cTropnT-0.04*
[**2152-5-6**] 06:44AM BLOOD CK-MB-5 cTropnT-<0.01
[**2152-5-8**] 10:50AM BLOOD Theophy-12.9
[**2152-5-5**] 09:24AM BLOOD Lactate-1.2
Brief Hospital Course:
Mr. [**Known lastname **] is a 69 year old gentleman with severe COPD who
presented with acute respiratory distress who was found to have
a large left sided pneumothorax. Chest tube was placed in the ED
complicated by subcutaneous empysema. He was intubated and later
extubated on [**2152-5-4**]. After transfer to the floor the patient
steadily improved, chest tube was removed without complication,
pt had significant hemoptysis and underwent bronchoscopy for
suctioning and diagnostic purposes, revealing bronchomalacea. Pt
should have an interval noncontrast chest CT for further eval as
an outpatient.
1) Respiratory failure:
Likely secondary to pneumothorax from ruptured bleb. Following
extubation the patient was quickly weaned to 6L by nasal
cannula, then 2-3L as his baseline O2 requirement. He was
treated empirically with cefpodoxime/azithromycin for 7 and 5
days respectively. Given IV solumedrol and later changed to
prednisone taper. Pt's subcutaneous emphysema steadily improved
over the course of the admission.
He will-follow up with Dr. [**First Name4 (NamePattern1) **] [**Known firstname **] in Pulmonary. Sutures
from the patients chest tube site should be removed in 10 days
following discharge on [**2152-5-11**].
2) Pneumothorax:
Likely secondary to ruptured bleb, complicated by chest tube
placement and subcutaneous emphysema (large amount). Chest to
suction during initial air leak, later resolved. Tube was
removed by interventional pulmonary [**2152-5-9**] without event.
Interval chest xray revealed resolution of pnemothrax with
persistent LLL collapse and volume loss. Pt went for
bronchoscopy as below for deep suction and diagnostic purposes.
3) hemoptysis:
likely secondary to intubation trauma vs multiple rupture blebs
in COPD. He has not had this prior to admission. Bronchoscopy
during this admission revealed bronchomalacia, follow up
noncontrast Chest CT should be performed in [**1-8**] weeks for
further elucidation of pt's lung disease.
.
4) tachycardia-
appearance of MAT by EKG. pt was stared on low dose diltiazem
for rate control. He may be weaned of this medication as an
outpatient beyond the acute phase of his illness.
.
5) Cardiovascular-
Tachycardia as above. Lasix was held in the setting of transient
rise in Creatinine clearance. He did not require re-introduction
of lasix during this admission. Close follow up as an outpatient
may require re-initiation of this medication. Aspirin therapy
was held in the setting of hemoptysis. Atorvastatin was
continued.
6) GERD-
Continued home dosing of protonix while inpatient.
Medications on Admission:
advair 250 mg 1 puff [**Hospital1 **]
combivent 2 puff four times / day
theophylline 200 mg [**Hospital1 **]
folate 1 mg daily
diovan 325 mg one tab daily
norvasc 5 mg daily
lipitor 60 mg daily
lasix 40 mg daliy
protonix 40 mg [**Hospital1 **]
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO BID (2 times a day).
5. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
9. Diltiazem HCl 60 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO twice a day.
Disp:*60 Capsule, Sust. Release 12 hr(s)* Refills:*2*
10. Atorvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day
for 1 days: Take 20mg Friday, then 10mg Saturday, then 5mg
Sunday, then off.
Disp:*7 Tablet(s)* Refills:*0*
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-7**] Sprays Nasal
QID (4 times a day) as needed.
13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY: Spontaneous Pneumothorax
SECONDARY:
Chronic Obstructive Pulmonary Disease
Hypertension
Glomerular nephritis
Hypercholesterolemia
History of Treated TB
Discharge Condition:
Stable 02 sats on [**1-8**] liters, req 4liters while ambulating.
Discharge Instructions:
You were admitted for difficulty breathing and found to have a
pneumothorax. You had a chest tube placed to drain the air from
around your lung and allow it to re-inflate. You required a
brief period of time on a mechanical ventilator. You underwent
bronchoscopy to help clear thick secretions and were found to
have bronchomalacia (thin airways).
.
Please take all of your medications as prescribed.
.
Call Dr. [**Last Name (STitle) 58**] or 911 if you have worsening shortness of
[**Last Name (STitle) 1440**], require more oxygen at home, worsening cough, fevers,
chills, chest pain, dizziness or any other concerning symptoms.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 58**] next week for follow up appointment.
.
Please have a non-contrast, high-resolution chest CT performed
as an outpatient for further evaluation of your lungs.
.
Please keep the following appointments:
PULMONARY BREATHING TEST Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2152-5-24**]
11:40
Provider [**Name9 (PRE) 1570**],[**Name9 (PRE) 2162**] [**Name9 (PRE) 1570**] INTEPRETATION BILLING
Date/Time:[**2152-5-24**] 12:00
Provider [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] NP/DR [**Known firstname **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2152-5-24**] 12:00
ICD9 Codes: 4589, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4023
} | Medical Text: Admission Date: [**2134-7-27**] Discharge Date: [**2134-8-12**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Transferred from OSH for managment of renal failure
Major Surgical or Invasive Procedure:
Repair of abdominal wound dehiscence
History of Present Illness:
87yo M with a h/o CAD s/p [**2124**] cath, HTN, and asthma, s/p recent
TKNR, who presented on [**2134-7-18**] to [**Hospital3 **] Hospital with abd
pain. Hospital course included unsuccessful ERCP on [**2134-7-21**]
which showed hemorrhage and stricture of posterior bulbar
duodenum. Given increasing bili, jaundice, with persistent WBC
and fevers, pt had laparotomy on [**2134-7-21**], where was noted to
have inflamed GB with necrosis over the pancreas. Patient had
CCY and removal of portion of biliary tree, but due to
inflammation, CBD exploration was not possible. Post-op
percutaneous cholangiography showed a beaded appearance of
intra-hepatic bile ducts. After operation, patient was left
intubated. Other post-op course: 1) afib, managed with
lopressor, 2) renal failure (baseline Cr 1.8). With worsening
RF, began renal dose dopamine and lasix drip. Pt was transferred
to [**Hospital1 **] for mgmt of worsening oliguric renal failure.
Past Medical History:
HTN, CAD s/p angina with [**2124**] cath (no pain since cath), lactose
intolerance, episode of syncope when when 11 yrs ago
Brief Hospital Course:
1. Gallstone pancreatitis, cholangitis.
a. GI was consulted and felt that in the absence of ductal
dilatation, with bili >> alk phos, the pt's elevated LFT's most
likely represented cholestasis (multifactorial), +/- and
underlying primary sclerosing cholangitis. A RUQ u/s showed no
intra/extra hepatic ductal dilitations. Surgery followed
throughout hospitalization and felt there was no role for
surgical intervention.
b. Abx: Pt completed 3 week course of imipenem for pancreatic
necrosis.
c. Patient began tube feeds on [**8-4**].
d. Patient was placed on ursodiol, with slowly decreasing T
Bili.
e. Abdominal wound dehiscence surgically repaired [**8-9**].
2. Renal failure - ATN felt secondary to prerenal state.
a. Pt had Quintin catheter placed and was placed on CVVH, with
decreasing Cr. On [**2134-8-2**], pt began significant autodiuresis and
on [**8-3**] catheter was d/c'ed.
b. Pt developed severe metabolic acidosis. Urine pH on [**8-10**]
revealed no RTA and etiology was thought to be from output from
JP drain but could not be resolved.
3. Hypotension.
a. On admission pt was hypotensive, felt secondary to sepsis,
and required levophed pressor support, which was slowly weaned
over the course of a week. Steroids were started on admission
for adrenal insufficiency, and were tapered over a 10 day
course. On [**8-8**], hydrocort taper was completed and insulin drip
was d/c'ed.
b. Pt had episode of hypotension after suctioning on [**8-4**] and
was re-started on levofed and received IVF with good response.
At that time, TWI seen on EKG and enzymes were rechecked.
Patient was taken off levophed on [**8-6**] and on [**8-8**] became
hypertensive.
c. On [**8-10**], pt became hypotensive. [**Last Name (un) **] stim was rechecked,
blood cultures resent. It was felt that pt may have been preload
dependent, and was given fluid with resolution of hypotension.
4. ID.
a. Pt was maintained on imipenem for a total of a 3 week course.
b. Patient completed a 2 week course of vancomycin for gram
positive cocci in blood, etiology presumed to be line sepsis.
c. On [**8-10**] began Zosyn for stenotrophomonas infection.
d. In setting of increasing tachypnea on [**8-9**], abdomen was
reimaged, without evident source of infection.
5. Respiratory.
Patient was admitted intubated and was continued on ventilatory
support -- respiratory failure was felt most likely d/t
combination of fluid overload and abdominal ascites. On [**8-8**] pt
self-extubated and afterwards was persistently tachypneic around
29. On [**8-9**] pt was re-intubated due to increasing tachypnea to
30's. Abdominal wound dehiscence was noted and pt underwent
surgery [**8-9**]; tachypnea felt to be secondary to dehiscence.
However, tachypnea continued to worsen despite intubation, with
a respiratory rate in 40's and patient's breathing not aligned
with ventilator despite many changes in vent settings and
attempts at heavy sedation. Blood gas showed a non-gap acidosis,
and on [**8-10**] respiratory rate was mildly improved with bicarb. On
[**8-10**], stanotrophomonous grew out from sputum and pt was placed
on Zosyn.
6. Altered MS. Despite minimal sedation, pt was unresponsive.
Head CT on [**8-3**] showed only old lacunar infarcts. Neuro thinks
that AMS was related to use of long-acting fentanyl vs
toxic/metabolic, and fentanyl was weaned. On [**8-8**] MS improved;
pt spoke minimally (1 word responses) and was a/o to
person/place. Had mild slurred speech. On [**8-9**] pt was
reintubated, with sedation and tachypnea, and MS [**First Name (Titles) **] [**Last Name (Titles) 39778**].
7. Melena began [**8-7**], etiology thought to be likely [**1-25**]
gastritis. Protonix increased to [**Hospital1 **]. Hcts were checked q12 with
slow decreased. Received 1 unit on [**8-10**].
8. Afib after surgery at OSH. Anticoagulation was held given
risk of bleed.
9. FEN. Amylase and lipase were WNL and TPN was started on [**8-3**],
per surgery. TF's were continued. During autodiuresis phase of
ATN, electrolytes were checked and repleted every 6hrs.
7. Massive scrotal edema on admission. Scrotal U/S showed no
epididymits/torsion. Urology consult felt that edema was [**1-25**]
edematous state, and scrotum was elevated with skin care. Edema
resolved with CVVH and autodiuresis.
8. Access
a. Central line - R quintin was d/c'd; L subclavian in placed
b. A-line - L radial
9. Prophylaxis
a. PPI
b. SQ heparin
***
10. Code status. The hospital team stayed in close contact with
the family throughout the hospitalization and multiple
conversations about pt's code status took place. Pt was
initially full code at family's request, but with the patient's
worsening ventilatory status on the week of [**8-10**], the family's
goals shifted to the patient's comfort. On [**8-12**] the pt was made
CMO and was extubated with the goal of comfort and pain control.
He passed away approximately 45 minutes after extubation.
Discharge Disposition:
Home with Service
Facility:
Deceased
Discharge Diagnosis:
Respiratory failure
Discharge Condition:
Deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 5845, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4024
} | Medical Text: Admission Date: [**2198-4-18**] Discharge Date: [**2198-4-23**]
Date of Birth: [**2148-2-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2198-4-19**]
Coronary Artery Bypass x 4 (LIMA-LAD, SVG-PDA, SVG-D1, SVG-D2)
History of Present Illness:
50 year old male with a history of hypertension for 5 years and
a
recent diagnosis of hyperlipidemia and glucose intolerance. One
month ago he began having pressure in his chest along his left
sternum. This would occur when he was under stress and lasts
for
several minutes and then resolve spontaneously. It did not
radiate to his neck, shoulders, arms. It did not occur with
exertion. It was not associated with diaphoresis, shortness of
breath, nausea. He had an exercise tolerance test where he had
chest discomfort which resolved with further exercise but did
have significant ST abnormalities at peak exercise. The ST
segment depression was new from his previous exercise test in
[**2187**]. He was subsequently sent for a cardiac catheterization
which revealed significant two vessel disease not amenable to
percutaneous intervention. He denies shortness of breath,
dyspnea
on exertion, orthopnea, paroxysmal nocturnal dyspnea,
palpitations, dizziness, syncope, and peripheral edema. He has
had left leg discomfort with walking which has been attributed
to
a disc abnormality. Given the severity of his disease, he was
referred on for surgical evaluation.
Past Medical History:
Coronary Artery Disease
post-op AFib
Lumbar disc disease
Hypertension
Hyperlipidemia
Obesity
Glucose intolerance
Social History:
Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx:
Other Tobacco use: Denies
ETOH: < 1 drink/week [X] [**1-2**] drinks/week [] >8 drinks/week []
Illicit drug use: Denies
Family History:
Father ruptured AAA at 59 Mother < 65 [X] Died of MI at 42
Brother with [**Name2 (NI) **] in his late 30's
Sister with stents in her late 40's
Physical Exam:
Pulse: 67 Resp: 16 O2 sat: 97%
B/P Right: 110/72 Left: 111/68
Height: 5'[**96**]" Weight: 249lbs
General: Well-developed male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema -
Varicosities: None [] superficial spider
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2198-4-19**] Intra-op TEE
Conclusions
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results at the time of
the study.
POST-BYPASS:
The patient is in Sinus Rhythm on low dose phenylephrine
infusion. Biventricular function is maintained. Valves remain
unchanged. The aorta remains intact.
[**2198-4-23**] 04:02AM BLOOD WBC-6.7 RBC-3.55* Hgb-10.3* Hct-31.8*
MCV-90 MCH-29.1 MCHC-32.5 RDW-13.0 Plt Ct-168
[**2198-4-17**] 11:18AM BLOOD Neuts-59.9 Lymphs-31.8 Monos-6.2 Eos-1.4
Baso-0.6
[**2198-4-23**] 04:02AM BLOOD Plt Ct-168
[**2198-4-23**] 04:02AM BLOOD PT-13.3* PTT-27.8 INR(PT)-1.2*
[**2198-4-23**] 04:02AM BLOOD Glucose-98 UreaN-17 Creat-0.9 Na-139
K-4.0 Cl-102 HCO3-29 AnGap-12
[**2198-4-23**] 04:02AM BLOOD Mg-2.0
Brief Hospital Course:
The patient was brought to the Operating Room on [**2198-4-19**] where
he underwent CABG x 4 with Dr. [**Last Name (STitle) **]. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. He was initially on nitro gtt for
hypertension. He was started on lopressor and the nitro gtt was
weaned off. He extubated without difficulty.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. He was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery on POD#1. Chest tubes and
pacing wires were discontinued without complication. He did
develop post-op afib on POD#3 and was started on amiodarone and
coumadin. Lopressor was titrated. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD #4 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged home in good
condition with appropriate follow up instructions.
Medications on Admission:
Simvastatin 20 mg Oral Tablet Take 1 tablet every evening
Lisinopril 40 mg Oral Tablet Take 1 tablet daily
Atenolol 100 mg Oral Tablet 1 tablet daily
Hydrochlorothiazide 25 mg Oral Tablet Take 1 tablet daily
ASPIRIN EC TABLET DR 81MG PO 1 tablet orally once a day
Isosorbide mononitrate ER 30mg daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. 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*
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Coumadin 2 mg Tablet Sig: as directed Tablet PO once a day:
take 3mg today [**4-23**].
Disp:*30 Tablet(s)* Refills:*2*
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): take tab tid x 1 week then 1 tab [**Hospital1 **] x 1 week then 1 tab
daily .
Disp:*90 Tablet(s)* Refills:*2*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: after lasix resume Hctz.
Disp:*14 Tablet(s)* Refills:*0*
11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day:
can increase lisinopril to pre-op dose as BP improves.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] [**Hospital **] Home Health and Hospice
Discharge Diagnosis:
Coronary Artery Disease
post-op AFib
Lumbar disc disease
Hypertension
Hyperlipidemia
Obesity
Glucose intolerance
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
1+ LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2198-5-3**]
10:15
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**], [**2198-5-23**] 1:30
Cardiologist Dr.[**Name (NI) 59117**] office will call you to arrange
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) 5147**] C. [**Telephone/Fax (1) 8036**] in [**3-1**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for post -op afib
Goal INR
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed
Results to be called to cardiac surgery service [**Telephone/Fax (1) 170**]
until f/u can be arranged with either PCP or cardiologist
Completed by:[**2198-4-23**]
ICD9 Codes: 4111, 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4025
} | Medical Text: Admission Date: [**2198-12-10**] Discharge Date: [**2198-12-21**]
Date of Birth: [**2145-11-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Trazodone / Levofloxacin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
facial edema, cough
Major Surgical or Invasive Procedure:
[**12-15**]: Craniectomy and wound washout
History of Present Illness:
This is a 53 yo M with an extensive neurosurgical history after
undergoing resection of hemangiopericytoma (a rare meningeal
tumor with high risk of recurrence) in [**2196**] at [**Hospital1 2025**] with
post-operative course complicated by hardware-associated MRSA,
recently hospitalized at [**Hospital1 18**] for cranioplasty and found to
have recurrent disease requiring placement of an external
ventricular drain for bleeding into the ventricles, subsequently
discharged to rehab in [**2198-10-19**] and seen for follow-up in
[**2198-11-19**] in good condition - and who now re-presents with
facial edema and cough with head CT showing no peri-operative
complications.
.
His pertinent past surgical history leading up to the current
hospitalization is as follows:
- [**6-/2196**]: Diagnosed with and underwent resection for
hemangiopericytoma of L frontal lobe
- [**2196-9-29**]: Craniolasty with synthetic bone graft c/b MRSA,
removal of graft, 6 week course of vancomycin
- [**6-/2197**]: tumor recurrence near anterior falx -> cyberknife
- [**8-/2197**]/[**2198**]: Scalp expanders -> removal of expanders
- [**9-/2198**]: Cranioplasty & found to have tumor recurrence in
posterior fossa with 4th ventrical obstruction -> External
Ventricular Drain placed and removed, treated with
Vanc/Ceftriaxone
- [**10/2198**]: Discharged on no antibiotics to rehab
- [**2198-11-28**]: Discharged home from rehab
- [**2198-12-4**]: Seen by plastics with no post-op problems
.
Two days prior to presentation he started developing swelling of
his face and redness of his face that started around both eyes.
The day of admission the swelling and redness worsened. Of note,
saw Dr. [**First Name (STitle) **], his plastic surgeon, on [**12-4**] because of wife's
concern for fluid draining from where a suture was removed on
his scalp; Dr.[**Name (NI) 27488**] note reflects a punctate area that was
healing with no evidence of seroma, cellulitis, or erythema.
.
His family notes that he has not had pain, fevers, chills,
vision problems, nausea, vomiting, or mental status change. He
has had a chronic cough, which started in [**Month (only) **] when he
developed and was treated for a pneumonia in the ICU
post-operatively; the cough has been improving since then.
.
Since he has returned from rehab, his wife notes that he has
been walking with a cane short distances in the home. He has
been eating and drinking more or less on his own with
supervision from his wife and 2 twin 22 year old daughters.
PT/OT and speach/swallow therapy have been seeing him at home as
well; otherwise he cared for by his family, who have rearranged
their schedule accordingly. His mental status has also been
stable - he responds appropriately to his wife and can
communicate in words but does not say much. His weight has been
stable according to his wife, and overall, she believes he has
been slowly showing signs of improvement since his discharge.
.
Of note, his wife reports that he has had PEG tubes in the past,
once after his surgery in [**2196**] and again after his most recent
surgery at [**Hospital1 18**] in [**2198**]; both times he pulled the PEG tubes
because of discomfort. His wife also notes that he used to love
cooking and now enjoys eating food.
.
In the ED, initial vitals were: T 100.4, HR 98, BP 118/89, RR
16, SaO2 98% RA. He was evaluated by neurosurgery and plastic
surgery. Neurosurgery recommended Head CT which showed frontal
subgaleal soft tissue edema without underlying fluid collection
or abscess; neurosurgery recommended discharge home with follow
up with Dr. [**First Name (STitle) **]. Plastics evaluated the patient and recommended
IV vancomycin and admission to medicine. The patient was given 1
gram IV vancomycin and was admitted to medicine.
.
<b>Review of systems:</b>
(+) Per HPI, constipation
(-) Denies recent weight loss. Review limited with patient
because of his expressive aphasia, but all other systems
reviewed with wife with no significant findings.
Past Medical History:
1. Hemangiopericytoma as above
2. CVA bilateral ACA, left MCA, left PCA - complications from
surgery according to his wife
3. BPH
4. Recent HA-PNA
Social History:
-Smoked cigarettes for 15 years x 1 pack per week but stopped
since [**2196-6-19**] when his hemangiopericytoma was diagnosed.
- Denies EtOH or illicits.
-Worked previously as a driver for UPS.
- Has wife, twin 22 year old daughters.
Family History:
His parents' healthy status is unknown. He has a brother and 3
sisters but he does not know their health status. He has 2
identical twin daughters and they are healthy.
Physical Exam:
Vitals: 98.5 (AF) 90 117/83 18 95 RA
General: somnolent male, nonverbal but able to follow simple
commands, no apparent distress
HEENT: Sclera anicteric, dry MM; EOM intact bilaterally but
limited exam because patient somnolent
Neck: supple, no LAD appreciated
Lungs: referral of upper airway rhonci posteriorly, no apparent
crackles or wheezes
Heart: RR, nl rate, no murmurs, rubs or gallops
Abdomen: Soft, NT/ND, BS+, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: erythema and warmth of bilateral cheeks, bilateral
forehead, edema noted bilateral forehead, well healed scars on
forehead and scalp; marked left infraorbital edema, greater than
anywhere else
Sacrum: diaper. no pressure ulcers
On Discharge:
right side paretic, left side follows commands, able to feed
self, oriented x 3 when given choices, PERRL, interactive
Pertinent Results:
Admission Labs:
[**2198-12-10**] 12:22PM TYPE-ART COMMENTS-GREEN TOP
[**2198-12-10**] 12:22PM LACTATE-1.3
[**2198-12-10**] 12:15PM GLUCOSE-90 UREA N-15 CREAT-0.6 SODIUM-139
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-16
[**2198-12-10**] 12:15PM estGFR-Using this
[**2198-12-10**] 12:15PM WBC-11.9* RBC-4.78# HGB-13.4*# HCT-39.3*
MCV-82# MCH-28.0 MCHC-34.0 RDW-14.4
[**2198-12-10**] 12:15PM NEUTS-80.6* BANDS-0 LYMPHS-10.4* MONOS-7.0
EOS-1.1 BASOS-0.3
[**2198-12-10**] 12:15PM PLT SMR-HIGH PLT COUNT-499*
[**2198-12-10**] 12:15PM PT-14.3* PTT-30.7 INR(PT)-1.2*
.
.
Imaging:
[**12-10**] CT-Head:
1. Mild subgaleal frontal soft tissue edema without underlying
focal fluid
collection or abscess.
2. Stable appearance of the cerebrum, status post left
frontoparietal
craniectomy and tumor resection. Left extra-axial fluid
collection stable in size, now slightly heterogeneous. Interval
resolution of multiple areas of intra-axial hemorrhage since
[**2198-10-5**]. Similar appearance of left ventriculomegaly.
New mild rightward midline shift.
.
[**12-10**] CXR PA-L:
Low lung volumes. Right base atelectasis, early consolidation
not excluded.
.
MR HEAD W & W/O CONTRAST Study Date of [**2198-12-14**] 7:26 PM
Prelim read awaited
.
XR CHEST (PRE-OP PA & LAT) Study Date of [**2198-12-15**] 4:15 PM
Final read awaited.
.
BC [**12-11**] Coag -ve staph 1/4 bottles
UCx [**12-11**] -ve
BCs [**12-11**], [**12-13**] x3 no growth to date
BC [**12-14**] no growth to date
.
[**2198-12-14**] 11:47 am SWAB Source: head.
GRAM STAIN (Final [**2198-12-14**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
.
[**2198-12-15**] 2:07 pm SWAB Source: sub-galeal abscess.
WOUND CULTURE (Pending):
.
[**2198-12-15**] 2:33 pm ABSCESS Source: Sub-galeal abscess.
GRAM STAIN (Final [**2198-12-15**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
.
.
Brief Hospital Course:
53 yo M with a complicated post-operative course s/p resection
of hemangiopericytoma in [**2196**] at [**Hospital1 2025**] including
hardware-associated MRSA, who was recently hospitalized at [**Hospital1 18**]
for cranioplasty [**2198-9-21**], last known to be in good condition in
[**2198-11-19**] on follow-up - who re-presented with new facial
edema for 2 days and was hospitalized for soft-tissue cellulitis
presumed to be post-operative polymicrobial in origin.head CT,
pointing to facial vs. pre-septal periorbital cellulitis. Rising
WBC. BC [**12-11**] showed 1 out of 4 coag -ve staph. Febrile on
[**12-12**]. WBCs were trending down but now stable. Latterly he was
found to have a sub-galeal abscess which started draining frank
pus from the vertex on [**2-13**]. MRI on [**12-14**] ruled out seeding to
the CNS but did demonstrate increased fluid. This was sent for
culture and grew GPCs and budding yeast. Neurosurgery drained
further pus on [**12-15**] and he was taken to the OR on [**12-15**] for
removal of his bone flap. Surgery was without complication and
he was admitted to the ICU post op. Post op head CT was stable.
Neurologically the patient was expressively aphasic but
continued to follow commands.
On POD#1 his drain was removed.
On POD#2 he was cleared for transfer to the step down unit after
a repeat Head CT remained stable. Speech and Swallow therapy
evaluated his ability to swallow and felt he was at a high risk
for aspiration therefore he was made NPO except medications.
On POD#3 his INR began to increase again for unknown cause (no
anticoagulation, LFT's WNL) therefore he was given 1x dose of
Vit K due to his recent surgery. PT & OT were consulted for
assistance with discharge planning.
.
# Sub-galeal abscess: Mr [**Known lastname 67736**] presented with increased facial
swelling and evidence of scalp cellulitis. ID's initial
impression was that the infection could be a post-operative
polymicrobial infection and recommended broad spectrum coverage
for G+/G-/Anaerobic bacteria with Vanc/Ceftaz/Flagyl. He had a
high WCC on presentation and was febrile. BCs grew coag neg
staph in 1 out of 4 bottles. The edema/erythema seemed to
improved and he had no further fevers. He went down for PICC
insertion on [**12-14**] and during this time he required suctioning
in the radiology department and he began draining frank
pus10-20ml from his forehead collection. The pus was sent for
culture and grew GPCs and budding yeast. An MRI scan on [**12-14**]
ruled out CNS seeding but did show an increased collection.
Further pus was drained on [**12-15**] and he was taken to the OR for
removal of his bone flap and wound washout on [**12-15**]. Cultures
were again sent from the operating room. Patient remained
afebrile and neurologically stable. He was followed by the
infectious disease team and as the cultures grew it was revealed
that his infection was MRSA. ID decided that a 6wk course of
vanco/ceftaz/flagyl would be necessary ([**12-16**] - [**1-26**]).
# CXR Consolidation: Admitted with a resolving chronic cough in
the setting of a recent history of HA-PNA and possible RLL
infiltrate on CXR concerning for aspiration. S/S saw that
patient and cleared him for liquids and groud solids.
Leukocytosis remained stable and was treated with aspiration
precautions and IV ceftazidime and metronidazole was continued.
Post op the patient was made NPO after failing a speech and
swallow exam.
He was trasnferred to the step down unit after being determined
stable enoguh for trasnfer where he failed speech and swallow
again. On [**12-20**] he underwent video swallow which showed that he
had silent aspiration with thin barium but was good with nectar
thick. as a result he was given a diet per the recommendations
of nutrition and speech/swallow. On [**12-21**] he recevied a bed at
[**Hospital6 **] and was discharged to rehab with instructions.
INACTIVE ISSUES:
.
# Seizure disorder: Continue seizure prophylaxis with Keppra
- Continue Levetiracetam 1,000 mg PO BID
.
#. Hemangiopericytoma: Appears stable at this time. Defects
appear to be at baseline. .
# Psych issues: Continued unchanged Mirtazapine 15 mg PO qHS.
Medications on Admission:
1. Levetiracetam 1,000 mg PO BID
2. Ranitidine HCl 150 mg PO BID
3. Acetaminophen 325 mg PO Q6H prn
4. Mirtazapine 15 mg PO qHS
5. Ambien 2.5mg PO qHS prn
6. bowel medication
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Crush in applesauce.
2. mirtazapine 15 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO HS (at bedtime): Crushed in applesauce.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever: crushed in applesauce.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for sob, wheeze.
10. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for eye
irritation.
11. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Day #1= [**12-11**]
. Tablet(s)
14. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
15. CefTAZidime 2 g IV Q8H
d1 = [**12-11**]
16. Vancomycin 1250 mg IV Q 8H
d1 = [**12-11**]
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
19. Ondansetron 4 mg IV Q8H:PRN N/V
20. HydrALAzine 10 mg IV Q6H SBP>140 Start: sustained SBP>140
21. Morphine Sulfate 2-4 mg IV Q4H:PRN pain
22. Heparin Flush (100 units/ml) 2.5 mL IV DAILY:PRN picc flush
/p use
23. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
24. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
MRSA Infection of Craniotomy wound
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
* Pt is to complete a 6 week course of Vancomycin, Ceftazadime
and Flagyl. Start day [**12-16**], end [**2199-1-26**] or per Infectious
Disease follow up.
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you
should not resume taking this until cleared by your surgeon.
?????? You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow-Up Appointment Instructions
* Please draw weekly CBC /c diff, Bun/Cr, LFT's, Vanc trough,
ESR, CRP and fax to the [**Hospital **] clinic at [**Telephone/Fax (1) 1419**].
??????Please return to the office in [**7-28**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain with contrast.
??????You will not need an MRI of the brain
Completed by:[**2198-12-21**]
ICD9 Codes: 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4026
} | Medical Text: Admission Date: [**2165-3-12**] Discharge Date: [**2165-3-15**]
Date of Birth: [**2122-4-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Chest Pain, NSTEMI (transient STE), s/p cath w/o intervention,
not candidate for rpt CABG
Major Surgical or Invasive Procedure:
Cardiac catheterization (x2)
History of Present Illness:
42 yo M with pre-mature CAD s/p CABG in [**2160**] presented to [**Hospital1 **] with severe chest pain which awoke him from sleep
concerning for STEMI. Strips by EMS showed inferior STE with
worsened lateral ST depression. Started on nitro drip and
heparin, emergent cath there showing vein grafts down and patent
LIMA to LAD with retrograde filling through re-stenosed old DES,
no culprit vessel was identified. STE resolved. He was
transferred here to the CVICU for consideration of repeat
bypass--films reviewed by CT surgery & pt not felt to be a
candidate. Nitro drip weaned over the course of the day with 1
episode of [**12-30**] chest pain lasting a few minutes. Called out to
Dr.[**Name (NI) 5452**] service for further management.
.
At All Saints, he was plavix loaded with 300mg (no longer on
plavix as an outpatient), received 80mg lipitor, nitro drip,
heparin drip, and integrillin (which was discontinued prior to
transfer). In the CVICE, nitro drip was weaned and plavix
discontinued. He received 75cc/hr of NS over the course of the
day.
.
Pt CURRENTLY denies chest pain/pressure and shortness of breath.
Also denies groin pain, leg pain, leg numbness. At the time of
transfer to the floor, 98.9, 74, 129/72, 18, 100% 2L
.
.
REVIEW OF SYSTEMS:
He denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems. Pt denies: paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: [**2161-10-21**]: Coronary artery bypass grafting x4; left
internal mammary artery grafted to the left anterior descending;
reversed saphenous vein graft to the ramus intermedius, marginal
branch, posterior descending artery.
-PERCUTANEOUS CORONARY INTERVENTIONS: multiple prior to CABG,
none today
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
NONE
Social History:
-Tobacco history: none
-ETOH: rare social
-Illicit drugs: distant past, no IVDU
Family History:
AUNT WITH CAD
Physical Exam:
VS: T=98.9 BP=127/89 HR=71 RR=20 O2 sat=100 3Lnc
GENERAL: NAD. Oriented x3. Drowsy. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not visible.
CARDIAC: S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. No hematoma, but
tender in right groin
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
Admission Labs ([**2165-3-12**]):
.
142 105 16
------------ 102
5.7 29 1.2
.
Ca: 9.5 Mg: 2.3 P: 4.0
.
PT: 13.3 PTT: 42.2 INR: 1.1
.
1st set: CK: 408 MB: 33 MBI: 8.1 Trop-T: 0.20
2nd set: CK: 435 MB: 39 MBI: 9.0 Trop-T: 0.63
.
ALT: 47 AP: 67 Tbili: 0.7 Alb: 4.3
AST: 59 LDH: 409
.
.....15.5
8.0 ------ 235
.....43.9
.
PT: 12.4 PTT: 53.7 INR: 1.0
.
.
EKG: several strips reviewed
-initial EMS strip [**1-12**]: STE (2mm in II, III, aVF), worsened
downloping ST depression I, AVL, V4-V6.
-these changes had resolved by 4:30 (am?) on a 12-lead, but
recurred at 5:30 on a strip labeled 'with pain'
-last 12-lead from CVICU showing resolved STE and lessened
lateral ST depressions
.
CARDIAC CATH:
FULL REPORT IN CHART
Both vein grafts are totally occluded. LIMA to LAD is patent and
most of the distribution is filled retrograde through a
partially re-stenosed old DES. LVEF~30%
.
Brief Hospital Course:
42 yo M with CAD s/p CABG presented to OSH with CP & STE,
Emergent cath revealed no culprit vessel. CP & STE resolved
without PTCI. He was tx to CVICU for consideration of prt CABG
for which he is not a candidate and is now called out to the
floor for continued treatment of NSTEMI.
.
# Transient STE/NSTEMI: Patient underwent emergent cath for
chest pain and transient ST elevations, but no culprit vessel
was seen on OSH cath. Patient was initially on integrillin
which was stopped prior to transfer, and a nitro drip which was
weaned off. Pt was evaluated for CABG and deemed not a
candidate due to diffuse 3VD without target areas for touchdown.
He was taken for a repeat catheterization to determine whether
PTCI could be performed on a re-stenosed [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 8532**] to LIMA
touchdown, but was seen to have 90% stenosis of LAD proximal to
LIMA insertion which was not amenable to PCI, and distal LAD
sub-total occlusion. Patient was medically managed for his
NSTEMI with Plavix, Heparin gtt, high dose ASA, high dose
statin, beta blocker, ACEi. Peak CK was 440, peak MB 37, peak
troponin 0.85.
.
# PUMP: Ventriculogram at OSH 30%. TTE [**3-13**] showed EF 25-30%
with mild MR, mild TR. Severe regional left ventricular
systolic dysfunction with inferior/inferolateral
akinesis/hypokinesis and apical akinesis/dyskinesis with
depressed free wall contractility. No signs of fluid overload,
cardiomyopathy likely ischemic in origin.
.
# HTN: Continued amlodipine, started ACEi in-house.
.
FULL CODE
Medications on Admission:
aspirin 325'
Caduet [**9-29**]''
lopressor 100''
NTG prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Non-ST Elevation Myocardiac Infarction
s/p cardiac catheterization without intervention
Secondary Diagnosis:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You presented to the hospital for chest pain and you were found
to be having a heart attack. You underwent cardiac
catheterization and it showed blockages in the arteries
supplying your heart. You underwent evaluation for a coronary
bypass surgery but you are not a candidate for surgery due to
the extent of your disease. You underwent a repeat cardiac
catheterization but the blockages were not able to be opened
with a procedure. Your heart attack was managed with
medications, which you should take every day when you are
discharged from the hospital.
The following changes were made to your medications:
- Atorvastatin-Amlodipine (Caduet) was STOPPED
- Atorvastatin 80mg daily was started
- Amlodipine 10mg daily was started
- Clopidogrel 75mg daily was started
- Lisinopril 5mg daily was started
It is extremely important to take your Aspirin and Clopidogrel
every day without missing a dose to prevent another heart
attack. Please do not stop taking these medications unless
specifically directed by your cardiologist.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] on [**4-3**] at 11:15am,
please call his office at ([**Telephone/Fax (1) 32215**] if you have any
questions.
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] M.
[**Telephone/Fax (1) 33146**], and schedule an appointment to be seen 1-2 weeks
after discharge from the hospital.
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4027
} | Medical Text: Admission Date: [**2193-7-23**] Discharge Date: [**2193-9-22**]
Date of Birth: [**2149-3-7**] Sex: F
Service: MEDICINE
Allergies:
Sulfasalazine / Zosyn
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
cardiac Catheterization with placement of BMS X2 to RCA
central venous line placements
IR guided exchange of HD catheter over wire
IR guided arterial line placement
Skin biopsy
Bone marrow biopsy
Kidney biopsy
History of Present Illness:
Patient is a 44 yo F with h/o asthma who presented to [**Hospital1 5979**] ER with dyspnea, found to have possible pneumonia and
asthma exacerbation, was intubated and found to have NSTEMI. Pt
is currently intubated and sedated. Per her family, her niece
visited her on [**7-22**] and found the patient feeling unwell and
short of breath. Her niece had called 911 and the patient was
taken to [**Hospital3 **] ER. VS were: 124/71, pulse 107, RR
30, O2 sat 84% on RA. On exam, she was noted to be diaphoretic
and have expiratory wheezing. CXR revealed bilateral airspace
opacities, bilateral infiltrates v. pulmonary edema, which were
noted to be rapidly increasing overal serial CXRs. Pt was
started on Bipap and admitted to the ICU. She failed Bipap and
was then intubated. Pt was treated with ceftriaxone,
azithromycin, and solumedrol. Tmax was 100.4. Sputum gram
stain showed few polys, few GPCs in pairs, rare GPCs in
clusters; sputum cx grew scant normal respiratory flora.
Further workup revealed increasing cardiac enzymes, CK of
153->1143, CKMB of 11->150, Troponin T of 0.06->2.03
(0.01-0.04). BNP was 1753. Preliminary ECHO work-up showed EF
of 30-35%, severe inferior wall hypokinesis, 2+ MR. [**Name13 (STitle) **] report,
EKG showed SR at rate of 100, with Q waves in lead III and AVF
and non-specific ST-T wave changes. She was treated with IV
Lasix, nitro gtt, heparin gtt, and plavix and transferred here.
.
In the cardiac cath lab, she was found to have 100% stenosis of
distal RCA, which was stented with 2 BMS. Resting hemodynamics
revealed elevated right and left ventricular filling pressures
with RVEDP of 27 mmHg and PCW of 25 mmHg.
.
Per family, ROS was positive intermittent substernal chest pain
for the past 2 years. Per sister, she had normal stress tests,
perhaps a year ago. Per PCP, [**Name10 (NameIs) **] had presented with pedal edema
and weight gain 3 months ago. She also has a chronic productive
cough. She had been hospitalized for pneumonia twice in the
last year and may have required intubation. Last
hospitalization was in [**2193-2-26**].
Past Medical History:
Asthma
Obesity, s/p gastric bypass in [**2187**]
Depression
s/p cesarean sections x2
Social History:
Patient is divorced with 2 sons. She is a nurse. Social
history is significant for [**11-28**] ppd x 30 years. There is history
of alcohol use, [**1-29**] drinks per day. Family is unaware of any
withdrawal issues.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 99.7, BP 107/76, HR 83, RR 27, O2 100% on AC 600x14, FiO2
100%
Gen: Middle aged female, intubated and sedated.
HEENT: Sclera anicteric. PERRL, EOMI. Mucous membranes moist.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, normal S1, S2. No S4, no S3. No murmurs.
Chest: No chest wall deformities, scoliosis or kyphosis. RLL
crackles. No wheezes.
Abd: Obese. Normoactive bowel sounds, soft, NT/ND, no HSM. No
abdominial bruits.
Ext: No edema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+; 1+ DP/PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+; 1+ DP/PT (but
undopplerable?)
Pertinent Results:
ADMISSION LABS:
[**2193-7-23**] 01:31PM BLOOD WBC-13.8* RBC-4.33 Hgb-12.7 Hct-38.9
MCV-90 MCH-29.4 MCHC-32.7 RDW-15.9* Plt Ct-322
[**2193-7-23**] 01:31PM BLOOD Neuts-92.0* Lymphs-6.1* Monos-1.8*
Eos-0.1 Baso-0
[**2193-7-23**] 01:31PM BLOOD PT-15.3* PTT-70.1* INR(PT)-1.4*
[**2193-7-23**] 01:31PM BLOOD Plt Ct-322
[**2193-7-23**] 01:31PM BLOOD Glucose-181* UreaN-18 Creat-1.7* Na-144
K-4.5 Cl-108 HCO3-22 AnGap-19
[**2193-7-23**] 08:59PM BLOOD K-5.9*
[**2193-7-23**] 01:31PM BLOOD CK(CPK)-2738*
[**2193-7-23**] 08:59PM BLOOD ALT-54* AST-375* LD(LDH)-1728*
CK(CPK)-3323* AlkPhos-82 TotBili-0.5
[**2193-7-23**] 01:31PM BLOOD CK-MB-276* MB Indx-10.1* cTropnT-7.82*
[**2193-7-23**] 08:59PM BLOOD CK-MB-185* MB Indx-5.6
[**2193-7-23**] 01:31PM BLOOD Calcium-7.6* Phos-4.7* Mg-1.7
[**2193-7-23**] 08:59PM BLOOD Cholest-150
[**2193-7-23**] 01:31PM BLOOD %HbA1c-5.5
[**2193-7-23**] 08:59PM BLOOD Triglyc-283* HDL-57 CHOL/HD-2.6
LDLcalc-36
[**2193-7-24**] 10:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5.3
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2193-7-23**] 01:40PM BLOOD Type-ART Tidal V-550 FiO2-100 pO2-104
pCO2-31* pH-7.43 calTCO2-21 Base XS--2 AADO2-597 REQ O2-95
Intubat-INTUBATED
[**2193-7-23**] 04:11PM BLOOD Lactate-2.3*
[**2193-7-24**] 09:21PM BLOOD Glucose-130* Lactate-1.2
.
.
[**2193-9-19**] 04:45AM BLOOD WBC-14.6* RBC-2.84* Hgb-8.7* Hct-27.2*
MCV-96 MCH-30.7 MCHC-32.1 RDW-22.7* Plt Ct-148*
[**2193-9-21**] 06:39AM BLOOD WBC-17.5* RBC-2.97* Hgb-9.0* Hct-29.7*
MCV-100* MCH-30.2 MCHC-30.2* RDW-23.1* Plt Ct-70*
[**2193-9-22**] 04:16AM BLOOD WBC-16.9* RBC-1.75*# Hgb-5.5* Hct-17.8*#
MCV-102* MCH-31.6 MCHC-31.0 RDW-22.6* Plt Ct-35*
[**2193-8-11**] 04:00AM BLOOD WBC-29.3* RBC-2.45* Hgb-7.3* Hct-23.3*
MCV-95 MCH-29.7 MCHC-31.2 RDW-18.1* Plt Ct-168
[**2193-8-13**] 11:34AM BLOOD WBC-25.3* RBC-2.74* Hgb-8.0* Hct-25.9*
MCV-94 MCH-29.1 MCHC-30.8* RDW-19.4* Plt Ct-104*
[**2193-8-18**] 03:51AM BLOOD WBC-18.8* RBC-2.36* Hgb-7.3* Hct-23.5*
MCV-100* MCH-30.8 MCHC-30.9* RDW-26.6* Plt Ct-65*
[**2193-9-20**] 03:36AM BLOOD PT-17.3* PTT-26.7 INR(PT)-1.6*
[**2193-9-21**] 03:39AM BLOOD PT-19.3* PTT-31.2 INR(PT)-1.8*
[**2193-9-21**] 10:23PM BLOOD PT-24.2* PTT-150* INR(PT)-2.4*
[**2193-9-22**] 04:16AM BLOOD PT-31.4* PTT-150* INR(PT)-3.2*
[**2193-7-27**] 12:04PM BLOOD Fibrino-667* D-Dimer-5093*
[**2193-8-15**] 04:28PM BLOOD Fibrino-121* D-Dimer-6300*
[**2193-8-16**] 03:26AM BLOOD Fibrino-106* D-Dimer-6475*
[**2193-9-17**] 02:02AM BLOOD QG6PD-19.1*
[**2193-8-3**] 05:30AM BLOOD ACA IgG-3.6 ACA IgM-7.6
[**2193-7-27**] 10:10PM BLOOD ACA IgG-3.2 ACA IgM-6.9
[**2193-9-21**] 10:23PM BLOOD Glucose-215* UreaN-20 Creat-0.7 Na-147*
K-5.3* Cl-98 HCO3-8* AnGap-46*
[**2193-9-22**] 04:16AM BLOOD Glucose-90 UreaN-16 Creat-0.6 Na-139
K-5.0 Cl-91* HCO3-10* AnGap-43*
[**2193-9-21**] 04:42PM BLOOD Glucose-260* Na-140 K-6.6* Cl-105 HCO3-<5
[**2193-9-21**] 03:39AM BLOOD Glucose-151* UreaN-26* Creat-0.9 Na-141
K-2.8* Cl-109* HCO3-20* AnGap-15
[**2193-9-20**] 03:36AM BLOOD ALT-32 AST-16 AlkPhos-79 TotBili-1.0
[**2193-9-21**] 10:23PM BLOOD ALT-205* AST-302* LD(LDH)-1137*
CK(CPK)-66 AlkPhos-79 Amylase-834* TotBili-1.0
[**2193-9-10**] 05:36AM BLOOD ALT-108* AST-27 LD(LDH)-596* AlkPhos-193*
TotBili-1.3
[**2193-9-21**] 10:23PM BLOOD Lipase-49
[**2193-8-20**] 03:55AM BLOOD cTropnT-1.50*
[**2193-9-21**] 06:50PM BLOOD CK-MB-NotDone cTropnT-0.68*
[**2193-9-21**] 10:23PM BLOOD CK-MB-NotDone cTropnT-0.56*
[**2193-9-22**] 04:16AM BLOOD CK-MB-8 cTropnT-0.41*
[**2193-8-18**] 04:16PM BLOOD CK-MB-123* MB Indx-2.2
[**2193-9-22**] 04:16AM BLOOD CK(CPK)-153*
[**2193-9-21**] 10:23PM BLOOD Calcium-10.6* Phos-6.1*# Mg-2.5
[**2193-9-22**] 04:16AM BLOOD Calcium-12.2* Phos-5.5* Mg-2.4
[**2193-9-21**] 10:23PM BLOOD Hapto-26*
[**2193-9-9**] 04:11AM BLOOD calTIBC-273 Ferritn-96 TRF-210
[**2193-8-13**] 04:55AM BLOOD TSH-6.1*
[**2193-9-9**] 09:41AM BLOOD PTH-365*
[**2193-7-29**] 02:12AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2193-7-29**] 10:33AM BLOOD ANCA-NEGATIVE B
[**2193-7-24**] 10:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5.3
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2193-9-22**] 08:01AM BLOOD Type-ART pO2-241* pCO2-28* pH-7.49*
calTCO2-22 Base XS-0
[**2193-9-22**] 04:21AM BLOOD Type-ART pO2-300* pCO2-17* pH-7.44
calTCO2-12* Base XS--9
[**2193-9-22**] 03:19AM BLOOD Type-ART Temp-33.3 pO2-411* pCO2-14*
pH-7.43 calTCO2-10* Base XS--11
[**2193-9-22**] 01:20AM BLOOD Type-ART Temp-33.3 Rates-0/20 pO2-68*
pCO2-37 pH-7.08* calTCO2-12* Base XS--18 Intubat-NOT INTUBA
[**2193-9-21**] 10:41PM BLOOD Type-ART Rates-/20 FiO2-40 pO2-117*
pCO2-31* pH-7.11* calTCO2-10* Base XS--18 Intubat-NOT INTUBA
[**2193-9-21**] 07:46PM BLOOD Type-ART pO2-111* pCO2-27* pH-6.94*
calTCO2-6* Base XS--26
[**2193-9-21**] 05:27PM BLOOD Type-ART Rates-20/ pO2-111* pCO2-22*
pH-6.87* calTCO2-4* Base XS--30 Intubat-NOT INTUBA
[**2193-9-21**] 04:59PM BLOOD Type-ART pO2-108* pCO2-24* pH-6.88*
calTCO2-5* Base XS--29 Intubat-NOT INTUBA
[**2193-9-21**] 11:15AM BLOOD Type-ART Temp-35.2 Rates-/22 pO2-83
pCO2-29* pH-7.33* calTCO2-16* Base XS--9 Intubat-NOT INTUBA
[**2193-9-21**] 03:51AM BLOOD Type-ART pO2-139* pCO2-35 pH-7.38
calTCO2-22 Base XS--3
[**2193-9-20**] 06:00PM BLOOD Type-ART pO2-115* pCO2-37 pH-7.38
calTCO2-23 Base XS--2
[**2193-9-20**] 12:26PM BLOOD Type-ART pO2-114* pCO2-31* pH-7.40
calTCO2-20* Base XS--3
[**2193-9-13**] 04:20AM BLOOD Lactate-3.1*
[**2193-9-13**] 11:28AM BLOOD Lactate-2.0 calHCO3-30
[**2193-9-19**] 04:58AM BLOOD Lactate-1.8
[**2193-9-19**] 11:05AM BLOOD Lactate-2.2*
[**2193-9-21**] 03:51AM BLOOD Lactate-2.3*
[**2193-9-21**] 05:27PM BLOOD Lactate-12.9*
[**2193-9-21**] 07:46PM BLOOD Lactate-15.* K-5.3
[**2193-9-21**] 10:41PM BLOOD Lactate-16.7*
[**2193-9-22**] 01:20AM BLOOD Lactate-14.7*
[**2193-9-22**] 03:19AM BLOOD Lactate-18.8*
[**2193-9-22**] 04:21AM BLOOD Lactate-20.2*
[**2193-9-22**] 08:01AM BLOOD Lactate-20.8*
[**2193-9-22**] 08:01AM BLOOD Hgb-3.1* calcHCT-9
[**2193-9-21**] 03:51AM BLOOD O2 Sat-98
[**2193-9-21**] 06:24PM BLOOD O2 Sat-24
[**2193-9-21**] 12:36PM BLOOD O2 Sat-27
[**2193-9-17**] 02:45PM BLOOD O2 Sat-49
[**2193-9-16**] 11:58PM BLOOD O2 Sat-83
[**2193-9-18**] 03:22PM BLOOD O2 Sat-98
[**2193-9-17**] 02:02AM BLOOD ANTI-PLATELET ANTIBODY-TEST
[**2193-9-5**] 06:26PM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2193-9-3**] 03:43AM BLOOD ADAMTS13 ACTIVITY AND INHIBITOR-ADAMTS13
A
[**2193-8-27**] 08:18PM BLOOD HERPES 6 DNA PCR, QUANTITATIVE-Test Name
[**2193-8-27**] 01:51PM BLOOD RIBOSOMAL P ANTIBODY-Test
[**2193-8-27**] 01:51PM BLOOD PURKINJE CELL (YO) ANTIBODIES-Test
[**2193-8-27**] 01:51PM BLOOD NEURONAL NUCLEAR ([**Doctor Last Name **]) ANTIBODIES-Test
[**2193-8-17**] 06:00PM BLOOD ADAMTS13 ACTIVITY AND INHIBITOR-ADAMTS13
A
[**2193-8-14**] 04:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2193-8-13**] 04:55AM BLOOD MI-2 AUTOANTIBODIES-Test
[**2193-8-7**] 03:30PM BLOOD SM ANTIBODY-Test
[**2193-8-7**] 03:30PM BLOOD RNP ANTIBODY-Test
[**2193-8-7**] 03:30PM BLOOD ALDOLASE-Test
[**2193-8-6**] 10:22AM BLOOD PROTHROMBIN MUTATION ANALYSIS-
[**2193-8-6**] 10:22AM BLOOD FACTOR V LEIDEN- T
[**2193-8-3**] 05:50AM BLOOD IGG SUBCLASSES 1,2,3,4-Test
[**2193-7-31**] 05:18AM BLOOD Beta-2-Glycoprotein 1 Antibodies IgG-Test
[**2193-7-25**] 06:56AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-
TEST
[**2193-7-25**] 06:56AM BLOOD B-GLUCAN-Test
PERTINENT LABS/STUDIES:
.
EKG demonstrated NSR with q waves in III and AVF, TWI in II,
III, AVF, 1 mm STE in V1, STD in V3, V4.
.
2D-ECHOCARDIOGRAM performed on [**2193-7-23**] demonstrated:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. There is mild regional left ventricular
systolic dysfunction with inferior/inferolateral akinesis.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] EF 45%.
Right ventricular chamber size is normal and free wall motion
is probably normal (views suboptimal). The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion.
.
CARDIAC CATH performed on [**2193-7-23**] demonstrated:
The LMCA, LAD, LCX showed no obstructive coronary artery
disease. The RCA showed a distal discrete 100% stenosis with
left to right collaterals.
.
CXR [**2193-7-23**]
AP single view of the chest is obtained with patient in supine
position. The patient is intubated, the ETT terminating in the
trachea some 3 cm above the level of the carina. An NG tube has
been placed and reaches far below the diaphragm. There is marked
cardiac enlargement configuration indicating a prominence of the
left ventricular contour as well as a beginning double contour
and widening of the tracheal bifurcation indicative of left
atrial enlargement. There is no pneumothorax. There are
bilateral mostly
centrally located parenchymal densities consistent with
pulmonary edema.
The lateral pleural sinuses are free. Possibility of some
bilateral pleural effusions layering in the posterior pleural
spaces in this patient in supine position can, however, not be
excluded.
.
MRA Head. [**2193-7-28**].
CONCLUSION: Findings remain suspicious for multiple infarcts,
shown to be
subacute in age.
.
Renal Biopsy. [**2193-8-2**].
Comment:
1. There is no evidence of an immune complex
glomerulonephritis.
2. The focal vascular changes noted are insufficient for a
definite diagnosis of a thrombotic microangiopathy. Clinical
correlation is indicated.
.
Skin biopsy:
Multiple thrombi within small vessels in dermis with overlying
ischemic epidermal changes consistent with thrombotic
microangiopathy.
No vasculitis is seen.
Echo [**9-19**]: The left atrium is markedly dilated. The right
atrium is markedly dilated. The estimated right atrial pressure
is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is mildly dilated.
There is mild to moderate regional left ventricular systolic
dysfunction with severe hypokinesis/akinesis of the inferior and
inferolateral walls. Transmitral Doppler imaging is consistent
with Grade III/IV (severe) LV diastolic dysfunction. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The mitral valve leaflets do not fully coapt.
Severe (4+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2193-9-4**],
the severity of tricuspid regurgitation has decreased. Severe
ischemic mitral regurgitation resulting from the mitral leaflets
failing to coapt is unchanged.
Echo [**9-21**]: The left and right atrium are markedly dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild to moderate regional left ventricular
systolic dysfunction with akineis of the inferior and
inferolateral walls. The remaining segments contract normally
(LVEF = 40 %). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size is normal. with
moderate global free wall hypokinesis. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The aortic valve leaflets
appear structurally normal with good leaflet excursion. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. At least moderate to severe (3+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is an anterior space which most likely represents a
fat pad.
Compared with the prior study (images reviewed) of [**2193-9-19**],
the findings are similar.
[**9-18**] Renal Ultrasound: FINDINGS: The right kidney measures 10.9
cm, and the left kidney measures 10.2 cm. No hydronephrosis is
identified in either kidney. The cortical thickness appears
normal bilaterally. No cysts or solid masses are identified.
IMPRESSION: No hydronephrosis. Normal cortical thickness
bilaterally.
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
MILDLY HYPOCELLULAR ERYTHROID DOMINANT BONE MARROW WITH
DYSERYTHROPOIESIS AND DYSMEGAKARYOPOIESIS.
Note: The findings are not inconsistent with the effects of
gangcyclovir +/- viremia. A primary myelodysplastic syndrome
appears less likely, but can not be entirely ruled out. Special
stains for microorganisms (Acid-fast, GMS, PAS) are negative.
By immunohistochemistry, T-cell markers CD3 and CD5 highlight
lymphocytes singly and in clusters. CD20 is immunoreactive in a
small subset. CD138 highlights plasma cells in interstitial and
perivascular distribution, which by Kappa/Lambda light chain
immunostaining appear polytypic.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes show
significant anisopoikilocytosis with polychromatophils,
macrocytes, target cells, echinocytes, dacrocytes, microcytes,
ovalocytes and basophilic stippling. A peripheral blood smear
was not submitted. Numerous nucleated RBC's are seen, some with
irregular nuclear contours and asymmetric nuclear budding. The
white blood cell count appears normal. Neutrophils with toxic
vacuolization are prominent and include hypogranular forms.
Platelet count appears normal. Large forms are seen.
Occasional Giant forms are present. Differential count shows
91% neutrophils, 3% monocytes, 8% lymphocytes, 1% other
myelocyte.
Aspirate Smear:
The aspirate material is inadequate for evaluation due to lack
of spicules.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation and consists of
two pieces of fragmented core biopsy with partial aspiration
artifact measuring 0.6 cm in aggregate. The marrow is variably
cellular, overall 20-30%. Interstitial debris and macrophages
appear prominent.
The M:E ratio estimate is decreased. Erythroid precursors are
relatively increased in number and show occasional dysplastic
forms (asymmetric nuclear budding and irregular nuclear
contours). Myeloid elements are decreased and show
full-spectrum maturation.
Megakaryocytes are present in normal number and are focally
present in clusters.
There is an interstitial infiltrate of plasma cells /
lymphoplasmacytic cells occurring singly and in small clusters
occupying 10% of marrow cellularity. Marrow clot section is
similar to the biopsy.
Special Stains:
Iron stain is inadequate for evaluation due to lack of spicules.
Brief Hospital Course:
In summary, Ms. [**Known lastname 62766**] is a 44 year old female admitted
initially to an OSH for multifocal pneumonia, found to have an
NSTEMI, s/p BMS to RCA on admission. Hospital course further
complicated by multiorgan system failure.
.
NSTEMI. Patient transferred to [**Hospital1 18**] due to NSTEMI. Found to
have mild regional left ventricular systolic dysfunction with
inferior/inferolateral akinesis on echo. She had cardiac cath
and was found to have 100% stenosis of distal RCA, which was
stented x2 with BMS. She was started on aspirin, atorvastatin,
and plavix. The patient remained hypotensive after cardiac
catheterization, and was found to have mitral regurgitation.
Her mitral regurgitation worsened thoughout her hospital course
and she developed cardiogenic shock dependent on dobutamine.
Her dobutamine was weaned off over several weeks, but she was
unable to tolerate hemodialysis while off dobutamine.
.
Respiratory failure. Patient was initially admitted to [**Hospital1 **] after presenting with a multifocal pneumonia. Upon
transfer to [**Hospital1 18**], patient had daily fevers in spite of broad
spectrum antibiotics and negative cultures. Her CXR improved,
however, she had persistent altered mental status and tachypnea
thought be secondary to a central process preventing extubation.
She was given steroids for a short period. However, given her
persistent respiratory alkalosis and cheynes-[**Doctor Last Name 6056**] breathing,
she underwent tracheostomy. Due to her distorted anatomy
secondary to gastric bypass, a PEG was not performed at the same
time. During her hospital course, she had episodes of small
amounts of hemoptysis. The patient eventually progressed to
being weaned off the vent entirely, and was breathing
comfortably on the trach mask.
.
Altered mental status. Following cardiac catheterization,
patient found to have several embolic strokes. Patient had
serial TTEs and a TEE looking for a source, but was not found.
She remained minimally responsive and with cheynes-[**Doctor Last Name 6056**]
breathing. EEG x 2 showed toxic-metabolic patterns. Patient
was ultimately started on dialysis in hopes that improvemento
her uremia might improve her mental status. Over time, her
mental status improved, and she began to follow commands.
.
Renal Failure. Patient developed renal failure during her
hospital course. Etiology of her renal failure was not clear.
A renal biopsy could not rule out thrombotic microangiopathy,
but was felt to be consistent with ATN. She was started on
dialysis. There was concern for TTP given thrombocytopenia that
developed three weeks into her hospital stay, but the decision
was made against empiric plasmapharesis after consultation with
transfusion medicine. Patient was given 2 units of
cryoprecipitate for increasing DIC picture, and also started on
heparin gtt without bolus for concern of TTP and increasing
ischemia in lower extremities. She was dialyzed with CVVH, then
hemodialysis. The patient progressed with hemodialysis for
several weeks. During the week of [**9-18**] she became intolerant to
fluid shifts during hemodialysis and would become hypotensive
either during or shortly after hemodialysis. She was reaching
the point where she was requiring fluid boluses after every
hemodialysis session. On [**9-20**], she was restarted on CVVH.
.
DIC/TMA. Patient developed thrombocytopenia, elevated fibrin
split products, low fibrinogen, thought to be consistent with
DIC. She had a biopsy of her skin consistent with thrombotic
microangiopathy. She had decreased perfusion to her feet as
well. This was felt to be due to DIC in adition to levophed.
She was transfused cryoprecipitate and other blood products as
needed. Her coagulopathy was treated with IV heparin. Her
thrombocytopenia and coagulation abnormalities resolved,
however, the patient suffered ischemia of her distal extremities
with resulting necrosis. The patient was left with stable dry
gangrene of her left foot up to her ankle, her toes of her right
foot, and several fingers on each hand. Vascular surgery was
consulted and they recomended pursuing ampuation of her feet
after the patient regained better functioning status after a
stay at rehab.
.
Fevers. Patient initially presenting with daily fevers. She
was treated with broad spectrum antibiotics but continued to
have daily fevers. Given yeast in multiple sites (lung, urine),
but never in blood, patient was started on caspofungin. She
was also given steroids for bronchospasm. In spite of broad
spectrum antiobiotics and steroids, she had daily fevers. Her
fevers resolved after discontinuation of steroids and
antibiotics. She subsequently developed a line infection
treated with seven days of vancomycin. The patient develped
numerous other infections during her stay. She developed
C.Difficile colitis and was treated with flagyl and oral
vancomycin. She developed a CMV viremia and was treated with
ganciclovir. She had an acitenobacter vent associated pneumonia
and completed a course of augmentin. In addition, she developed
multiple other fevers which were attributed to line infetions,
treated with vancomycin. Her central lines were changed by
interventional radiology on multiple occasions.
.
Rhabdo. Patient developed rhabdo during her hospital stay. CK
reached levels greater than 10,000. This was thought to be due
to decreased mobility secondary to her altered mental status.
Her CK trended down to normal levels.
.
Pain Control: The patient experienced continuous pain from her
necrosed and gangrenous feet and fingers. She was treated with
IV fentanyl to treat her pain. The family raised concerns that
fentanyl administration was causing increased drowsiness of the
patient, and requested that it be curtailed. The patient's pain
was continuously evaluated by the nursing staff and physicians
and treated appropriately with fentanyl. The patient was
eventually transitioned to a fentanyl patch with the idea of
weaning off her IV fentanyl administration. Despite the
fentanyl patch she was still requiring additional IV fentanyl.
.
Shock. The patient developed shock on [**7-27**] and remained in shock
for the majority of her hospitalization. Initially attributed to
septic etiology; she was treated with broad spectrum antibiotics
and placed on neosinephrine, vasopressin, and levophed. Her
neosinephrine and vasopressin was discontinued and she
eventually remaned on levophed for blood pressure support. On
[**9-1**], TTE findings of 4+ MR, plus low central venous O2
saturations rasied the concern for a cardiogenic componenet.
Her levophed was discontinued and dobutamine was begun. Her
blood pressure, lactate levels, and central venous O2
saturations improved with initiation of dobutamine. She
remained in cardiogenic shock, dependent on dobutamine until
[**9-18**]. Her dobutamine was weaned off and she was able to
maintain a mean arterial pressure over 60. She continued with
periods of hypotension, most notable during or immediately after
hemodialysis, and required fluid suport during these periods.
After one such hypotensive episode [**9-20**] she was not responsive
to fluids and was restarted on levophed. her CVVH was restarted
on [**9-20**].
The afternoon of [**9-21**] @4pm her routine ABG showed a pH of 6.87,
a bicarbonate of 4, and a lactate of 12.9. These results came as
a surprise as an ABG at noon [**9-21**] showed a pH of 7.33, with a
bicarbonate of 16, and a lactate of 2.0. She remained otherwise
hemodynamically stable during this period without alterations in
her baseline blood pressure or heart rate. Her CVVH fluid was
immediately changed to provide the maximum amount of
bicarbonate. She slowly became hypotensive and was started on
vasopressin, in addition to levophed. She was bolused with a
total of 15 amps of sodium bicarbonate over the next 10 hours,
in addition to tromethamine which is a bicarbonate alternative.
ABGs showed her pH slowly improving to 7.1, with bicarbonate
levels improving to 9, however her lactate continued to rise to
a peak of 20.9. The cause of her acte lactic acidois and
electrolyte abnormaities were unknown, but it was thought that
she may be in worsening cardiogenic shock from a new myocardial
infarction, cardiac tamponade, or massive pulmonary embolism,
she may have been in septic shock, or she have suffered an
insult to another organ system such as acute bowel ischemia.
Stat cardiac echo did not show cardiac tamponade, or new wall
motion abnormalities suggestive of pulmonary embolism or
myocardial infarction. Cardiac enzymes were trended and were
flat. She was started on broad spectrum antibiotics with
vancomycin and meropenem to cover for possible infection causing
shock, in addition to coverage for clostridial species with
flagyl, PO vancomycin, and clindamycin. Physical examination
revealed a distended abdomen. Liver enzymes showed elevated
transaminases consistent with ishemic liver, normal bilirubin
and alkaline phosphatase, normal lipase, but an elevated amylase
to 853. The acuity of the patient's deterioration, in addition
to rising lactate, elevated amylase, and distended abdomen, led
us to believe that the patient was experiencing bowel ischemia.
this would not be surprising in a patient with an underlying
coagulopathy of uncertain etiology. The family was spoken to at
9pm and told of her grave prognosis. The family was fixated on
the patient's fentanyl use, and believed that her depressed
mental status was due to fentanyl. It was explained to her
family that her current condition was not secondary to fentanyl
administration, and that an acute unidentified event occured
which is causing the patient's deterioration. They were told
that this event was most likely mesenteric ischemia but that it
was uncertain, because the patient was too ill to be imaged.
At 4am the patient PEA arrested. CPR was initiated for 90
seconds. She was given epinephrine and atropine, and begun on
neosinephrine and dopamine. Her blood pressure increased and
her pulse returned. Her sister [**Name (NI) **] was called and told of
the events. She was told that the cause of her impaired cardiac
contractility was her underlying acidosis, and that nothing
medically could be done to stop the acidosis from worsening.
[**Doctor First Name **] requested the patient remain full code. The patient
progressed to apnea and was placed on the ventilator. She
underwent a second PEA arrest at 5am, progressing to torsades de
pointes. She was defibrillated once with return to her
junctional rhythm. She underwent another round of CPR lasting
90 seconds. She was given epinephrine, atropine, and sodium
bicarbonate and her blood pressure returned. her sister [**Name (NI) **]
was notified once again after this second PEA arrest. again,
she was told of her grave prognosis, and that her acidosis could
not be alleviated. She again requested that the patient remain
full code. She requested the patient remain full code so that
she could contact family members, and have them arrive to the
hospital so they could see the paitient while she was still
alive. From the hours of 6am through 8:30am the patient was
given epinephrine, atropine, and sodium bicarbonate in order to
stabilize her blood pressure. The patient's hematocrit dring
this time decreased from 18.0 to 9.0, possibly from
intrabdominal hemorrhage from perforated bowel as a result of
bowel ischemia. At 8:30 am the patient's extended family had
arrived. After they had a chance to see the patient alive they
requested she be made DNR. All resuscitative efforts ceased and
the patient passed away at 9am.
The following day the family requested an autopsy be performed.
Medications on Admission:
HOME MEDICATIONS:
Albuterol prn
.
MEDICATIONS ON TRANSFER:
ASA 325 mg
Azithromycin 500mg IV daily
Ceftriaxone 1 gm daily
Plavix 75 mg
Combivent 2 puffs QID
Lasix 40 mg IV BID
ISS
Methylprednisolone 80 mg IB [**Hospital1 **]
Heparin gtt
Nitro gtt
Propofol gtt
Lorazepam 1 mg IV q2 hrs prn
Morphine 2 mg IV q1 hr prn
Discharge Disposition:
Expired
Discharge Diagnosis:
NSTEMI
Cardiogenic Shock
Septic shock
CMV viremia
Disseminated Intravascular Coagulation
Thrombotic Microangiopathy
Dry gangrene of feet, fingers
Ventilator associated pneumonia
Cerebral infarcts
C.Diff colitis
Line infections
Likely Bowel Ischemia
Discharge Condition:
expired
ICD9 Codes: 0389, 5845, 486, 4280, 311, 3051, 4240, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4028
} | Medical Text: Admission Date: [**2138-4-4**] Discharge Date: [**2138-4-18**]
Date of Birth: [**2138-4-4**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: The patient was the 2405 gram
product of a 34 and [**4-20**] week twin gestation born to a 35
year-old G4 P1 mother. [**Name (NI) **] pregnancy was complicated by
preeclampsia. Prenatal screens were notable for O positive
antibody negative blood type, RPR nonreactive, Rubella
immune, hepatitis B surface antigen negative. The mother was
group B strep colonized and had rupture of membranes less
then 24 hours prior to delivery. No fever and received no
antibiotics prior to delivery. The patient was delivered by
C section for preeclampsia.
The patient did well in the delivery room with Apgars of 7
and 8. Physical examination on admission showed a weight of
405 grams (50th percentile), head circumference 32 cm (50th
percentile) and a length of 49 cm (90th percentile).
Examination of the skin was unremarkable. HEENT examination
was unremarkable. Cardiac examination showed normal S1 and
S2 without murmurs. Lungs were notable for severe
intercostal retractions on admission to the Neonatal
Intensive Care Unit. Abdomen was benign. Hips were normal.
Anus was patent. Spine was intact. Neurological
examination was notable for a slightly decreased tone, but an
otherwise nonfocal examination.
HOSPITAL COURSE: 1. Cardiovascular/respiratory: The
patient required intubation and treatment with a single dose
of Surfactant on admission to the Neonatal Intensive Care
Unit. He remained ventilated through the second hospital
day. He them rapidly weaned to room air. He has never had a
patent ductus arteriosis noted. Apnea and bradycardia has
not been a prominent issue during his hospitalization. He
never required treatment methylxanthine.
2. Fluids, electrolytes and nutrition: He was initially
made NPO and intravenous fluids. Feeds were started on the
second hospital day and he rapidly advanced to full volume
feedings. He is currently receiving ad lib feedings with a
limited volume of 130 cc per kilo with breast milk or Enfamil
24. His weight at the time of this dictation on [**2138-4-17**]
is 2465 grams. DC weight 2520 grams.
3. Hematologic: CBC on admission showed a hematocrit of 45,
white blood cell count of 13.6 with 14 polys and 0 bands.
Platelet count was 344,000. The patient received no
transfusions during his hospital stay.
4. Infectious disease: The patient was treated with
antibiotics for 48 hour rule out. Blood culture remained
negative and the patient remained clinically well and
antibiotics were discontinued at 48 hours.
5. Gastrointestinal: The patient had hyperbilirubinemia
with a maximum level of 11.0/0.2 on [**4-8**]. He did not require
phototherapy.
6. Neurological: The patient manifested normal neurological
examination throughout his hospital stay.
7. Routine health care maintenance: The patient has passed
a hearing screen bilaterally as well as a car seat test. He
received hepatitis B vaccination on [**4-15**].
8. Care and recommendations: Feeds at discharge breast milk
or Enfamil 24 at a minimum volume of 120 cc per kilogram per
day. Immunizations recommended, Synagis RSV prophylaxis
should be considered from [**Month (only) 359**] through [**Month (only) 547**] for patients
who meet any of the following three criteria, one born at
less then 32 weeks, born between 32 and 35 weeks with two to
three of the following; day care during the RSV season,
smoker in the household, neuromuscular disease, airway
abnormalities or school age siblings, or three with chronic
lung disease. Two, influenza immunizations 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. Follow up appointment is recommended with Dr.
[**Last Name (STitle) 52390**] within two days following discharge.
DISCHARGE DIAGNOSES:
1. 34 and a half week infant.
2. Respiratory distress syndrome.
3. Rule out sepsis.
4. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 37102**]
MEDQUIST36
D: [**2138-4-17**] 11:13
T: [**2138-4-17**] 11:39
JOB#: [**Job Number 52391**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4029
} | Medical Text: Admission Date: [**2132-1-2**] Discharge Date: [**2132-1-15**]
Date of Birth: [**2057-5-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
[**1-3**]: Placement of External Ventricular Drain
[**1-11**]: Endoscopic Biopsy
History of Present Illness:
74 y/o female brought to [**Hospital3 7362**] by her co-workers for
lethargy; Patient was falling asleep at work and difficult to
arrouse; CT there showed a third ventricular tumor with
hydrocephalus.
Past Medical History:
Unknown
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
BP: 116/56 HR:70's R 12 O2Sats 97%
Gen: Grimicing, shaking head from side to side
HEENT: Pupils: R: 6mm and hippus 6mm to 4mm brisk EOMs: Exam
limited secondary to lethargy and poor mental status.
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Pt. oriented to self only, disoriented to place and year, has
significant difficulty staying awake for exam.
Cranial Nerves:
I: Not tested
II: Pupils as above
Motor: Normal bulk, weak hand grasps [**3-28**] bilaterally
Toes downgoing bilaterally
On Discharge pt is A&Ox2-3, MAE, follows commands. She is sl.
deconditioned in Upper extremities and has sl. quad weaknes on
the L however she is difficult to asses because although she
understand what questions are being asked she may not respond
approriately.
Pertinent Results:
Labs on Admission:
[**2132-1-2**] 07:45PM BLOOD WBC-13.5* RBC-4.28 Hgb-12.5 Hct-36.7
MCV-86 MCH-29.2 MCHC-34.0 RDW-13.2 Plt Ct-374
[**2132-1-2**] 07:45PM BLOOD Neuts-83.9* Lymphs-12.7* Monos-3.0
Eos-0.3 Baso-0.2
[**2132-1-2**] 07:45PM BLOOD PT-13.0 PTT-22.7 INR(PT)-1.1
[**2132-1-2**] 07:45PM BLOOD Glucose-106* UreaN-15 Creat-0.7 Na-138
K-4.1 Cl-102 HCO3-27 AnGap-13
[**2132-1-7**] 02:17AM BLOOD ALT-35 AST-55* AlkPhos-118* TotBili-0.1
[**2132-1-2**] 07:45PM BLOOD TSH-0.92
[**2132-1-6**] 11:05PM BLOOD Cortsol-14.2
Liver Function Test Trend:
[**2132-1-8**] 01:47AM BLOOD ALT-128* AST-203* AlkPhos-159*
TotBili-0.2
[**2132-1-9**] 03:07AM BLOOD ALT-159* AST-176* AlkPhos-146*
TotBili-0.2
[**2132-1-10**] 04:20AM BLOOD ALT-117* AST-71* AlkPhos-133* TotBili-0.1
[**2132-1-11**] 05:00AM BLOOD ALT-97* AST-53* AlkPhos-132* TotBili-0.2
[**2132-1-12**] 05:33AM BLOOD ALT-69* AST-23 LD(LDH)-172 AlkPhos-120*
TotBili-0.2
[**2132-1-13**] 09:16PM BLOOD ALT-46* AST-23 AlkPhos-96 TotBili-0.2
[**2132-1-14**] 06:40AM BLOOD ALT-45* AST-21 AlkPhos-104 TotBili-0.3
[**2132-1-15**] 05:14AM BLOOD ALT-35 AST-21 AlkPhos-89 TotBili-0.2
Labs on Discharge:
[**2132-1-15**] 05:14AM BLOOD WBC-7.7 RBC-3.39* Hgb-10.0* Hct-28.9*
MCV-85 MCH-29.5 MCHC-34.6 RDW-13.8 Plt Ct-495*
[**2132-1-15**] 05:14AM BLOOD PT-13.3 PTT-27.5 INR(PT)-1.1
[**2132-1-15**] 05:14AM BLOOD Glucose-94 UreaN-13 Creat-0.6 Na-139
K-4.1 Cl-103 HCO3-30 AnGap-10
[**2132-1-15**] 05:14AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.9
Imaging:
Head CT [**1-2**]:
IMPRESSION:
1. Interventricular mass in the left lateral ventricle appearing
to arise from the roof of the third ventricle causing
obstruction of the foramen of [**Last Name (un) 2044**] with subsequent
hydrocephalus. Diagnostic consideration include ependymoma or
intraventricular meningioma. If there is a history of tuberous
sclerosis, then a giant cell astrocytoma could be considered. A
choroid plexus papilloma may have a similar appearance, however,
unlikely given patient age.
CXR [**1-2**]:
IMPRESSION:
No acute intrathoracic process.
CSF Sample [**1-3**]:
Cerebrospinal fluid:
NEGATIVE FOR MALIGNANT CELLS.
ECG 12-lead [**1-3**]:
Sinus rhythm
Normal ECG
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 134 82 374/402 70 36 54
Head MRI [**1-3**]:
FINDINGS: The study is significantly limited due to motion
artifact,
rendering the T2 sequence nondiagnostic. Multiple attempts did
not
significantly improve motion artifact due to patient's inability
to hold
still.
Within the limitations of the study, there is a T1 hypointense
lobulated
intraventricular mass involving the left lateral ventricle and
measuring 1.8 x 1.4 cm. A ventriculostomy catheter is noted in
situ, frontal approach. The ventricles are asymmetric with left
ventricle being relatively dilated, this could result from mass
effect due to the intraventricular tumor. There are no other
obvious lesions, masses on pre- contrastr T1- weighted images.
Head MRA [**1-3**]:
MRA HEAD:
The study is somewhat limited due to motion artifacts. Within
these
limitations, the well visualized portions of the intracranial
internal carotid arteries, the anterior and the middle cerebral
and the distal vertebral and the basilar artery, appear to be
grossly patent, without focal flow-limiting stenosis or
occlusion. No aneurysm more than 3 mm within the resolution of
MR angiogram is noted on the well visualized portions of the
arteries.
On the axial T2-weighted images, there is increased signal in
the maxillary sinuses, and ethmoid air cells on both sides from
fluid and/or mucosal thickening along with retention cysts or
polyps in the maxillary sinus, the largest one in the left
maxillary sinus measuring approximately 2.5 x 1.7 cm.
CT of Chest/Abdomen/Pelvis [**1-5**]:
TECHNIQUE: MDCT axially acquired images were obtained from the
thoracic inlet to the symphysis after the uneventful intravenous
administration of 130 ml Optiray 350 contrast material.
Multiplanar reformatted images were obtained and reviewed.
CT CHEST WITH CONTRAST: Endotracheal tube and NG tube are in
standard
position. No axillary, mediastinal, or hilar adenopathy is
detected per CT
size criteria. Small lymph nodes are present within the
mediastinum. No
dissection flap is present within the thoracic aorta. There is
no pericardial effusion. Coronary artery calcifications are
present. Bibasilar atelectasis is noted within the lungs. Small
tree-in-[**Male First Name (un) 239**] opacities are present within the right lower lobe
with a 1.4 cm opacity (series 2: image 31). A subpleural nodular
density measuring 1 cm is noted in the lateral right upper lobe
CT ABDOMEN WITH CONTRAST: No masses are identified within the
liver. The
gallbladder, pancreas, spleen, and adrenal glands appear
unremarkable. No
free fluid or free air is present within the abdomen. Incidental
note is made of a retroaortic left renal vein. Calcified
atherosclerotic plaque is present within the abdominal aorta and
iliac branches without aneurysmal dilatation.
CT PELVIS WITH CONTRAST: A Foley catheter is noted within the
bladder lumen. The rectum, sigmoid colon, and unopacified loops
of small bowel appear unremarkable without evidence of
obstruction. No lymphadenopathy is detected.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
detected.
Moderate degenerative changes are present within the lower
lumbar spine with facet joint sclerosis.
CT w/3D rendering [**1-11**]:
FINDINGS: There have been no significant changes since the prior
study. Again identified is a mass arising within the frontal
[**Doctor Last Name 534**] of the left lateral ventricle. A ventriculostomy catheter
is in place. The mass is seen to be inhomogeneously hyperintense
on the post- contrast images currently available. Comparison
with prior studies indicates that this represents contrast
enhancement within the tumor. No other abnormalities are
detected.
The tumor volume measures 1.4 cc on the axial short TR images.
CONCLUSION: No change since the study of [**2132-1-4**]. Left frontal
[**Doctor Last Name 534**]
intraventricular tumor. This appears to arise from the choroid
plexus, and
thus choroid plexus-origin tumors such as meningioma or
papilloma appear to be the most likely diagnoses.
Head CT [**1-11**]:
FINDINGS: There is diffuse increased edema with blurring of the
sulci and
complete effacement of the basal cisterns, which is very
concerning for
impending transtentorial herniation. High-density fluid in the
left lateral ventricle (average 70 [**Doctor Last Name **]), which likely represents
contrast, although underlying hemorrhage cannot be excluded. A
left craniotomy with catheter tip terminating in the third
ventricle is noted. There is a 5-mm shift of normally midline
structures which is grossly unchanged since [**2132-1-11**]. There are
scattered opacifications in the paranasal sinuses, which are
unchanged since [**2132-1-4**]. The mastoid air cells are clear.
IMPRESSION:
1. There is complete effacement of the basal cisterns which is
concerning for impending transtentorial herniation. There is
diffuse brain edema, which has markedly increased since
[**2132-1-11**].
2. High-density fluid in the left lateral ventricle likely
represents
contrast, although evaluation for underlying hemorrhage is
limited.
ATTENDING NOTE: It is unclear how much of the effacement of
sulci and basal cistern obliteration is due to the presence of
contrast. However, complete obliteration of the quadrigeminal
cistern and deformity of the mid brain are suggestive of central
herniation.
Brief Hospital Course:
74F brought to [**Hospital3 7362**] by her co-workers for concerns of
lethargy. This patient was falling asleep at work and difficult
to arouse. The initial CT there showed a third ventricular
tumor with hydrocephalus. On initial presentation she was
febrile to 101.8 and ID was immediately involved pending her
neurological diagnosis over concern of potential infectious
process. CSF was sent which showed RBC 985 and WBC 720, Protein
59, and Glucose 46. He was started on broad spectrum
antibiotics (Vancomycin, Ampicillin, and Ceftriaxone) pending
isolation of sensitive organism. On [**1-5**] she underwent CT of
the torso to evaluate for alternate etiology of intracerebral
mass, which was negative to that effect. On [**1-8**] an additional
CSF sample was sent which showed no isolated WBC/leukocytes and
CSF had RBC of 900 and WBC of 0. On [**1-9**] her neurological
examination was much improved and she passed a speech and
swallow examination to allow leisure eating. She was also found
to have a bump in her LFT's but given the mild elevation, ID
opted to continue to monitor daily. On [**1-11**] she underwent 3rd
ventricular tumor biopsy and Rickham catheter placement. Post
operatively was initially nonverbal, and not following commands.
This was attributed to recovery from anesthesia in the setting
of a stable head CT. On [**1-13**] her examination was much improved
and following commands very briskly. As of [**1-14**] all cultures
have not returned any organism. At this point she had been on
antibiotics for 13 days, and ID felt very comfortable
discontinuing further treatment in the setting of no WBC in the
most recent CSF sampling. She was also evaluated by PT/OT and
determined appropriate for rehabilitation. She was discharged to
an appropriate facility on [**1-15**] with instructions to follow up
with Dr. [**First Name (STitle) **]
Medications on Admission:
unknown
Discharge Medications:
.
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): to continue until follow up appointment with Dr.
[**Last Name (STitle) **].
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
3rd Ventricular Mass
Hydrocephalus
Fevers
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-2**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
*Please call [**Telephone/Fax (1) 1669**] to schedule a follow up appointment
with Dr. [**First Name (STitle) **] in approximatley 4 weeks. You will be required to
have a MRI with contrast prior to you appointment.
Completed by:[**2132-1-15**]
ICD9 Codes: 2761, 2762, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4030
} | Medical Text: Admission Date: [**2134-4-12**] Discharge Date: [**2134-4-17**]
Date of Birth: [**2058-1-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4611**]
Chief Complaint:
acute renal failure, hyperkalemia
Major Surgical or Invasive Procedure:
CT guided Peritoneal Biopsy
History of Present Illness:
76yo M diagnosed w/metastatic melanoma w/peritoneal
carcinomatosis diagnosed 3 wks ago seen by [**Hospital1 18**] oncology for
the first time as outpatient today, found to be hypotensive to
SBP 76 and to have K 6.9. Pt has had abdominal fluid drained
q3-4 days (~2.5-3 L at a time), due for drainage tomorrow.
Reports some diffuse abdominal discomfort, which has been usual
when he is due for fluid drainage. Has had increase in
abdominal girth with discomfort and fatigue for several weeks,
in addition to mild nausea (pt reports no use of PRN meds) and
constipation. Mild SOB with abdominal distention. Pt reports
limiting PO intake recently [**3-4**] anorexia and fear it will end up
in his abdomen. Has noticed minimal urine output over the past
few days, "dark [**Location (un) 2452**]" in color. No fevers, chills, dysuria.
In the ED, initial VS: 97.8, 62, 87/65. K was 7.2. EKG showed
no peaked T waves. Received insulin/D50, calcium gluconate, and
kayexalate; also 2 L IVF. VS on transfer were 111/62, 69,
satting well on room air.
On arrival to the ICU, pt appears uncomfortable but is speaking
in full sentences. Pt vomited up the half-[**Location (un) 6002**] he ate
earlier today and had a large BM.
Per Hem/Onc note from today, pt needs to have a biopsy sample to
test for BRAF V600E mutation. If BRAF V600E positive, pt will
be candidate for vemurafenib (high response rates, acts
quickly). If BRAF wildtype, there will be no therapeutic
options.
Past Medical History:
Oncologic History (metastatic melanoma w/peritoneal
carcinomatosis):
[**2134-3-22**] CT abdomen and pelvis demonstrated a moderate-to-large
amount of abdominal ascites with extensive carcinomatosis and
hepatic metastasis potential measuring 1.3 cm.
[**2134-3-22**] CT scan abdomen and pelvis, diffuse peritoneal
thickening and nodularity consistent with carcinomatosis.
Moderate-to-large amount of abdominal and pelvic ascites. 1.3
cm right posterior segment liver lesion. Liver diffusely low
density consistent with fatty infiltration.
[**2134-3-23**] numerous calcified bilateral pleural plaques
bilaterally
indicating asbestos exposure, well-marginated fluid collection
in
the mediastinum in station 2R and 4R 2.6 cm in width.
Epicardial
node 1.1 cm.
[**2134-3-26**] CT-guided biopsy of the omental mass: positive for
poorly differentiated malignant cells compatible with metastatic
melanoma, positive for S100 and Melan-A, negative for CK7, CK20,
PSA, TTF-1 and CDX2.
[**2134-3-29**] PET scan, extensive soft tissue density along the
anterior peritoneum consistent with diffuse omental caking with
marked hypermetabolism, maximum SUV 9. Diffuse perisplenic and
perihepatic ascites, omental implants anterior to the liver,
relatively focal areas of hypermetabolism adjacent to the liver.
Posterior right lobe, likely focal liver met, SUV 10.5.
Essentially physiologic distribution elsewhere in chest, abdomen
and pelvis. Small amount of fluid in the pericardial recesses.
[**2134-3-30**] ultrasound-guided paracentesis, 3 liters of
blood-stained fluid.
[**2134-4-1**] PET scan, MRI brain, no findings for metastatic
disease, nonspecific white matter abnormalities consistent with
old microvascular infarcts.
Other Past Medical/Surgical History:
DM2
HTN
HL
CAD (last cardiac cath unknown date in [**State 1727**] [Dr. [**First Name (STitle) **]]:
nonobstructive block in left main trunk, normal EF)
CHF
Hypothyroidism
Restrictive lung disease
Asbestosis (exposure in [**2082**], worked at factory that made
asbestos pipe insulation)
Anemia
Obesity
BPH
Depression
GERD
Arthritis
Hearing loss
Cholelithiasis s/p cholecystectomy
Inguinal hernia s/p repair
Chronic low back pain s/p laminectomy
s/p thyroidectomy
s/p tonsillectomy
s/p femur fracture
Social History:
Lives with wife of 27 [**Name2 (NI) 1686**]. Has 6 children from a previous
marriage and three adopted children; 21 grandchildren and 14
great grandchildren. Retired, used to work in asbestos pipe
insulation factory.
- Tobacco: past smoker, stopped many [**Name2 (NI) 1686**] ago
- Alcohol: none
- Illicits: none
Family History:
No cancer.
Physical Exam:
ON ADMISSION:
Vitals: 96.9, 76, 98/57, 18, 94% on RA
General: Alert, oriented, breathing comfortably, no acute
distress
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear (wears
full upper denture, partial lower)
Neck: supple, JVP to angle of jaw
Lungs: Faint dry crackles at bases, no wheezes/rhonchi
CV: RRR, no murmurs, rubs, gallops
Abdomen: impressively distended, mildly tense, no rebound
tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities spontaneously
Pertinent Results:
ON ADMISSION:
[**2134-4-12**] 03:35PM UREA N-40* CREAT-1.8* SODIUM-135
POTASSIUM-6.9* CHLORIDE-101 TOTAL CO2-26 ANION GAP-15
[**2134-4-12**] 03:35PM ALBUMIN-2.8* CALCIUM-8.7 PHOSPHATE-4.5
[**2134-4-12**] 03:35PM WBC-9.2 RBC-3.49* HGB-10.3* HCT-31.5* MCV-90
MCH-29.4 MCHC-32.6 RDW-13.8
[**2134-4-12**] 03:35PM NEUTS-76.5* LYMPHS-15.6* MONOS-5.6 EOS-2.0
BASOS-0.3
[**2134-4-12**] 06:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-TR
[**2134-4-12**] 06:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.032
Brief Hospital Course:
#ARF/Hyperkalemia: Per Hem/Onc note, only other Cr "on file"
before admission was 1.2; 1.7-1.8 on admission. DDx for ARF
included compression of renal veins from ascites (abdominal
compartment syndrome), prerenal ARF (high spec gravity on UA)
[**3-4**] poor PO intake and/or third-spacing (due to malignancy
causing exudative ascites; hypoalbuminemia also decreasing
intravascular oncotic pressure), less likely ureteral/renal
obstruction from mets (would need to be bilateral to cause Cr
bump). UA not suggestive of primary glomerulonephritis. Pt had
K of 6.9-7.2 on admission without any EKG changes; he received
insulin/D50, calcium gluconate, and Kayexalate x2. Follow-up K
was 5.5. His potassium slowly rose on the floor reaching a
maximum of 5.5. He was given IVF bolus with Lasix and repeat
potassium was 5.0. He was discharged home on 20mg PO Lasix for
potassium control.
.
#Metastatic melanoma/Malignant ascites: Pt has been requiring
ascitic fluid drainage every 3-4 days likely [**3-4**] increased
vascular permeability and blockage of lymphatic drainage. No
clinical evidence of SBP and also labs were negative for
bacterial growth. His abdomen was drained twice during this
admission. Ascitic fluid labs (ANC 131 cells/uL; SAAG 0.9,
ascitic-fluid-to-serum LDH ratio >1, protein >2.5) consistent
with exudative ascites, non-infected. Ascitic fluid gram stain
and culture were negative. A CT guided biopsy of a peritoneal
tumor was performed by IR and sample was sent for BRAF V600E
testing to determine whether pt is a candidate for vemurafenib.
.
#Hypotension: Likely [**3-4**] decreased PO intake and extensive
third-spacing from malignancy, resolved after 2L IVF. Possible
contribution from increased abdominal pressure pushing on IVC
and decreasing preload. AM cortisol 24 ruled out adrenal
insufficiency. Remained normotensive during the rest of his
hospitalization. We held Lisinopril.
.
Chronic Issues:
#DM2: glipizide and metformin were held. Pt was placed Insulin
SS.
#HTN: lisinopril was held given ARF and hypotension.
#HL: home atorvastatin continued.
#CAD: home ASA, SL NTG PRN chest pain (pt has not used NTG in
several months) continued.
#Hypothyroidism: home levothyroxine continued.
#Depression: home bupropion, mirtazapine, divalproex continued.
#BPH: tamsulosin held given hypotension. Pt on finasteride
instead of dutasteride (not available) while inpatient.
.
#Transitional-
1. Pt was discharged on 20mg Lasix for potassium control
2. Repeat lytes to be checked as outpt, results will be faxed to
PCP
3. F/U BRAF mutation result
Medications on Admission:
glipizide 5 mg daily
metformin 1,000 mg [**Hospital1 **]
ASA 81 mg daily
atorvastatin 80 mg daily
lisinopril 40 mg daily
levothyroxine 175 mcg daily
divalproex (Depakote) 500 mg E.C. (delayed release) QHS (for
mood stabilization, per pt)
bupropion XR 150 mg daily
mirtazapine 60 mg QHS
dutasteride 0.5 mg daily
tamsulosin 0.4 XR [**Hospital1 **]
ferrous sulfate 325 mg [**Hospital1 **]
NTG 0.4 mg SL PRN chest pain
ondansetron 8 mg TID PRN nausea
oxycodone-acetaminophen (5mg-325mg) 1-2 tablets q3-4hrs PRN pain
prochlorperazine 10 mg q4hrs PRN nausea
multivitamin
omega 3 fatty acid supplement
Discharge Medications:
1. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
7. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
8. mirtazapine 30 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO at
bedtime.
10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
12. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
13. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours) as needed for nausea.
14. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
16. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
q3-4hrs as needed for pain.
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
androcoggin home care and hospice
Discharge Diagnosis:
Metastatic Melanoma with carcinomatosis
Acute Renal Failure
Hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with low blood
pressure, high potassium levels and kidney failure. We have
corrected these problems with IV fluids and medications and now
your potassium level is normal, your blood pressure has improved
and your kidneys are functioning back at your baseline. You
underwent a biopsy under CT guidance for furthing testing on
your tumor. Those tests are still pending and will be followed
up by your primary oncology team.
The following changes have been made to your medications:
STOP:
Lisinopril, Tamsulosin because both medicines can lower your
blood pressure
START:
Furosemide 20mg by mouth daily to decrease potassium levels
Your potassium level was mildly elevated the day you left. We
discussed this with you and your family. You demonstrated strong
wishes to go home. You will need to have your potassium level
checked tomorrow, [**2134-4-18**], to ensure it is not rising and is a
safe level.
Please discuss with Dr. [**Last Name (STitle) 91856**] how often you should have
fluid drained from your abdomen, to help with the discomfort.
Followup Instructions:
Please call to make a follow up appointment with in 2 weeks with
[**First Name8 (NamePattern2) 610**] [**Last Name (NamePattern1) **], MD. The office phone number is ([**Telephone/Fax (1) 14703**].
Please call your local oncologist, Dr. [**First Name4 (NamePattern1) 37893**] [**Last Name (NamePattern1) 91856**], to
schedule a follow-up appointment in ~ 1 week. You will also need
to discuss with her how frequently the abdomen needs to be
drained.
ICD9 Codes: 5849, 4589, 2767, 4019, 2724, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4031
} | Medical Text: Admission Date: [**2152-5-2**] Discharge Date: [**2152-5-8**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
weakness, epigastric discomfrot
Major Surgical or Invasive Procedure:
attempted L sided thoracentesis
History of Present Illness:
84 male with heavy EtOH consumption, hypothyroidism and dementia
was admitted to an OSH on [**2152-4-27**] with 2-3 days of generalized
weakness and epigastric discomfort. In their ED, he had melena
and hematocrit of 21.4. His was markedly hypovolemic with Cr of
1.8, BUN 88, SBP 95, HR:80. He never had gross bleeding but his
Hct failed to improve with transfusion. During his admission
there, he was transfused 12U PRBC and 4U FFP. He underwent an
EGD twice, both times revealing large duodenal ulcer with
overlying clot; intervention was not possible as the endoscopist
found it difficult to keep the scope in the duodenum. On
admission, [**4-27**], he was noted to be in NSR but ECG dated [**4-28**]
shows him in atrial fibrillation. On the AM of transfer, he was
noted to be mottled and cold, clammy with HR in the 150s, BPs
160/110, tachypnic and with sats in the 70s. There was concern
for volume overload due to multiple transfusions vs. aspiration
pneumonia. He was intubated and given propofol for sedation; his
BP dropped perhaps due to positive pressure ventilation vs.
propofol. He was given neosynephrine for hypotension. He spiked
a fever to 103.3. Tanish secretions were noted coming from ETT.
He was placed on Zosyn but when PCN allergy was detected, he was
changed to levofloxacin. An OG tube was placed with drainage of
400 cc of greenish-brown material. His left AC IV was noted to
be erythematous (?reaction to levaquin). He was given benadryl
and the levaquin was discontinued. There was a long discussion
with the patient's wife (his healthcare proxy) about his goal of
care. She "wanted to do everything possible to save his life."
His friends, who came to visit, however, stated that "Mr.
[**Name14 (STitle) 66617**] did not wish to have heroics done or any invasive
procedures." It was their impression that the patient's wife was
somewhat demented. The team decided to respect the wife's
statements as the patient's goals given that she is his proxy.
As his neo was being infused through a peripheral IV, a right IJ
was placed by the surgical service under sterile conditions. He
was transferred to the MICU on [**2152-5-2**] at [**Hospital1 18**] for management of
GI Bleed and shock.
.
In the [**Hospital1 18**] MICU, the right IJ was removed (based on the new
[**Hospital1 18**] line policy that requires all lines placed at outside
hospitals to be removed), and a left subclavian line was placed.
He was extubated as his oxygenation and ventilation were normal.
His neo was weaned off. GI was consulted to evaluate him. It was
their impression that since his Hct was stable and he was known
not to have varices that they would not perform another EGD
here. They recommended [**Hospital1 **] IV PPI and vitamin K to reverse his
Vitamin K deficiency (likely nutritional). The patient's WBC
count on admission was 21 with 14% bands. He was placed on
ceftriaxone, vanco and flagyl empirically. The bandemia rose to
24% on [**2152-5-3**]. He remained hemodynamically stable
post-extubation, afebrile with lactate of 1.6. Cortisol level of
20. All blood cultures were negative, with the exception of a
sputum culture from [**5-2**] which grew gram negative rods. A TTE was
performed on [**5-3**] given the patient's afib, low voltage and
transient hypotension. The LVEF was 55%, 1+MR/1+AR, LA was
dilated. Trivial effusion. His Hct remained stable for 24 hours
and was 28 on the day of transfer ([**5-5**]).
FLOOR COURSE [**5-5**] -> TODAY
Upon transfer, [**First Name5 (NamePattern1) 636**] [**Last Name (NamePattern1) 29286**] from social work was consulted
regarding confusion with code status. It was determined that the
patient's wife was stated that his wanted all measures because
she was "terrified that her husband would not come home to take
care of her." Patient also confirmed that he wished to remain
full code and have cardioversion and be reintubated if need
arose as he would always look forward to seeing his wife again.
Upon arrival to the floor patient has no specific complaints and
is very stoic. He is unclear of why he is in the hospital but he
does know he is in [**Hospital3 **]. Alert to place, month and name.
Remmembers family phone members, no long term memory deficits.
.
ROS: he DENIED any fever, chills, no n/v, no dysphagia, sore
throat, no chest discomfort, dyspnea, no cough, he even equates
his breathing close to his baseline, no ABD pain, no dysuria, no
myalgias/arthralgias
Past Medical History:
PMH:
Hernia Repair [**9-5**]
PNA [**2149**] (details unknown)
Hypothyroidism - for years
Dementia (details unknown)
Social History:
SH: Large EtOH use, 2 shots of bourbon per night with a few
glasses of wine. Never had EtOH W/D. No cigarette use - quit
[**2100**] after 15 year smoking x 4 ppd. Lives @ home w/wife who he
takes care of. He does the cooking in the house. Married x 55
years. No children but have a friend, [**Name (NI) **] [**Name (NI) 66618**], whom they
consider to be their son. [**Name (NI) **] is the next in line after his wife
per the durable power of attorney form.
- [**Last Name (un) **] [**Known lastname **] (their home #) [**Telephone/Fax (1) 66619**]
- [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 66618**] - [**Telephone/Fax (1) 66620**]
Family History:
FH: NC
Physical Exam:
PE:
Temp:98.4/98.3 HR: 70s-80s, BP:110-140s/70s, RR:16, O2:98% 2L NC
Gen: NAD. A/O x 2. speaks in full sentences, audible wheezes
HEENT: PEARLA. EOMI. anicteric. OP: no exudates, no LAD, no JVD,
no carotid bruits.
CV: Irreg, irreg, nl S1, S2, no extra HS
Pulm: Coarse sounds b/l with inspiratory/exp wheezes; I:E 1:2
ABD: + BS, SNT/ND, no masses, no rebound,
Ext: trace edema, + 1 full DP b/l
Neuro: Motor: Hip flexors [**4-5**] b/l. Moves all extremities.
Sensation GI to LT. CN II-XII GI. Followed commands
appropriately. No asterixis. Mild extended tremor.
Skin: Mutiple stage 1 decub on coccyx. Left SC line with minimal
oozing - no erythema or pus noted.
Pertinent Results:
ECG: Bordline low-voltage. Nl Axis. P-waves not clearly visible.
Most likely Afib with VR of 60. No ischemic ST/T changes.
.
Micro:
Blood cultures [**2152-5-2**] from OSH: NGT
Blood cultures x 4: NGT, last set [**5-3**] - NGTD
Urine culture: NGT [**5-2**]
Sputum culture ([**2152-5-2**]): Klebsiella:
.
RESPIRATORY CULTURE (Final [**2152-5-5**]):
RARE GROWTH OROPHARYNGEAL FLORA.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
CXR ([**2152-5-3**]:
Opacity in the left mid and lower lung could represent
pneumonia.
Small left pleural effusion persists. Left subclavian central
venous catheter at the junction of the brachiocephalic vein and
superior vena cava.
.
ECHO [**2152-5-3**]
1. The left atrium is markedly dilated. The left atrium is
elongated. The right atrium is moderately dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic
function is normal (LVEF>55%).
3.Right ventricular chamber size is normal. Right ventricular
systolic function is normal.
4.The aortic root is mildly dilated.
5.The aortic valve leaflets are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7.Moderate [2+] tricuspid regurgitation is seen.
8. There is mild pulmonary artery systolic hypertension.
9.There is a trivial/physiologic pericardial effusion.
.
CT [**5-6**]:
CT OF THE CHEST WITHOUT IV CONTRAST: The heart is top normal in
size with extensive coronary artery calcifications. There are
mural calcifications of the aortic arch. Multiple small lymph
nodes of the mediastinum are present in the paratracheal,
pretracheal and aorticopulmonary window regions measuring up to
12 mm maximum. There is no axillary lymphadenopathy. There is
extensive consolidation of the left lower lobe as well as
lingula and apex of the left upper lobe with associated air
bronchograms consistent with pneumonia. There are large
bilateral pleural effusions with associated bilateral lower lobe
posterobasal atelectasis. Consolidation and air bronchograms of
the posterior right lower lobe are likely due to atelectasis.
Fluid also tracks into the fissures and peripheral interlobular
septae bilaterally. There are wedge- shaped pleural-based
opacities of the right middle and right upper lobes which are
likely inflammatory, possibly spread of pneumonia, infarcts are
much less likely. There are multiple small bilateral apical
blebs. No pneumothorax. Limited evaluation of the abdomen
demonstrates an atrophic appearing pancreas but otherwise
unremarkable limited views of the liver, spleen, adrenal glands,
and kidneys.
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions
are identified. There are degenerative changes of the thoracic
spine including anterior osteophyte formation.
IMPRESSION:
1. Multifocal pneumonia of the left lower lobe, lingula, and
left upper lobe.
Two small wedge-shaped pleural-based opacities of the right
upper and middle lobes may represent spread of pneumonia.
2. Moderate bilateral layering pleural effusions with associated
posterobasal atelectasis of the lower lobes bilaterally.
3. Probable component of congestive heart failure given pleural
effusions, fissural fluid, and interstitial prominence.
4. Multiple small bilateral apical blebs.
.
CXR [**5-8**]:
CHEST: The left subclavian line has been removed. The asymmetric
interstitial [**Doctor Last Name 5926**] present on the prior chest x-ray is again
seen and allowing for differences in penetration it is not
significantly changed. Blunting of the left costophrenic angle
is present. No pneumothorax is identified on this side.
IMPRESSION: No pneumothorax. No significant change in chest
appearance.
.
Labs:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2152-5-8**] 05:26AM 9.7 3.15* 9.4* 28.8* 91 29.8 32.7 15.7*
268
[**2152-5-7**] 05:30AM 9.0 3.15* 9.5* 29.0* 92 30.2 32.8 15.5
236
[**2152-5-6**] 05:25AM 8.7 3.22* 9.9* 29.4* 91 30.7 33.6 15.5
213
[**2152-5-5**] 04:45PM 28.2*
[**2152-5-5**] 05:28AM 11.8* 3.07* 9.5* 27.8* 91 30.8 34.0 15.9*
190
[**2152-5-4**] 10:03PM 28.3*
[**2152-5-4**] 03:29AM 15.4* 3.13* 9.4* 28.1* 90 30.1 33.6 16.3*
163
[**2152-5-3**] 08:07PM 28.2*
[**2152-5-3**] 12:49PM 27.4*
[**2152-5-3**] 03:54AM 15.1* 3.10* 9.6* 27.6* 89 31.0 34.8 16.2*
157
[**2152-5-2**] 11:30PM 17.0* 3.04* 9.5* 27.3* 90 31.4 34.9 16.2*
161
[**2152-5-2**] 08:02PM 21.4* 3.31* 10.2* 29.0* 88 30.9 35.3*
16.3* 194
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2152-5-6**] 05:25AM 81.1* 9.6* 4.3 4.8* 0.2
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Ovalocy
[**2152-5-6**] 05:25AM 1+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2152-5-8**] 05:26AM 268
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2152-5-2**] 08:02PM 474*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2152-5-8**] 05:26AM 101 14 0.9 137 3.6 106 22 13
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2152-5-3**] 03:54AM 24 59* 49
OTHER ENZYMES & BILIRUBINS Lipase
[**2152-5-2**] 08:02PM 10
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2152-5-8**] 05:26AM 7.6* 3.0 1.6
PITUITARY TSH
[**2152-5-5**] 05:28AM 1.8
[**2152-5-2**] 08:02PM 2.3
OTHER ENDOCRINE Cortsol
[**2152-5-2**] 08:02PM 20.8*
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calHCO3 Base XS Intubat Vent
[**2152-5-2**] 09:30PM ART 37.4 50 115* 35 7.40 22 -1
INTUBATED SPONTANEOU
[**2152-5-2**] 08:00PM ART 35.2 188* 31* 7.44 22 -1
ASSIST/CON INTUBATED
Brief Hospital Course:
A/P: 85 male with chronic EtOH use transferred from OSH to MICU
with UGIB, shock, and respiratory failure, now much improved
being transferred to medical floor for further management
.
1) GI [**Name (NI) 66621**]
Pt w/EGD X 2 @ OSH showing likely source as duodenal ulcer. It
was felt that there was no indication for repeat intervention as
patient's Hct remained stable. His last transfusion was before
arrival to [**Hospital1 18**] on [**5-2**]. His discharge Hct is 28.8 and he
appears to have settled in that range. Patient is to continue
on Protonix [**Hospital1 **] in the meantime for his ulcer. He is to avoid
any anticoagulation for his afib. He may require a repeat EGD
if his Hct starts to drop or if he experiences hematemesis.
.
2) Hypotension/Shock - Now resolved. Most likely etiology was
sepsis given bandemia with pneumonia as seen with lung
infiltrates. +/- hypovolemia due to blood loss. Patient
subsequently with hypertension. Patient underwent cortisol stim
test and it was norm la, there was no evidence of adrenal
insufficiency. Patient's BCx remained negative while in house.
His UCx was unremarkable as well. Patient finished 7 day course
of IV CTX/Flagyl while in house. He is to complete 5 days more
of Levoquin/Flagyl PO.
.
3) Hypoxia -
Pneumonia -
Patient was found to have Klebsiella on sputum on [**5-2**] that was
pan-sensitive. A CT done on [**5-6**] showed multilobular PNA that
was treated with 7 days of IV CTX/Flagyl. Patient is to
complete another 5 day course of Levofloxacin at acute rehab.
Interventional Pulmonary service was consulted in house to
attempt a diagnostic/therapeutic thoracentesis. The effusion
was visualized with US and a tap was attempted. No fluid was
extracted. The procedure was without complication. Follow up
CXR was without pneumothorax. Patient remained afebrile since
after his d/c from ICU on [**5-5**] and his WBC remained normal.
.
? diastolic CHF - patient with E/E' <8, thus suggesting PCWP
<12, and EF > 55%, but patient does have 55%. Patient was
attempted at diuresis as his CT appeared to have b/l pleural
effusions and he was given prn IV lasix (20-40) prior to
discharge with good UO.
.
Patient is sating 95%+ on 2L at the time of discharge. However
desats quickly with little movement.
- He would certainly benefit from pulmonary reevaluation at the
end of his antibiotic course as his treatment course may need to
be extended for this complicated multilobar pneumonia. Continued
diuresis and rate control for chf will also likely be helpful.
.
3) Afib- Appears new and likely secondary to medical conditions.
Large atrial size suggests that it will most definitely be
recurrent. Patient tolerated low dose BB well and remained well
controlled with rate in 50-60s.
.
4) R shoulder pain - patient states the pain has been there for
last few years. CXR here showed no evidence of fracture, with
some suggestion of OA changes. The high riding humerus may
suggest an underlying chronic rotator cuff injury that should
perhaps be further evaluated by an orthopedic specialist -
nonacutely.
- tylenol/oxycodone for pain
.
5) EtOH use: no evidence of withdrawal despite use of [**2-4**]
drinks a day.
>>> d/c CIWA scale as patient with neglible scores, likely out
of window. Received versed (benzo) in MICU which may confound
the withdrawal period.
.
7) Hypothyroid:
>>> continue synthroid 50 mcg QD
>>> TSH - nl
.
8) FEN- clear diet- ADAT; pt continue on thin liquids and
regular consistency
solids.
.
9) CODE/COMM: d/w patient who appears competent and he wishes to
be FULL CODE. His wife confirmed his wishes. After speaking to
family's caretaker, [**Name (NI) **] [**Name (NI) 66622**] it appears that the situation
should be readressed where Mr. [**Known lastname **] to remain
intubated/trached for a long time .
Medications on Admission:
Meds: Pharmacy is [**Company 4916**] in [**Location (un) 5028**] - confirmed meds.
Synthroid 50 mcg QD - [**2152-4-6**] - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66439**] ([**Telephone/Fax (1) 66623**]
Nemenda 10 mg QD - [**2152-4-27**]
Aricept 10 mg [**Hospital1 **] - [**2152-3-2**]
Arthrotec 75 QD -
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
neb Inhalation Q6H (every 6 hours) as needed.
8. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Namenda 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<100, HR<60 .
11. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
1. PNEUMONIA - MULITIFOCAL
- L lower lobe, lingula, L upper lobe; R upper and middle lobes
2. Upper GI Bleed
3. Duodenal Ulcer
4. Atrial Fibrillation
5. Hypotension
6. Anemia - chronic
7. EtOH abuse
8. Hypothyroidism
Discharge Condition:
stable. Oxygenating well on RA. Tolerating PO. Requires
assistance with transfer from chair.
Discharge Instructions:
Please take all your medications as instructed. It is very
important for you to avoid further intake of alcohol. You will
also need to follow up with Dr. [**Last Name (STitle) 66439**] in [**1-3**] weeks after your
discharge from rehab. Please seek immediate medical attention
if you experience fevers/chills, increasing productive cough,
chest pain or lightheadeness. Do the same if you notice a
change in your stool color, or have blood in your cough, vomit
or stool.
Followup Instructions:
Please follow up with your primary care doctor in [**1-3**] weeks
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2152-5-8**]
ICD9 Codes: 0389, 2851, 4280, 5119, 5849, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4032
} | Medical Text: Admission Date: [**2118-2-5**] Discharge Date: [**2118-2-12**]
Date of Birth: [**2052-11-25**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Head trauma
Major Surgical or Invasive Procedure:
[**2118-2-5**]: Cerebral angiogram
[**2118-2-11**]: Cerebral angiogram
History of Present Illness:
This is a 65 year old white female who was sweeping snow at 1pm
the day of admission and had a sudden onset of headache. The
headache was associated with nausea. She saw her PCP [**Last Name (NamePattern4) **] 4pm and
was sent to [**Last Name (un) 1724**] for imaging. The CT/CTA
there revealed SAH and she was transferred to [**Hospital1 18**] for furhter
care.
Past Medical History:
high cholesterol, fatty liver, osteopenia, Hepatitis B, high
cholesterol, MVP
Social History:
She lives alone on [**Location (un) 1773**] of a three family home.
She is a retired "cashbook" technician, 20+ pack yr tobacco use,
uses alcohol daily. +wine/ one gin and tonic nightly
Family History:
unknown
Physical Exam:
ON ADMISSION:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 3 GCS 15
: T: af BP:118 / 63 HR:76 R 16 O2Sats96
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**4-18**] EOMis
Neck: Supple.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
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,4 to2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-21**] throughout. No pronator drift
Sensation: Intact to light touch
At discharge:
Awake, alert, oriented x3, MAE full motor, nonfocal exam
Pertinent Results:
[**2118-2-5**] 12:40AM WBC-12.1* RBC-4.99 HGB-14.7 HCT-44.6 MCV-89
MCH-29.5 MCHC-33.0 RDW-13.8
[**2118-2-5**] 12:40AM GLUCOSE-125* UREA N-7 CREAT-0.6 SODIUM-142
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-26 ANION GAP-15
[**2118-2-5**] 12:40AM PLT COUNT-210
[**2118-2-5**] 12:40AM PT-11.7 PTT-31.9 INR(PT)-1.1
[**2118-2-5**] 12:40AM CK-MB-2 cTropnT-<0.01
CXR [**2-5**] - normal
The heart and mediastinum are normal. The lung fields are clear.
Costophrenic angles are sharp.
IMPRESSION: Normal chest.
Cerebral Angiogram - [**2-5**]
[**Known firstname **] [**Known lastname 92419**] underwent cerebral angiography which failed to
reveal a source for the subarachnoid hemorrhage she sustained.
Specifically there was no evidence of dural AV fistula,
arteriovenous malformation or aneurysm.
Cerebral Angiogram [**2-11**]
Negative for any vascular anomaly.
Brief Hospital Course:
Ms. [**Known lastname 92419**] was evaluated in the ED after transfer from OSH
with report of head bleed. She was found to have
perimesencephalic blood on imaging with concern for aneurysm.
She was neurologically intact on exam. She was admitted to the
CVICU overnight and remained stable.
On [**2-5**] she had a cerebral angiogram which did not reveal
aneurysm. She remained stable and had no issues post-procedure.
She was transferred to SDU then floor in stable condition. She
had mild nuccal rigidity and headache but remained stable during
her course until [**2-9**]. She was made NPO after midnight for
repeat angiogram on [**2-11**]. Her angio was negative. Post-angio the
patient was intact.
She was discharged home on [**2-12**].
Medications on Admission:
milk thistle
vit B12
calcium
flax seed
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain / fever.
2. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*1*
3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-17**]
Tablets PO every six (6) hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*1*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Perimesencephalic subarachnoid hemorrhage
Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Medications:
?????? Continue all other medications you were taking before
surgery, unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for
any post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin
incision, rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs)
for 1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and
distance walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double
vision, half vision)
?????? Slurring of speech or difficulty finding correct words to
use
?????? Severe headache or worsening headache not controlled by
pain medication
?????? A sudden change in the ability to move or use your arm or
leg or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow
or green drainage from incisions
?????? Bleeding from groin puncture site
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with a Head CT w/o
contrast. Please call [**Telephone/Fax (1) 4296**] to make this appointment.
Completed by:[**2118-2-12**]
ICD9 Codes: 2720, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4033
} | Medical Text: Admission Date: [**2194-3-30**] Discharge Date: [**2194-3-31**]
Date of Birth: [**2163-12-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Hematemesis.
Major Surgical or Invasive Procedure:
EGD.
History of Present Illness:
30 y/o M with PMHx of Anxiety and substance abuse who presented
to [**Hospital3 4107**] c/o multiple episodes of hematemesis and
coffee-ground emesis that began 12hrs prior to presentation. He
reports decreased appetite on Sat with some Etoh consumption and
cocaine use. On sat evening, he had one episode of dark purple
emesis that he attributed to grapes that he had eaten early in
the day. Of note, he also reported dark black stool that began
recently and he has been taking [**11-30**] Aspirin up to three
times/day for headache this week. On Sunday morning, he had 12
episodes of emesis, both coffee grounds and later bright red
blood in his emesis. He had palpitations and was concerned
about the bleeding so he presented to [**Hospital3 **] ER for
evaluation. He was notably tachycardic in 130s, normotensive
and had one witnessed episode of bloody emesis. Hct was 45 and
pt was transfused 1u of prbcs for hct 45 prior to transfer to
[**Hospital1 18**] ER.
.
In the ED, initial vs were: T 97 HR 130 BP 119/63 RR 18 Sats 97%
RA. Gi was consulted and recommended starting a PPI & octreotide
gtt. Pt was c/o mild abdominal pain with mild transaminitis and
Tbili 1.7. He received 4L NS IVF and tylenol 1 gram po with
some HR response.
.
On arrival to the MICU, pt was comfortable lying in bed. He is
denying abd pain, nausea, lightheadedness, palpitations or chest
pain.
Past Medical History:
ETOH abuse with h/o withdrawal (?seizure)
Polysubstance abuse
Anxiety d/o with panic attacks
Social History:
Pt lives with his fiance and has a history of ETOH abuse,
including withdrawl and possible seizure. He reports remote
IVDU and occaisional cocaine abuse.
Family History:
Non-contributory.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admission:
[**2194-3-30**] 06:55PM WBC-20.6* RBC-4.44* HGB-13.8* HCT-40.1 MCV-90
MCH-31.1 MCHC-34.5 RDW-13.0
[**2194-3-30**] 06:55PM NEUTS-91.3* LYMPHS-6.6* MONOS-1.0* EOS-0.8
BASOS-0.3
[**2194-3-30**] 06:55PM PLT COUNT-236
[**2194-3-30**] 06:55PM PT-12.4 PTT-27.3 INR(PT)-1.0
[**2194-3-30**] 06:55PM GLUCOSE-121* UREA N-45* CREAT-0.7 SODIUM-138
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15
[**2194-3-30**] 06:55PM ALT(SGPT)-91* AST(SGOT)-60* CK(CPK)-47 ALK
PHOS-83 TOT BILI-1.9*
[**2194-3-30**] 06:55PM LIPASE-14
[**2194-3-30**] 06:55PM LIPASE-14
[**2194-3-30**] 06:55PM cTropnT-<0.01
[**2194-3-30**] 06:55PM CK-MB-NotDone
[**2194-3-30**] 06:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2194-3-30**] 08:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
[**2194-3-30**] 08:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2194-3-30**] 08:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2194-3-30**] 08:30PM URINE RBC-[**1-31**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0
[**2194-3-30**] 08:30PM URINE HYALINE-[**5-8**]*
.
EGD:
Coffee grounds in the whole stomach
No blood was seen in the duodenum.
Small hiatal hernia
Mucosa suggestive of Barrett's esophagus
Esophageal erythema
Brief Hospital Course:
30 y/o M with PMHx of polysubstance abuse who presents with GI
bleed and leukocytosis.
.
# GI bleed: Etiology was initially unclear unclear though likely
upper source. H/o NSAID use with ETOH suggest gastritis and
possibly esophageal tear with violent recurrent emesis on sunday
morning. Hct stable in 40s and now s/p 1u prbcs from [**Hospital1 **].
Variceal bleed less likely given stable hct and pt refusing
guiaic but reporting black stools at home. Tachycardia has
resolved with IVF, now normotensive and comfortable. He
underwent EGD, which showed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear. He received 1
RBC unit and did not bump HCT from 30 to 30. Patient was aware
that he was still bleeding and still decided to sign out AMA. He
was advided to come back if vomiting/melena recurred,
lightheadedness, or anything else that concenred him. He wa able
to repeat to us with his own words the risks of leaving AMA.
.
# Leukocytosis: Suspect stress response to upper GI bleed vs GI
illness causing vomiting/diarrhea. Low grade temp at [**Hospital1 **] but
denies any other infectious symptoms on ROS. Cultures were
pending at time of discharge.
.
# Polysubstance Abuse: Pt with long h/o substance abuse and
significant h/o ETOH but reports decreased use over last 6mths.
Pt was going to be seen by social work, but left AMA.
Medications on Admission:
Xanax prn
ASA prn
Discharge Medications:
None. Left AMA.
Discharge Disposition:
Home
Discharge Diagnosis:
Left AMA.
Discharge Condition:
Left AMA.
Discharge Instructions:
Left AMA.
Followup Instructions:
Left AMA.
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4034
} | Medical Text: Admission Date: [**2108-4-2**] Discharge Date: [**2108-4-6**]
Date of Birth: [**2054-5-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
3-vessel coronary artery disease c chest pain, N/V.
Major Surgical or Invasive Procedure:
1. CABG x4 (LIMA-LAD, SVG-OM, SVG-OM, SVG-diag)
History of Present Illness:
53M who presented to OSH c complaints of chest pain, N/V.
Cardiac enzymes were negative, but ETT showed apical and
anterolateral septal defects. He was then transferred to [**Hospital1 18**]
for cardiac cath, which showed 3-vessel disease. He was then
referred for CABG.
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:
Quit smoking 20 y ago.
Family History:
Noncontributory
Physical Exam:
Afebrile, VSS
NAD, alert
Neck: no JVD, no bruits
Heart: RRR, no murmurs
Lungs: CTAB
Abd: soft, NT, ND
Ext: no edema, palp pulses throughout
Brief Hospital Course:
53M who presented to OSH c complaints of chest pain, N/V.
Cardiac enzymes were negative, but ETT showed apical and
anterolateral septal defects. He was then transferred to [**Hospital1 18**]
for cardiac cath, which showed 3-vessel disease. He was then
referred for CABG.
He was taken to the OR [**2108-4-2**] for CABG x4 (LIMA-LAD, SVG-OM,
SVG-OM, SVG-diag). For more detailed account, please see op
note. Post-op he was taken to the CSRU, where he was extubated
on POD 0, PA catheter was removed on POD 1, and was transferred
to the floor on POD 1. Chest tubes were removed on POD 3. He
met PT requirements on POD 3. Discharged to home on POD 4.
Medications on Admission:
1. Meclezine 25 mg PO QID
2. Metformin 1000 mg PO QD
3. Glipizide 10 mg PO QD
4. Gabapentin 300 mg PO BID
5. Zetia 10 mg PO QD
6. Omeprazole 20 mg PO BID
7. HCTZ 25 mg PO QD
8. Diovan 160 mg PO QD
9. Diltiazem 300 mg PO QD
10. ASA 81 mg PO QD
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. 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*
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Meclizine HCl 12.5 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
Disp:*240 Tablet(s)* Refills:*2*
8. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. CAD
2. HTN
3. DM type 2
4. Hepatitis C
5. Hypercholesterolemia
6. Peptic ulcer disease
Discharge Condition:
Good
Discharge Instructions:
1. Resume medications as directed.
2. Call office or go to ER if fever/chills, drainage from
surgical sites, chest pain, shortness of breath.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2108-5-7**] 9:30
PCP, 2 weeks, call for appointment.
Dr. [**Last Name (STitle) **], 4 weeks, please call for appointment.
ICD9 Codes: 4111, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4035
} | Medical Text: Admission Date: [**2150-10-24**] Discharge Date: [**2150-11-2**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89yoM with 4v CABG (LIMA-LAD, SVG-D1, SVG-OM, SVG-AM in [**2132**]),
chronic systolic HF 35%, DM with neuropathy, h/o stroke s/p L
ICA stenting, CKD, peripheral and carotid artery disease
admitted to CCU for SOB and increasing angina.
.
Last night he had some angina (see below), dry cough, and SOB
last night for which he took his home inhalers and a SL NTG
without relief. He went to bed but did not sleep well overnight.
This am his relatives checked up on him and noted him to be SOB,
"felt like he was going to die" per family, so EMS was called
and he was brought to the hospital on a non-rebreather.
.
He triggered on arrival to ED and looked very poor, with RR 38
and 79%RA -> 98% on 10L NRB, otherwise temp 98.7 p92 147/79.
Comboneb was given, Bipap'ed with PS 10 for 2 hrs, then on NRB
and desat to 89% when put on 6L NC so put back on NRB. Was given
40 mg IV Lasix with 800 cc UOP through ED, and started on Nitro
gtt. Foley placed with some BRB in bag, thought due to BPH. 325
ASA given.
.
Vitals before transfer: 97.2 111/52 73 19 99%NRB.
.
On further interview with pt and family, he has not had
significant angina in the past year or two. However, for the
past [**2-15**] wks, he's had increasing frequency of left sided chest
discomfort (slight radiation to his L arm) up to 4 times in the
past week, associated with exertion (making the bed, or when he
was rushing to meet someone, or with anxiety) for which he took
[**2-15**] SL NTG's in the past week; he states he only seldomly used
them previously. Of note, PCP note in [**6-/2150**] indicates
occasional angina for which he would do nothing and that he'd
had it "off and on over the years."
.
Also endorsed increased BLE edema from not using his stockings;
he has not had an increase in sleeping with 3 pillows, and his
wt is down to 143 from 153 intentionally. Endorses med
compliance and low salt diet; however his family states possible
salty diet. No PND, palpitations, LOS, dizziness.
.
ROS: denies fevers, chills, nausea, vomiting, diaphoresis, LH,
palpitations, but some "sweatiness" last night. All other ROS
negative.
Past Medical History:
Past Medical History:
Chronic stable angina
Claudication
h/o stroke s/p left ICA stenting
sciatica
aortic insufficiency
anemia
CAD, s/p CABG
DM
hypercholesterolemia
Social History:
lives with wife who is suffering from [**Name (NI) 11964**]. Denies alcohol
or smoking history. family members present and active in life.
Retired worked as a book keeper and accountant.
Family History:
Family [**Name (NI) 41850**] Mother died of breast Ca [**99**]'s
Father expired from gastric CA [**99**]'s
Brother MI [**99**]'s
Physical Exam:
ON ADMISSION:
97.8 p75 114/54 23 98% on 15L NRB, lowered to 6L NC
and 88-95%
Elderly M in no distress appears very comfortable and speaking
full sentences. EOMI, +arcus senilis, no scleral icterus, mouth
very dry appearing, wearing NRB.
Bilateral external jugular pulses noted ~5cm above the sternal
notch at 30 deg, and internal pulsations noted around 13cm
Light wet sounding crackles heard at the bases, otherwise fair
air movement
RRR with early peaking crescendo systolic murmur overlying S1
best heard at BUSB's, clear S2.
Abd soft but lightly distended, NT, benign
Pitting edema noted to mid shin with hyperemic chronic venous
stasis changes
CN 2-12 grossly intact, no focal neuro deficits noted, moving
all extremities, mood affect appropriate, conversant, alert
Pertinent Results:
[**2150-10-24**] 10:19PM GLUCOSE-153* UREA N-36* CREAT-1.5* SODIUM-139
POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2150-10-24**] 10:19PM CK(CPK)-166
[**2150-10-24**] 10:19PM CK-MB-23* MB INDX-13.9* cTropnT-0.75*
[**2150-10-24**] 10:19PM WBC-10.2 RBC-3.13* HGB-10.0* HCT-27.6* MCV-88
MCH-32.0 MCHC-36.3* RDW-15.0
[**2150-10-24**] 03:04PM LACTATE-1.7
EKG [**10-24**]: Sinus rhythm. Prolonged A-V conduction is now
present. Non-specific ST-T wave changes are present. Compared to
the previous tracing findings are not significantly different.
ECHO [**10-26**]: The left atrium is moderately dilated. The estimated
right atrial pressure is 5-10 mmHg. Left ventricular wall
thicknesses and cavity size are normal. There is moderate to
severe regional left ventricular systolic dysfunction with
hypokinesis of the inferolateral and distal half of the anterior
septum and near akinesis of the distal third of the left
ventricle with an apical aneurysm and akinesis. The remaining
segments contract normally (LVEF = 25-30 %). The estimated
cardiac index is normal (>=2.5L/min/m2). No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**2-15**]+) mitral regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with extensive
regional systolic dysfunction and apical aneurysm c/w
multivessel CAD. Mild-moderate mitral regurgitation. Pulmonary
artery hypertension.
Compared with the prior study (images reviewed) of [**2149-5-12**],
the findings are similar.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2146**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
CXR [**10-26**]: As compared to the prior examination, moderate
pulmonary edema is similar in extent. No pneumothorax is seen. A
moderate right-sided pleural effusion and basilar atelectasis
are likely present. Cardiomegaly is unchanged. Median sternotomy
wires and markers and mediastinal clips from CABG are unchanged.
[**2150-11-2**] 07:00AM BLOOD WBC-11.6* RBC-2.97* Hgb-9.0* Hct-25.8*
MCV-87 MCH-30.5 MCHC-35.0 RDW-15.2 Plt Ct-258
[**2150-11-2**] 07:00AM BLOOD Plt Ct-258
[**2150-11-2**] 07:00AM BLOOD Glucose-160* UreaN-56* Creat-1.4* Na-133
K-5.1 Cl-97 HCO3-29 AnGap-12
[**2150-10-26**] 04:20AM BLOOD CK(CPK)-63
[**2150-10-26**] 04:20AM BLOOD CK-MB-4 cTropnT-0.95*
[**2150-11-2**] 07:00AM BLOOD Calcium-9.7 Phos-2.9 Mg-2.3
[**2150-10-25**] 05:42AM BLOOD Digoxin-0.8*
Brief Hospital Course:
ASSESSMENT AND PLAN
89yoM with 4v CABG (LIMA-LAD, SVG-D1, SVG-OM, SVG-AM in [**2132**]),
chronic systolic HF 35%, DM with neuropathy, h/o stroke s/p L
ICA stenting, CKD, peripheral and carotid artery disease
admitted to CCU with SOB, worsening angina, and pulmonary edema
consistent with acute on chronic systolic heart failure.
.
1. Acute on chronic systolic heart failure: Patient presented
with symptoms of worsening angina and SOB. Upon arrival to the
ED patient triggered with RR 38 and 79%RA was placed on a NRB.
Comboneb was given and patient put on BiPAP after diuresis his
condition improved and was placed on nitro drip for afterload
reduction. Inpatinet ECHO showed a EF 30% which was largely
unchanged from the prior. Patient was treated wih aggressive
diuresis and had an improvement in his symptoms. Exact cause of
the patient's decompensation was unclear, but likely related to
dietary non-compliance and under dosing of home diuretic.
Patient was continued on ramipril 5 mg and digoxin 250 mcg every
third day and metoprolol tartrate was changed to metoprolol
succinate and increased to 75 mg daily. Patient was
transitioned to PO diuretics and discharged at a weight of 139
pounds.
.
2. Coronary artery disease: S/p 4v CABG in [**2132**] with last
nuclear in [**2143**] showing multiple fixed perfusion defects.
Suspect his accelerating angina and current enzyme leak reflects
demand related ischemia from cardiac congestion, and not ACS
given resolution of dynamic EKG changes and chest pain with
decrease in rate, diuresis, and O2 therapy (and lack of
antithrombotic / antiplatelet administration). He currently
looks and feels very well without chest pain. Patient was
continued on home Simvastatin 5 daily, Plavix 75, ASA 81 daily.
.
3. Leukocytosis: Patient presented with a new leukocytosis and
no clear infectious source, patient did not receive antibiotics
and his white count normalized by the time of discharge.
.
4. CKD: Patient presented with a creatinine of 1.5 which was
near his baseline and creatinine at discharge was 1.4.
.
5. Diabetes: Non-insulin dependent, patient's Glyburide and
Acarbose were held while inpatient and restarted at the time of
discharge.
.
6. BPH: Patient had a traumatic foley placement in the setting
of his home BPH. Foley wad discontinued and patient continued
to pass dark clotted blood in his urine without evidence of
obstruction. Prior to discharge he had his bladder irrigated
with subsequent marked improvement in his hematuria. he was
discharged with a foley catheter that was draining clear yellow
urine. His terazosin was discontinued and tamsulosin and
finasteride was started. Plan is to have his foley catheter
discontinued on Wednesday [**11-4**] with a voiding trial, either at
his PCP appt or at the [**Hospital1 1501**]. He has a urology appt on [**2150-11-18**]
with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 767**] Urology.
.
7. Asthma: Continue home Spiriva handihaler, albuterol prn
.
TRANSITIONAL ISSUES:
1. Daily weights with adjustment of torsemide to maintain
current weight, please discuus with with Dr. [**Last Name (STitle) 911**], his outpt
cardiologist
2. Please check Chem-7 and CBC on Thursday [**11-5**]
3. D/C foley with voiding trial on [**2150-11-4**]
Medications on Admission:
lyburide 2.5mg po 2 tabs in the am and 1 at night
Imdur 120 mg daily
Toprol XL 50 mg [**Hospital1 **]
Mupirocin 2% ointment occasionally
SL NTG 0.4 mg prn
Ramipril 2.5 mg daily
Ranitidine 150 mg [**Hospital1 **]
Simvastatin 5 mg daily
Acarbose 25 mg tid before meals
Albuterol 90 mcg inhaler 2 puffs qid prn
Amlodipine 5 daiyl
Plavix 75 mg daily
Aranesp 100 mcg/mL q3 wks based on Hct
Digoxin 250 mcg every 3rd day
Lasix 40 mg every other day
Gabapentin 300 mg hs
Terazosin 4mg hs
Tiotropium bromide 18 mcg inhaled daily
Aspirin 81 mg daily
Cyanocobalamin 1000 mcg daily
Magnesium OH (milk of magnesium)
Discharge Medications:
1. ramipril 5 mg Capsule Sig: 0.5 Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
2. glyburide 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
one tablet at hs.
3. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
6. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. acarbose 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation four times a day as needed for
shortness of breath or wheezing.
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aranesp (polysorbate) 100 mcg/0.5 mL Syringe Sig: One (1)
syringe Injection every three weeks: according to blood count.
11. digoxin 250 mcg Tablet Sig: One (1) Tablet PO EVERY THIRD
DAY ().
12. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
14. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
Disp:*30 packet* Refills:*2*
18. Milk of Magnesia Oral
19. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
20. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
21. Outpatient Lab Work
Please check Chem-7 and CBC on Thursday [**11-5**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Acute on Chronic systolic congestive heart failure
Hematuria
Leukocytosis
Chronic Kidney Disease
Coronary Artery Disease
Diabetes Mellitus Type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You had an acute exacerbation of your congestive heart failure
and required intravenous diuretics to get rid of the extra
fluid. We think you were probably eating too much salt at home
and that led to the fluid buildup. You will need to weigh
yourself every morning, call Dr. [**Last Name (STitle) 911**] if weight goes up more
than 3 lbs in 1 day or 5 pounds in 3 days. Your weight at
discharge is 132 pounds. You also need to eat a low sodium diet
every day. Information about this diet and medications was
provided to you. When we took the catheter out of your bladder,
you had some bleeding in your urine. This was treated by a
bladder irrigation but did not improve so a large catheter was
placed by the urologists here and you will need to see a
urologist after you are discharged. We have arranged a urology
follow up appt after you go home for further testing.
.
We made the following changes to your medicines:
1. STOP taking Terazosin
2. Increase metoprolol to help your heart pump better and take
once a day.
3. Change furosemide to torsemide 20 mg daily to get rid of
extra fluid
4. Start Miralax to prevent constipation
5. STOP taking Imdur and amlodipine
6. STOP taking Terazosin
7. START taking finasteride and tamsulosin to shrink your
prostate and help you to urinate.
Followup Instructions:
.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2150-11-4**] at 8:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2150-11-4**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: TUESDAY [**2151-9-14**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2150-11-18**] at 3:30 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 4168, 3572, 4280, 412, 4241, 5859, 2859, 2720, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4036
} | Medical Text: Admission Date: [**2116-3-21**] Discharge Date: [**2116-4-1**]
Date of Birth: [**2042-10-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
DATE: [**2116-3-21**]
.
OUTPATIENT CARDIOLOGIST: [**Last Name (LF) **],[**First Name3 (LF) **]
.
Chief Complaint: SSCP
Major Surgical or Invasive Procedure:
Cardiac Cath
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
.
Patient is a 73 y/o F w/ a hx of CAD, s/p DES to OM1, [**7-29**], CHF
no echo on file, Paroxysmal Afib, not on anticoagulation, Severe
Pulmonary HTN on Viagra 20mg TID, hx of COPD home oxygen of 4L,
PVD, PUD, who presents on [**3-20**] to [**Hospital 487**] hospital with
Nausea/Vomiting, Abdominal Pain, Acute on Chronic renal failure
w/ Cr of 2.1, found to have BP in [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) **] of 196/99, dig
level of 4.6, w/ 5mg IV morphine, 2.5mg IV lopressor w/
improvement of BP to 140/60 and HR in 90s. Nausea and vomiting
had been going on for 3 days prior to presentation.
.
Patient's N/V and Renal failure were thought to be secondary to
dig toxicity. An abdominal non-contrast CT scan was done which
showed no acute finding, atrophic R kidney, and sigmoid
diverticula. They suspected patients findings were secondary to
dig toxicity.
.
At 4am on [**3-21**] patient developed Severe [**10-2**] SSCP w/ radiation
to her back the pain continued for 30minutes. Patient was noted
to have ECG findings significant for 3mm ST depression in leads
v3-v6, 2mm ST elevation in AVR, 2-3mm downward sloping ST
depressions in leads 2, 3, avf. Patient was noted to have BP
183/88 in L arm and 155/97 in L arm.
.
Patient was transferred to [**Hospital1 18**] for work up of a possible
aortic dissection.
Past Medical History:
Percutaneous coronary intervention, in [**7-29**] anatomy as follows:
.
COMMENTS:
1. Coronary angiography of this right dominant system
demonstrated
single vessel coronary artery disease. The LMCA had a 30% distal
stenosis. The LAD had diffuse irregularities. The LCx had 70%
disease
in the mid-OM1. There was a 70% ostial stenosis of a small AV
branch.
The RCA had diffuse irregularities.
2. Limited resting hemodynamics revealed normal systemic
arterial
hypertension (125/57 mm Hg).
3. Successful PTCA and stenting of a 70% OM1 lesion was
performed with
a 2.5x23 mm Cypher stent. Final angiography revealed 0% residual
stenosis, no dissection, and TIMI 3 flow. (See PTCA comments)
.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Successful PTCA and drug-eluting stenting of OM1
.
Other Past History:
PMHX:
PVD
CAD w/ known stents
Oxygen dependent w/ chronic dyspnea, 4L home o2.
Pulmonary HTN, came in on viagra
Afib
COPD
Past GI bleeds
CHF
Prior left carotid endarerectomy
Social History:
Patient quit smoking 10 years ago. She started at age 12 for a
greater than 50 pack year history. No etoh or illicit drugs.
Lives at home with husband. [**Name (NI) **] to complete daily ADLs.
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION:
VS - T 96.9, HR 90, BP L arm 170/90, R arm 160/80
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 14 cm at 90 degree
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. distant heart sounds. No thrills, lifts. No
S3 or S4.
Chest: Crackles bilaterally, [**12-25**] way up posteriorly.
Abd: Soft, NTND. No HSM or tenderness.
Ext: trace edema lower ext, weak dp/pt bilaterally
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Pertinent Results:
OSH LABS
sodium 138=>133
K 4.7
Cl 99
bicarb 26
BUN 27=>37
Cr1.5=>2.1
Glucose 180-210
.
BNP 3395
.
Normal LFTs
.
Lipase 37
.
Dig level 4.7
.
WBC 11.78=>10.5
Hct 32.6
Plt 248
.
CK 60
Trop 0.06=>0.10
.
ABG=7.47/35/72/
ADMISSION LABS:
.
[**2116-3-21**] 09:30AM BLOOD WBC-8.9 RBC-4.53 Hgb-12.5 Hct-37.8 MCV-83
MCH-27.6 MCHC-33.0 RDW-16.2* Plt Ct-251
[**2116-3-21**] 09:30AM BLOOD Neuts-91.6* Bands-0 Lymphs-6.5*
Monos-1.7* Eos-0.1 Baso-0.1
[**2116-3-21**] 09:30AM BLOOD PT-11.8 PTT-23.5 INR(PT)-1.0
[**2116-3-21**] 09:30AM BLOOD Glucose-197* UreaN-34* Creat-1.6* Na-130*
K-4.7 Cl-92* HCO3-25 AnGap-18
[**2116-3-21**] 09:30AM BLOOD ALT-18 AST-31 LD(LDH)-326* CK(CPK)-264*
AlkPhos-56 Amylase-65 TotBili-0.6
[**2116-3-21**] 09:30AM BLOOD Albumin-3.9 Calcium-8.8 Phos-4.2 Mg-1.5*
Cholest-156
[**2116-3-21**] 09:30AM BLOOD Triglyc-144 HDL-47 CHOL/HD-3.3 LDLcalc-80
[**2116-3-21**] 09:30AM BLOOD TSH-0.65
CARDIAC ENZYMES
.
[**2116-3-21**] 09:30AM BLOOD ALT-18 AST-31 LD(LDH)-326* CK(CPK)-264*
AlkPhos-56 Amylase-65 TotBili-0.6
[**2116-3-21**] 02:40PM BLOOD CK(CPK)-837*
[**2116-3-22**] 12:20AM BLOOD CK(CPK)-244*
[**2116-3-22**] 06:00AM BLOOD CK(CPK)-606*
[**2116-3-23**] 05:15AM BLOOD CK(CPK)-PND
[**2116-3-21**] 09:30AM BLOOD CK-MB-26* MB Indx-9.8* cTropnT-0.21*
[**2116-3-21**] 02:40PM BLOOD CK-MB-88* MB Indx-10.5* cTropnT-2.04*
[**2116-3-22**] 12:20AM BLOOD CK-MB-88* MB Indx-36.1* cTropnT-3.95*
[**2116-3-22**] 06:00AM BLOOD CK-MB-65* MB Indx-10.7* cTropnT-3.54*
Digoxin levels
.
[**2116-3-21**] 09:30AM BLOOD Digoxin-5.0*
[**2116-3-22**] 06:00AM BLOOD Digoxin-4.5*
[**2116-3-23**] 05:15AM BLOOD Digoxin-3.2*
[**3-21**] TTE
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with focal basal inferior/inferolateral hypokinesis.
The remaining segments contract normally (LVEF = 50%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity
imaging are consistent with Grade I (mild) LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. There are focal calcifications in the aortic arch
and in the descending thoracic aorta. No dissection flap seen in
the aortic arch. The aortic valve leaflets (?number) are
moderately thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
IMPRESSION: Symmetric left ventricular hypertrophy with mild
regional systolic dysfunction, c/w CAD. Calcific aortic valve
disease with minimal stenosis and mild regurgitation. Diastolic
LV dysfunction with elevated filling pressures. Moderate
pulmonary hypertension.
.
Findings discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] at 1305 hours on the
day of the study.
[**3-21**] CXR
CHEST (PA & LAT)
.
Reason: mediastinal widening.
.
INDICATION: Possible aortic dissection. Evaluate for mediastinal
widening.
.
Mediastinal width is normal. The aorta is tortuous and
calcified. The heart is mildly enlarged, and there is slight
upper zone vascular redistribution, accompanied by vascular
indistinctness and a bilateral interstitial pattern affecting
the right lung to a greater degree than the left. Additionally,
there are subtle patchy areas of increased opacification in the
right mid and both lower lung regions. No pleural effusions or
acute skeletal abnormalities are identified.
.
IMPRESSION:
.
1. Diffusely tortuous and calcified thoracic aorta, but no
direct radiographic signs to suggest aortic dissection. Because
chest radiographs are not very sensitive for detecting
dissection, an MRA of the aorta could be considered given
clinical concern for avoiding iodinated contrast.
.
2. Cardiomegaly and asymmetrical parenchymal opacities that are
likely due to asymmetrical edema from CHF. Followup radiographs
after diuresis would be helpful to confirm resolution and to
exclude a more chronic interstitial abnormality.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2116-3-27**] 1:44 PM
.
CT CHEST POST-ADMINISTRATION OF INTRAVENOUS CONTRAST:
.
There are extensive increased interstitial markings throughout
both lungs. The appearances are suggestive of diffuse pulmonary
fibrosis. There are scattered pulmonary nodules within the
background interstitial change with the largest measuring 9 x 8
mm in the left lower lobe. There are several tiny mediastinal
lymph nodes with the largest measuring 17 x 10 mm. The pulmonary
arteries are enlarged. There is no definite pulmonary embolism.
There is coronary artery atherosclerosis present. There is
extensive calcified and noncalcified plaque in the aorta. There
is no pericardial or pleural effusion.
.
The liver and spleen appear unremarkable.
.
MUSCULOSKELETAL: There is a wedge compression through the
superior end plate of one of the mid-thoracic vertebral bodies.
There are no worrisome bone lesions.
.
CONCLUSION:
.
1. Extensive interstitial changes in the lungs are consistent
with diffuse fibrosis. There are several scattered pulmonary
nodules and enlarged mediastinal lymph nodes. A PET CT is
advised to rule out an underlying malignancy.
.
2. Enlarged pulmonary arteries suggestive of pulmonary arterial
hypertension. Coronary and aortic atherosclerosis is present.
.
The findings were added to the critical results communication
dashboard.
Cardiac cath [**2116-3-24**]: R dominant.
LMCA 40-50% with distal taper
LAD: modest diffuse calcification, no critical lesion
LCX; previous stent widely patent
RCA: dominant vessel with origin dampening and 70% with
mid-segment 60% hazy lesion.
Intervention: Cyper stent proximal RCA 70% lesions, POBA to
midsegment lesion.
[**2116-3-24**] CT ABD/PELVIS:
1. No evidence of intraperitoneal or retroperitoneal hematoma.
2. Retention of contrast within the renal cortices bilaterally.
Correlation with the time of previous administration of
contrast is recommended as ATN cannot be excluded. Segmental
lack of enhancement of thinned areas of renal cortex bilaterally
likely relates to chronic scarring.
3. Cardiomegaly, coronary artery calcifications and pulmonary
edema. Small bilateral pleural effusions.
4. Sigmoid diverticulosis, without evidence of diverticulitis.
TTE [**2116-3-24**]
There is mild symmetric left ventricular hypertrophy. There is
mild regional left ventricular systolic dysfunction with
inferior hypokinesis. There is no ventricular septal defect.
There is mild global RV free wall hypokinesis. The aortic valve
leaflets are moderately thickened. The study is inadequate to
exclude significant aortic valve stenosis. Mild to moderate
([**12-25**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mitral regurgitation is present but cannot
be quantified. There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2116-3-21**], RV
systolic function is less vigorous.
Brief Hospital Course:
Mrs. [**Known lastname 3012**] is a 73 y/o F w/ hx of COPD, home o2 of 4L,
Paroxysmal Afib in NSR, not on anti-coagulation, moderate pulm
HTN, CAD s/p DES to OM1, CHF w/ EF of 50% who presents to OSH w/
nausea, vomiting, digoxin toxicity, Acute on Chronic renal
failure who was then transferred to [**Hospital1 18**] for [**10-2**] SSCP. SSCP
lasted for 30 min radiating to the back, initial ? of aortic
disection at OSH. Patient arrived at [**Hospital1 18**], CTA not done because
of renal failure. No enlarged medistinum on CXR. TTE did not
show any AI. Discussed checking for Aortic disection on TEE, but
felt to be high risk if patient was ischemic, which we felt more
likely the case. Patient ruled in for an NSTEMI trop peak 3.95.
Kept on heparin for the first 48 hours as TIMI was 6. Viagra was
held, so that nitrates could be given.
.
On 3rd day, patient was taken to cardiac cath where successful
stenting of the ostial RCA was completed. PTCA of the mid RCA
also done, but unable to deploy stent. Post-cath one hour after
angioseal removal patient became hypotensive BP 60/40 and
hypoxic 77% on 4L. Patient mentating through out time period. A
code was called. Patient received fluids and BP came up to mid
90s. Patient was transferred to CCU for further monitoring.
Noted to have stable hct. No RP bleed on CT, no groin hematoma,
or other vascular access issue. Bedside TTE was done and there
was no signs of tamponade, but new RV dysfunction was noted.
Thought to be due to long procedure involving RCA where there
were time periods of diminished coronary flow. Patients anti-bp
meds, diltiazem, BB, hydralazine and nitrates were held. Pt
received 2.5 L of fluid in CCU. SBP in mid 80s then 90s. Called
out to the general cardiology wards. On that time on a much
reduced dose of lopressor. Patient was still relatively
hypotensive SBP in 90s on only one [**Doctor Last Name 360**], BP had been in 160s,
before on 4 bp agents. Concern that their might have been RV
infarct. BP meds held for this reason.
.
In the evening on [**3-26**] patient had a large amount of epistaxis,
followed by elevation in blood pressure to 200 mmHg and went
into atrial fibrillation with rapid ventricular response. She
also became acutely short of breath. RVR was controlled with
metoprolol. It was felt that shortness of breath was due to
hypertension causing elevated filling pressures and pulmonary
edema. Chest xray did not show significant pulmonary edema, but
this would not necessarily be expected during the acute event as
some time is required for transudate to develop. She was taken
to CCU where BP was controlled and patient was diuresed.
.
Patient came out to the general cardiology floor the following
evening, and then the next morning triggered for respiratory
distress and hypoxia 77% on 4L. She was placed on NRB, felt to
be fluid overloaded. Question of PNA on CXR pt received one day
of antibiotics, but on further pulm consultation not thought to
be pna and abx stopped. She had been maintained on IV heparin,
but still sub-therapeutic at times. Pt still had impaired renal
function w/ cr 1.4, but felt it necessary to r/o PE w/ CTA. No
pulmonary embolism on CTA. CT also showed multiple pulmonary
nodules, enlarged mediastinal lymphnodes and interstitial
markings consistent with fibrosis. The pulmonary team was
consulted for management of pulmonary issues and recommended
diuresis intially and the addition of CCB. Pt was diuresed w/
PRN IV lasix, but renal function worsened in the setting of
diuresis and dye load and becaome hypoinatremic, with rising
BUN. Over 3 days Cr 1.4=>2.3. Diuresis was stopped and renal fn
normalized. Patients BP, Resp, HR issues stabilized and she was
transferred to rehab.
.
Problems:
.
#Hypoxia: Problem at baseline at the time of d/c to rehab with
O2 sat >93% on 4L. Multifactorial due to COPD, moderate
pulmonary hypertension, question of underlying pulmonary
fibrosis based on CT scan. [**Month (only) 116**] also have had an element of fluid
overload after the MI as she appears to have improved somewhat
with diuresis but definitely dry on discharge with preserved EF
and no need for further diuresis. CCB started for HTN as well as
for pulmonary hypertension. Viagra held given the hypotension
and MI but should be considered in f/u with her primary
pulmonologist although if she takes this will not be able to
take nitrates if has chest pain.
.
#COPD: Patient not felt to be in flare. Continued on home dose
of 10mg prednisone. Received ipratropium nebs and advair.
.
#NSTEMI: Patient ruled in for nstemi, trop max 3.95, DES to RCA
and PTCA of mid-rca. Patient continued on aspirin, plavix, bb,
atorvastatin 40mg.
.
#HTN: Hypotension and hypertension as in above narrative.
Patient BP regimen was modified to include a BB for post-MI
benefit and rate control as well as a CCB for pulm hypertension
and rate control.
.
#Acute on Chronic Diastolic CHF: Preserved EF >55%. BB and CCB
as above.
.
#Paroxsysmal Atrial Fibrillation: Patient was in NSR on
admission, discharge and most of hospitalization. During period
of BB withdrawal patient flipped into afib w/ RVR. Patient later
converted on her own. Patient was kept on heparin and bridged
over to coumadin and rate controlled with CCB and BB. ON this
regiment whe was maintained in NSR for most of the time and well
rate controlled.
.
#. Elevated Digoxin: Patient was noted to have elevated digoxin.
All dig was held while pt at [**Hospital1 18**]. Dig level of 5.0=>3.2,
trending down.
.
#. Acute on Chronic renal failure: On admission Cr 1.6 reported
to be 2.1 at OSH, patient received dye load from cath and CTA on
[**3-24**] and [**3-27**] respectively, and was overdiuresed causing renal
failure with Cr 1.4=>2.3 in matter of 3 days. At this point
diuretics were held with creatinine improving and at the time of
discharge ot was 2.0. Pls check in the next few days to make
sure this continues to improve.
.
#Pulmonary HTN: Held home viagra, so that nitrates could be
given instead w/ out risking synergy leading to hypotension.
.
#GERD: Cont Pantoprazole while inpatient
-episode of nausea and heart burn after eating yesterday [**3-23**]
.
#Full code
.
#Patient was evaluated by physical therapy who thought that
rehab was appropriate.
#Pt needs pulmonary, cardiac and PCP f/u within 2 weeks
Medications on Admission:
CURRENT MEDICATIONS:
MEDICATIONS
Advair 250/50 1puff [**Hospital1 **]
Spiriva 1mg daily
Nexium 40mg daily
Nitro-[**Hospital1 **] 6.5mg TID
Lipitor 40mg qhs
Lasix 20mg PO prn
Lopressor 25mg PO BID
ASA EC 325mg daily
[**Last Name (un) **]-dur 200mg PO BID
Cardizem 30mg PO TID
Prednisone 10mg daily
Plavix 75mg daily
Citracal unknown daily
Potassium 10mg daily
viagra 20mg TID
Cozaar ? PO daily
.
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary Diagnosis:
NSTEMI
Elevated digoxin
Acute on Chronic Renal Failure
COPD
Pulmonary Artertial Hypertension
Diastolic Heart failure
Paroxysmal Atrial Fibrillation
.
Secondary Diagnosis
GERD
Hypertension
Discharge Condition:
Stable, 98% on 4L
Discharge Instructions:
Mrs. [**Known lastname 3012**] you were transferred to [**Hospital1 18**] out of concern for your
chest pain. You were found to have had a Non-ST elevation
myocardial infarction or heart attack. You were also noted to
have an abnormal elevation in your digoxin and worsening kidney
function.
.
Please keep all of your follow up appointment.
.
Please take all of your medications as prescribed.
.
We have given you sublingual nitroglycerin to take in the case
that you have another episode of chest pain. If you have chest
pain place one pill under your tongue every 5 minutes (ONLY IF
YOU HAVE NOT TAKEN ANY VIAGRA), until you have done this 3
times. If you have to do this please call 911.
.
Please call 911 or go to the Emergency Department if you develop
chest pain, worsening shortness of breath, or any other
worsening of your overall condition.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) **] Jr,Ph#[**Telephone/Fax (1) 69287**], in the next two weeks.
.
Please follow up with your Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] in
the next 2 weeks. [**Street Address(2) 26336**], [**Location (un) 1468**], [**Numeric Identifier 11562**] Phone:
([**Telephone/Fax (1) 5687**]
.
Please also schedule an appointment with your pulmonologist to
be seen within 2 weeks. [**First Name9 (NamePattern2) 69288**] [**Location (un) 20473**] [**Telephone/Fax (1) 69289**].
.
Please draw creatinine in the next couple of days and early next
week to make sure creatinine continues to improve.
ICD9 Codes: 5849, 4280, 4168, 5859, 4439, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4037
} | Medical Text: Admission Date: [**2178-7-22**] Discharge Date: [**2178-7-23**]
Service: NMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
sudden onset left-sided weakness tonight at 6 pm
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 yo RH woman with history of dementia, HTN, upper GI bleed
who presents from her nursing home after being found with left
sided weakness and drooling from the left side of her mouth. She
lives at [**Hospital 100**] Rehab at baseline due to memory problems and the
inability to take care of herself. She was in her USOH until
about 6 pm tonight when she complained of right sided headache
and was noted to have left sided weakness. Her VS at [**Hospital 100**]
REhab
were pulse 72, BP 160/90. She was alert and answering questions.
She was transferred to [**Hospital1 18**] for evaluation. Here she does not
complain of left sided weakness or sensory loss. She currently
denies headache, change in vision. She is most worried about
leaking urine down her left leg.
Past Medical History:
Hypertension
upper GI bleed, Gastric and duodenal ulcers [**2177**]
left hip fracture, s/p ORIF [**2177**]
glaucoma
dementia - she used to live alone until about a year ago, but
her
daughter was worried about her because she was forgetting to
take her meds, her apartment was a mess, and her memory was
poor. At [**Hospital **] Rehab, she can reportedly eat, walk and toilet
independently, but need constant assistance with dress and
hygiene and has "moderately impaired mentation."
History of incontinence, indwelling foley, now removed
Social History:
SHx: Code Status: DNR/DNI - signed paperwork by her daughter the
health care proxy, in the chart, no expiration date. Lives at
[**Hospital 100**] Rehab, used to live in [**Location (un) 15158**] for years. No etoh or
tobacco.
Family History:
not obtained
Physical Exam:
PE: T 99.3, 173/93, 71, 16, 99% 2 liters
GEN: awake and alert in NAD, half naked and disheveled
NC/AT, MMM, o/p clear, neck supple, no carotid bruits,
lungs clear, heart regular rate and rhythm, abdomen
benign, extremities without edema, no skin lesions
NEURO EXAM: oriented to person, hospital and "[**Location (un) 15158**]" does not
know year or month, but knows it is summer, when told it is
[**Month (only) **],
she says "It must be late [**Month (only) **] if it is summer." DOWB intact and
perserverative (she does it twice), mildly inattentive but able
to cooperate with exam, follows simple commands with
reinforcement and then perseverates on the task, language fluent
with normal naming to low frequency objects including
"stethoscope, lapel, knuckles", repetition intact, speech mildly
dysarthric, no left/right confusion, mildly inattentive to the
left side, but able to point to her left face/arm and leg.
Positive extinction to DSS on left face/arm and leg.
CN: P4/4-2/2RRL, EOMF, decreased blink to threat on left, but
able to count fingers in all four quadrants with slight tendency
to ignore the fingers in her left visual field to simultaneous
stimulation, facial sensation decreased to light touch on left,
mild left facial droop, palate moves symmetrically, shrug
[**5-27**], tongue midline with normal movements
MOTOR: left pronator drift, [**4-27**] left deltoid, triceps, finger
extensors. Full strength on right. Left leg with 4/5 IP,
hamstrings. Bilateral TE weakness and atrophy of small muscles
of
feet and hands, no adventious movements, paratonias bilaterally
SENSATION: extinction to DSS on left, but able to feel light
touch, light touch decreased on left compared to right
DTR: 2+ and symmetric, absent ankle jerks, upgoing toe on left
COORDINATION: Finger nose finger without dysmetria on right,
some
difficulty finding my finger on the left, but minimal dysmetria,
[**Doctor First Name **] quite slow on left compared to right
GAIT: deferred
Pertinent Results:
[**2178-7-21**]:
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is an intraparenchymal hemorrhage centered in
the right thalamus measuring approximately 2.4 x 1.7 cm in its
largest dimension. There is no significant shift of normally
midline structures, mass effect or hydrocephalus. There is mild
prominence of the ventricles and sulci consistent with
age-related involutional change. There is diffuse
periventricular white matter hypodensities, extending into the
subcortical [**Doctor Last Name 352**] matter, consistent with small vessel ischemic
change. The osseous structures are remarkable for a lens-shaped
calcific density measuring 4.1 x 1.1 cm along the outer table of
the left temporal bone with a benign appearance, perhaps an
osteoma. The visualized paranasal sinuses are unremarkable.
IMPRESSION:
1) Right thalamic intraparenchymal hemorrhage.
2) Chronic small vessel ischemic change.
[**2178-7-22**]:
CT HEAD WITHOUT CONTRAST:
TECHNIQUE: Axial noncontrast CT scans of the brain were
obtained.
Comparison is made to previous films from [**2178-7-21**].
FINDINGS: There is no change in the size or extent of the right
thalamic hemorrhage, compared to the previous study. No other
changes are apparent within the brain.
IMPRESSION: Stable appearance of the right thalamic hemorrhage
and brain, compared to the previous day's exam.
[**2178-7-21**] 08:13PM PT-12.0 PTT-25.3 INR(PT)-1.0
[**2178-7-21**] 08:13PM PLT COUNT-238
[**2178-7-21**] 08:13PM NEUTS-71.3* LYMPHS-19.8 MONOS-7.1 EOS-1.5
BASOS-0.3
[**2178-7-21**] 08:13PM WBC-13.3* RBC-4.35 HGB-13.0 HCT-39.2 MCV-90
MCH-30.0 MCHC-33.2 RDW-13.5
[**2178-7-21**] 08:13PM GLUCOSE-97 UREA N-28* CREAT-1.2* SODIUM-139
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2178-7-22**] 06:15AM HDL CHOL-44 CHOL/HDL-3.2
[**2178-7-22**] 06:15AM %HbA1c-5.7
[**2178-7-22**] 06:15AM CALCIUM-9.2 PHOSPHATE-3.3 MAGNESIUM-1.9
CHOLEST-139
[**2178-7-22**] 06:15AM cTropnT-<0.01
[**2178-7-22**] 04:45PM URINE RBC-0 WBC-0 BACTERIA-MANY YEAST-NONE
EPI-0
[**2178-7-22**] 04:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2178-7-22**] 04:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2178-7-22**] 07:07PM TYPE-ART TEMP-36.7 RATES-/16 O2 FLOW-2.5
PO2-77* PCO2-43 PH-7.46* TOTAL CO2-32* BASE XS-5 INTUBATED-NOT
INTUBA
CXR [**7-22**]: FINDINGS: AP portable view of the chest. The patient
appears markedly rotated. The heart and mediastinal contours are
suboptimally evaluated secondary to rotation. There is increased
opacity in the left upper lobe, which may be an artifact of
patient rotation, but may represent aspiration or pneumonia.
There is no pleural effusion. The bones are demineralized. There
is a healed fracture in the right humeral neck.
IMPRESSION: Limited study. Possible aspiration or pneumonia in
the left upper lobe.
EKG:Sinus rhythm. Modest non-specific low amplitude
inferolateral T wave changes.
No previous tracing available for comparison
Brief Hospital Course:
IMPRESSION/PLAN:
86 yo woman with sudden onset headache and mild left
hemiparesis,
hemisensory loss at 6 pm on day of admission. On exam she has
mild left sided
weakness, left sided sensory loss, extinction on left, decreased
attention to left space, and possible field cut on left. She is
otherwise alert and talkative with intact language except mild
dysarthria. She perserverates and is not oriented to place or
year. She has a low grade fever and mildly elevated wbc count
with CXR c/w aspiration pneumonia. Head imaging shows a right
basal ganglia bleed.
Neuro issues:
Intracranial hemorrhage likely related to high blood pressure:
she was placed on a
nipride drip for her blood pressure to keep SBP<140. She was
weaned off the nipride drip and transitioned to a PO regimen of
metoprolol and did well. As an outpatient she is on amlodipine
for BP control. We will defer to her PCP [**Last Name (NamePattern4) **]: BP control with
amlodipine vs. metoprolol. She was evaluated by
neurosurgery recommended no interventions. Repeat head CT
showed no change in size of hemorrhage. She is DNR/DNI and
the order is signed in the chart from [**Hospital 100**] Rehab by her HCP.
Admitted to the ICU and discharged from the ICU back to [**Hospital **]
rehab. Will benefit from PT services at [**Hospital **] rehab. At time
of discharge, patient was able to eat soft foods and thickened
liquids without difficulty. Able to transfer from bed to chair
without difficulty.
Pneumonia: CXR showed LUL pneumonia, likely aspiration. Will
treat with 10 day course of levofloxacin, renally dosed.
CODE: DNR/DNI
Medications on Admission:
tylenol 650 qhs
amlodipine 5 qd
artificial tears ointment OU qhs
calcium 650 [**Hospital1 **]
aricept 10 qd
cholestyramine 4 gm qam
MVI
lansoprazole
timolol 0.5 % 1 gtt ou [**Hospital1 **]
tobradex ointment ou qhs
ALL: NKDA
Discharge Medications:
1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days: pneumonia, likely aspiration.
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): please hold for sbp<110, HR<55.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Aricept 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
7. Cholestyramine 4 g Packet Sig: One (1) PO once a day.
8. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
9. TobraDex 0.3-0.1 % Ointment Sig: One (1) Ophthalmic at
bedtime: OU.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Right basal ganglia hemorrhage with resulting left sided
weakness
Left upper lobe pneumonia, on levofloxacin (to complete a 10 day
course).
H/O: dementia, hypertension, upper gastrointestinal bleed, left
hip fracture, glaucoma
Discharge Condition:
stable, eating soft food without difficulty, transferring from
bed to chair without difficulty.
Discharge Instructions:
Please take all medications.
Please attend all followup appointments - it is very important
that you attend your stroke followup appointment.
Please return to the ED if you experience loss of consciousness,
new weakness, numbness or other concerning symptoms.
Your hypertension medication has changed from amlodipine to
metoprolol. Please followup with your PCP [**Last Name (NamePattern4) **]: your blood
pressure regimen.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) 1693**] in the
stroke clinic [**Telephone/Fax (1) 1694**]. Provider: [**Name10 (NameIs) 7476**] [**Name11 (NameIs) **], MD Where:
[**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2178-8-17**] 3:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4038
} | Medical Text: Admission Date: [**2142-10-27**] Discharge Date: [**2142-10-31**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
SDH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a [**Age over 90 **] year old man with history of parkinsonism
followed by Dr. [**First Name (STitle) 951**] of neurology who presents to ED today with
head trauma s/p fall. History is given by daughters. This
morning, his 89 year old wife was helping him put his pants on
in
the morning, when he tried to stand and fell straight forward.
He
his head directly on the floor, resulting in a large bruise over
his left forehead. His wife is sure that there was no LOC prior
to or after the fall. The patient was conversant throughout. The
family waited at home for an hour prior to coming to ED after
contacting PCP. [**Name10 (NameIs) 3754**] has been no evidence of seizures or
urinary incontinence since. His daughters tell me that at
baseline he has a poor working memory and can only remember
events for several minutes. He regularly forgets what his last
meal was. He has no major motor deficits. He has fallen twice in
the past year.
In the [**Hospital1 18**] ED, he presented in a hard collar. A CT C- spine
showed marked degenerative change with anterolisthesis of C2-3
and of C5-6. Then, a head CT showed an acute 6mm subdural
hematoma over the left frontal convexity with ~1mm midline
shift.
There is no evidence of acute ischemia around the subdural
collection. The L MCA is hyperdense, raising the suggestion of
an
evolving infarct vs. layering of blood.
Past Medical History:
parkinsonism
high chol
s/p CABG, CAD
bladder cancer
eosinophila-stronglyides
Social History:
Patient lives with wife in [**Name (NI) 2436**], and daughters describe
him to be dependent on someone during the day to perform his
ADL's There is no nurse during the weekdays.
Family History:
Non-contributory
Physical Exam:
T-99.1 BP-200/90 HR-87 RR-17
Gen: lying in bed in no apparent distress
Heent: NCAT, oropharynx clear
Neck: supple, no carotid bruits
Chest: clear to auscultation b/l
CV:regular rate, normal s1s2, no m/r/g
Neuro Exam:
MS:
Patients eyes are open, he is alert to voice. He tells me his
correct name, but thinks it is [**2082-5-10**] and we are in [**Country 6171**].
He is able to name [**Doctor Last Name **] forward in 1 minute, but cannot recall
the
months before decemeber. He can name my watch, wristband, but
not
clasp. He follows midline commands. He has impressive frontal
release signs- a marked b/l grasp, glabellar, snout and L
palmonetal reflex.
CN:
The EOM are intact with no diplopia. Visual file testing was
difficult, but all fields are intact with no enxtinction. Pupils
are 2->1.5 mm and reactive. Facial muscles symmetric with
emotional and command smiles. Tongue midline.
Motor:
There is cogwheeling with distraction L>R. No resting tremor
component. he is mildly bradykinetic. Strength testing was [**6-14**]
and robust from our resistance while he was lying down in bed.
Reflexes:
There are 3+ reflexes throuout.
Plantar reflexes extensor left
Sensory:
He will withdraw to painful stimulus only. He was not able to
complete proprioception testing secondary to cooperation.
Coordination:
not tested.
Gait:
not tested
Pertinent Results:
[**2142-10-27**] 12:40PM BLOOD WBC-10.2 RBC-3.93* Hgb-13.4* Hct-39.3*
MCV-100* MCH-34.2* MCHC-34.2 RDW-13.2 Plt Ct-186
[**2142-10-27**] 12:40PM BLOOD Neuts-49.6* Bands-0 Lymphs-9.0* Monos-4.5
Eos-36.5* Baso-0.3
[**2142-10-27**] 12:40PM BLOOD PT-13.5* PTT-28.2 INR(PT)-1.2
[**2142-10-27**] 12:40PM BLOOD Glucose-97 UreaN-33* Creat-1.4* Na-128*
K-4.7 Cl-96 HCO3-25 AnGap-12
[**2142-10-28**] 02:53AM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.9 Mg-1.8
[**2142-10-29**] 07:20AM BLOOD VitB12-775 Folate-17.3
[**2142-10-28**] 02:53AM BLOOD Phenyto-3.1*
[**2142-10-27**] 03:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2142-10-27**] 03:30PM URINE Blood-SM Nitrite-POS Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2142-10-27**] 03:30PM URINE RBC-10* WBC-33* Bacteri-MANY Yeast-NONE
Epi-<1
---
Urine Cx with >100,000 ORGANISMS/ML pan-sensitive E Coli.
----
Head CT:
IMPRESSION:
1. Subdural hematoma with additional component of subarachnoid
hemorrhage layering adjacent to the left frontal, temporal, and
parietal lobes.
2. Small amount of intraventricular hemorrhage.
3. Hyperdensity along tthe left middle cerebral artery most
likely blood layering within the region of the left middle
cerebral artery. However, if the patient has right sided
neurologic symptoms, MRI with diffusion would help in excluding
acute infarct.
4. Mild subfalcine shift. Prominence of the ventricles is
consistent with involutional change.
5. Chronic small vessel ischemic change and left pontine old
infarct.
----
Ct Head 8 hrs later:
Stable appearance of left-sided subdural hematoma, subarachnoid
hemorrhage and intraventricular hemorrhage. Stable minimal
rightward midline shift.
----
C-spine Xray:FINDINGS: Flexion and extension views of the
cervical spine demonstrate minimal anterolisthesis of C2 on 3
and minimal anterolisthesis of C4 on 5. There is also minimal
retrolisthesis of C5 on 6 and minimal anterolisthesis of C7 on
T1. All of these findings appear similar on the flexion and
extension views. These degenerative changes are noted.
----
CT C-spine:
1. No fracture of the cervical spine.
2. Marked multilevel degenerative change of the cervical spine
with grade I anterolisthesis of C2 on C3 and of C5 on C6. While
these findings likely relate to degenerative change, if there is
clinical symptomatology referable to these levels, MR of the
cervical spine would be more useful for assessing for possible
ligamentous injuries.
3. Sclerotic T4 vertebral body lesion may represent a bone
island.
----
Head MRI:
IMPRESSION: No evidence of acute infarction. Subdural and
subarachnoid hemorrhage appears similar compared to the CT scan
of [**2142-10-27**].
----
MRI C-spine:
IMPRESSION:
1. No fracture is seen. There is no evidence of edema in the
region of the interspinous ligaments, or the anterior or
posterior longitudinal ligament.
2. There is some edema at the far posterior tips of the C6 and
C7 spinous processes, suggesting injury to the nuchal ligament.
3. There is multilevel spondylosis. As noted on the plain film
and CT, there is minimal anterolisthesis of C2 on C3 and of C5
on C6. Osteophytes narrow multiple foramina.
----
CXR:
A 19 mm wide nodule at the base of the left lung has grown since
[**2142-6-11**] probably not contributing to current clinical
decompensation. Moderate atelectasis at the right lung base
medially is longstanding, though more severe on today's study.
[**Month (only) 116**] be mild bronchiectasis in the right upper lung, but no
pneumonia or pulmonary edema. Vascular deficiency suggests COPD.
Heart size is normal.
Brief Hospital Course:
Pt is a [**Age over 90 **] yo male with h/o PD, HTN, CAD who presented with a
stable 6 mm left frontal SDH with SAH and small ICH after a
mechanical fall. He was admitted to the neuro stepdown unit for
close monitoring. We obtained further history to confirm that
Mr [**Known lastname **] did not lose consciousness or have another
neurological event such as a seizure that may have prompted his
fall. It appeared that it was solely a mechanical issue though.
1. C-spine clearance:He had flex/ex films of his C-spine that
showed some mild spondylolisthesis, so a CT was recommended.
This was obatined and essentially negative for fracture. An MRI
was recommended to rulew out ligamentous injury, so this was
also obtained. He had only mild ligamentous changes and no neck
pain on exam, so his C-spine was cleared.
2. Neuro/SDH: The patient had a stable subdural hematoma after
his fall. He had slight mass effect that was not causing
symptoms during his admission. He hd a follow-up CT scan that
showed no change in the bleed. He then had a follow-up MRI scan
scan which showed stability of the bleeding. It also showed no
evidence of stroke or other abnormality. Clinically, the
patient displayed his baseline memory problems, but was
otherwise pleasant and conversant throughout his stay on the
floor. He had no complaints and no obvious neurological changes
from his baseline. He did have a headache while he was here.
Given the bleeding, we wanted to keep his BP well controlled and
it stayed in a good range throughout.
3. Pulm:The patient had several episodes of wheezing while he
was here. His respiratory rate and oxygen saturations remained
normal throughout. A CXR was obtained and showed no obvious
reason for these changes, but did show COPD. This may have been
causing his wheezing. On speaking with his cregiver, he
apparently has similar episodes at home. He was therefore sent
home with a nebulizer machine and albuterol q6h prn. Albuterol
wasn't used due to his heart condition.
4.CV:Pt was continued on his home antihypertensives and had no
issues. He was also continued on his statin.
5.Parkinsonism:Pt was at his baseline neurologically from a
Parkinsonism point of view. He was continued on Simemet and
Celexa. He was seen by his outpatient neurologist. Also, the
PT department taught his caregiver how to care for him better
from a Parkinson's point of view. A hospital bed was sent to
his house as well. His family wanted to take him home, so they
arranged for more constant care for him and had their questions
about home care answered by various staff members here. This
was an acceptable arangement. They will watch closely to prevent
further falls. He will follow up with Dr [**Last Name (STitle) 25922**].
He will see his PCP [**Last Name (NamePattern4) **] [**2-11**] weeks. They can follow-up on his
neurologic status, and discuss the need to get repeat CXRs to
evaluate the nodule at the base of his left lung.
Medications on Admission:
Sinemet 25/100 TID
Lipitor 40 daily
Atenolol 25 daily
Lisinopril 20 daily
Celexa 10 daily
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atrovent 0.02 % Solution Sig: One (1) neb Inhalation every
six (6) hours as needed for shortness of breath or wheezing.
Disp:*100 nebs* Refills:*2*
7. Nebulizer
Please provide 1 nebulizer machine with instructions to patient.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left subdural hematoma with subarachnoid hematoma
---
Parkinsonism
CAD s/p CABG
Hypercholesterolemia
h/o bladder cancer
Discharge Condition:
Stable neurologically. Out of bed with assistance.
Discharge Instructions:
Please call your PCP or return to the ED if you have any chest
pain, shortness of breath, abdominal pain, seizure, dizziness,
or lightheadedness. Also call if you become overly sleepy or if
your family has difficulty waking you up from sleep or if you
become confused.
No changes were made in your medications, except we added an as
needed breathing treatment to use for wheezing.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2142-11-16**] 2:30
--
Please see your PCP [**Last Name (NamePattern4) **] [**2-11**] weeks for follow-up.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 5990, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4039
} | Medical Text: Admission Date: [**2199-5-10**] Discharge Date: [**2199-5-11**]
Date of Birth: [**2126-3-7**] Sex: M
Service: SURGERY
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
septic shock
toxic c. diff s/p subtotal colectomy
Major Surgical or Invasive Procedure:
invasive monitoring
History of Present Illness:
Pt is 73yo male who was recently diagnosed with lyme myelitis
and was hospitalized. He was treated with Ceftriaxone and
discharged home. At home, he developed watery diarrhea for
several weeks and became severely dehydrated. He presented to
OSH and was found to have C diff toxic megacolon. On [**5-10**],
he was taken to the OR by an outside surgeon and underwent
subtotal colectomy and end ileostomy. Pt's postop condition was
moribund, with oliguria, in septic shock, and he was transferred
to [**Hospital1 18**] for further management.
Past Medical History:
spinal stenosis
CAD, s/p CABG & RCA stent
Recurrent 3 vessel coronary disease
hypercholesterolemia
htxn
prostate CA, s/p XRT
hx of pancreatitis [**9-/2198**]
Barrett's esophagus / gastritis
Social History:
unable to obtain from patient
Family History:
unable to obtain from patient
Physical Exam:
VS unstable, while on pressors
Intubated, sedated
PERRL, nonicteric sclera
supple neck
RR S1 S2 tachycardic
course breath sounds bilaterally with ronchi in lower lobes
soft mildly distended, no guarding or rebound, pink ostomy right
lower quadrant, retention sutures and staples, no significant
drainage, no erythema
ext with bilateral 2+ pitting edema, mottled to thigh
bilaterally
Pertinent Results:
[**2199-5-10**] 03:48PM WBC-32.1*# RBC-3.23* HGB-9.9* HCT-30.3*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.9
[**2199-5-10**] 03:48PM PLT SMR-VERY LOW PLT COUNT-53*#
[**2199-5-10**] 03:48PM PT-14.1* PTT-59.2* INR(PT)-1.3
[**2199-5-10**] 03:48PM FIBRINOGE-596*
[**2199-5-10**] 03:48PM GLUCOSE-138* UREA N-37* CREAT-2.3*#
SODIUM-139 POTASSIUM-4.9 CHLORIDE-116* TOTAL CO2-16* ANION
GAP-12
[**2199-5-10**] 03:48PM ALT(SGPT)-72* AST(SGOT)-208* LD(LDH)-812*
CK(CPK)-2376* ALK PHOS-61 AMYLASE-79 TOT BILI-0.2
[**2199-5-10**] 03:48PM LIPASE-17
[**2199-5-10**] 03:48PM CK-MB-38* MB INDX-1.6 cTropnT-0.15*
[**2199-5-10**] 03:48PM ALBUMIN-1.1* CALCIUM-6.1* PHOSPHATE-5.4*
MAGNESIUM-1.7
[**2199-5-10**] 04:15PM TYPE-ART PO2-68* PCO2-43 PH-7.15* TOTAL
CO2-16* BASE XS--13
[**2199-5-10**] 04:15PM LACTATE-3.0*
Brief Hospital Course:
Mr. [**Known lastname 26644**] arrived on a ventilator and was aggressively
resuscitated using invasive monitoring. He was given intravenous
boluses, transfused blood products and was placed on four
pressors: Levophed, Neo-Synephrine, Dobutamine, and Pitressin.
(Later, pt was also placed on epinephrine gtt as well.) Pt
arrived with a Swan [**Last Name (un) 26645**] catheter, and cardiac parameters were
hyperdynamic.
Given the pt's cardiac hx and mildly elevated cardiac enzyme, a
STAT cardiology consult was obtained. STAT TTE showed preserved
EF and no grossly abnormal wall motions. There was no
pericardial effusion. All these findings essentially ruled out
cardiogenic shock.
Pt arrived anuric to [**Hospital1 18**]. Pt was acidodic as well. Pt was
started on sodium bicarbonate gtt. Nephrology consult was
obtained. L femoral dialysis line was placed, and pt was
initiated on CVVH.
LFT's began to rise, indicating likely shock liver.
Presuming septic shock, pt was given broad spectrum IV
antibiotics. Given the severity of the shock, he was also
started on activated Protein C gtt.
Despite all these measures, pt required increasingly higher
doses of all the pressors to maintain bp. Serum lactic acid
level peaked to > 10. Ventilation was difficult, requiring FiO2
of 1.0 and high PEEP.
Family members were present and understood the critical state of
pt's multi-organ failure. When pt's blood pressure could not be
maintained, family members decided to make the pt DNR. Slowly,
pt became bradycardic and hypotensive. Cardiac arrest ensued. Pt
was pronounced deceased 4:45am, [**2199-5-11**]. Cause of death
was cardiopulmonary arrest due to septic shock.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
C.Diff collitis
s/p subtotal colectomy, ileostomy
acute renal failure
acute respiratory failure
post operative anemia
liver failure
hypokelimia
hypocalcemia
hypomagnesimia
CAD
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2199-5-11**]
ICD9 Codes: 0389, 5849, 2851, 4019, 2720, 2859, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4040
} | Medical Text: Admission Date: [**2200-3-19**] Discharge Date: [**2200-3-25**]
Date of Birth: [**2200-3-19**] Sex: F
Service: NEONATOLOGY
HISTORY: A 660 gram, diamniotic-dichorionic IUI, twin A,
delivered at 34-3/7 week gestation to a 33-year-old gravida
2, para 1 now three mother.
PRENATAL SCREENS: B positive, antibody negative, rubella
immune, RPR nonreactive, hepatitis B surface antigen
negative, GBS unknown. This twin noted on ultrasound to be
25th percentile and decreasing to the 5th percentile last
week. Decision was made to deliver the infants by cesarean
section.
[**Hospital **] MEDICAL HISTORY:
1. Hypothyroidism.
2. Hypercholesterolemia.
3. Nephrocalcinosis.
MEDICATIONS:
1. Levoxyl.
2. Ranitidine.
DELIVERY ROOM COURSE: Infants delivered by cesarean section,
this infant was transverse, infant transferred to warmer with
weak spontaneous cry. Apgars were seven at one minute and
eight at five minutes. [**Hospital **] transferred to Neonatal
Intensive Care Unit for management of prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 1660 grams
(10th percentile), length 44 cm (25th-50th percentile), head
circumference 31 cm (40-50th percentile). Nondysmorphic,
very quiet, and poorly reactive to stimulation. Anterior
fontanels are open and flat. Pupils are equal and reactive
to light. Positive red reflex bilaterally. No murmur,
regular, rate, and rhythm, pulses equal, pink. Good breath
sounds bilaterally. No grunting, flaring, or retracting.
Soft abdomen, positive bowel sounds, no hepatosplenomegaly.
Hypotonic, quiet, poorly reactive to stimulation, appears
flaccid with little spontaneous movement.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory:Infant has remained in room air throughout this
hospitalization with respiratory rate 30s to 40s, O2
saturation 92-99%. An arterial blood gas on day of life two
was 7.38/39/111/29/-1. Infant's last apnea and bradycardic
episode on [**3-22**] (day of life three).
Cardiovascular: Infant has remained hemodynamically stable
this hospitalization, no murmur, heart rate 120-140, blood
pressure means 40-51.
Fluids, electrolytes, and nutrition: The patient was started
on 80 cc/kg/day and was nothing by mouth until day of life #3
and enteral feedings were started at 30 cc/kg/day, and was
advanced to full volume feeding by day of life five. Infant
is currently on breast milk 20 calories per ounce at 140
cc/kg/day all gavage feeding. Infant tolerated feeding
advancement without difficulty. The most recent electrolytes
on day of life five were sodium of 141, chloride 109,
potassium 3.8, TCO2 of 223. The most recent weight is 1685
grams, head circumference 31 cm, length 48 cm.
GI: Infant was started on phototherapy on day of life three
for a maximum bilirubin level of 6.4, 0.3. Phototherapy was
discontinued on day of life four, and the rebound bilirubin
on day of life five was 4.8, 0.3.
Hematology: Infant has not received any blood transfusions
this hospitalization. The most recent hematocrit on day of
life two was 47.7%. The admission hematocrit was 49.7%.
Infectious Disease: A complete blood count, differential,
and blood culture were sent on date of delivery, antibiotics
were not started at that time. The admission complete blood
count showed a white blood cell count of 10.4, hematocrit
49.7%, platelets of 321,000, 26 polys, 0 bands. The blood
culture remains negative to date.
Due to decreased tone, another complete blood count,
differential, and blood culture were sent on day of life two,
and ampicillin and gentamicin were also begun at that time.
The white blood cell count on day of life two was 12.5,
hematocrit 47.7%, platelets 355,000, 71 polys, 0 bands. The
infant received 48 hours of ampicillin and gentamicin with
blood cultures remaining negative.
Neurology: Due to persistent hypotonia, Neurology was
consulted. The [**Hospital3 1810**] Neurology consult
attending was Dr. [**Last Name (STitle) 37113**]. A MRI was done on day of life #3,
results are preliminarily normal.
Metabolic: Chromosomes were sent on [**3-24**], results are
pending. Serum amino acids were also sent on [**3-21**],
results are pending.
Sensory: Hearing screening is recommended prior to
discharge.
Ophthalmology: Infant did not meet criteria for eye
examination.
Psychosocial: [**Hospital1 69**] social
work involved with family. The contact social worker can be
reached at [**Telephone/Fax (1) 8717**]. Parents involved.
CONDITION ON DISCHARGE: Former 34-3/7 week gestation now
35-2/7 weeks corrected twin #1, stable on room air.
DISPOSITION: Transferred to [**Hospital3 **], Level 2
nursery.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] ([**Location (un) 2274**]).
CARE RECOMMENDATIONS: Feedings at discharge: Breast milk,
20 calories per ounce, 140 cc/kg/day all gavage.
MEDICATIONS: None.
CAR SEAT POSITION SCREENING: Recommended prior to discharge.
STATE NEWBORN SCREEN: Sent on day of life two, results are
pending.
Infant has not received any immunizations this
hospitalization. A hip ultrasound is recommended after
discharge due to breech position.
DISCHARGE DIAGNOSES:
1. Premature twin #2 34-3/7 weeks.
2. Status post rule out sepsis.
3. Hypotonia.
4. Status post hyperbilirubinemia.
DR.[**First Name (STitle) **],[**First Name3 (LF) 36400**] 50-595
Dictated By:[**Last Name (NamePattern1) 43219**]
MEDQUIST36
D: [**2200-3-25**] 09:12
T: [**2200-3-25**] 09:33
JOB#: [**Job Number **]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4041
} | Medical Text: Admission Date: [**2109-4-25**] Discharge Date: [**2109-5-2**]
Date of Birth: [**2050-11-8**] Sex: M
Service: MEDICINE
Allergies:
Nsaids / Acetaminophen
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD, TIPS
History of Present Illness:
59 yo old gentleman with alcoholic cirrhosis transfered from
[**Hospital 8641**] hospital, NH for hematemesis from Esophageal and gastric
varices. Reports drinking 2 cases of beer daily and last bleed
[**4-1**] with banding. He states he had increased fatigue over
the course of ten days without nausea, vomiting, abdominal pain,
hematemesis, melena hematochezia. Day of admission to [**Location (un) 8641**]
[**4-21**] patient with hematemesis. This was the patients third
admission in recent months. Banding performed in [**Month (only) 956**]
admission only. While admitted, it appears from review of the
records that his hematocrit remained stable and he did not
receive any blood products. EGD revealed grade I-II varices in
Esophagus and gastrocardiac junction without stigmata of recent
hemorrhage. No evidence of banding. He was maintained on an IV
PPI, no octreotide nor antibiotics were administered. Patient
was transferred for further evaluation and potential TIPS.
Several episodes of encephalopathy in the setting of bleed in
the past.
.
The patient reports that he continues to have small episodes of
hematemesis as recently as this morning. He has abdominal pain,
chronic back/leg pain and a headache that has lasted several
days. Has loose, non-melanotic guaiac positive stools.
.
VS on admission to the floor: 98.7 158/60 61 18 96%RA. Patient
was transferred to MICU for closer monitoring and potential EGD.
.
Past Medical History:
Alcoholic Cirrhosis
Chronic Alcohol abuse, last drink "was the superbowl"
Portal Hypertension
Gastric/Esophageal Varices
COPD
Hypothyroidism
Chronic Back pain
Social History:
Lives alone. History of ETOH Abuse. 70pkyr history, (current
1.5ppd). Unable to obtain other illicity use
Family History:
Father died from unknown CA @ 77, brother died, age unknown from
esophageal Ca.
Physical Exam:
Vitals: T: 98.2 BP:115/57 P:59 R: 11 O2: 97% on RA
General: Arousable, ill appearing.
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, distended, non-tender, bowel sounds present, no
rebound tenderness or guarding.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+Ox0. No asterixis. Non focal.
skin: palmar erythema, numerous tatoos, telangiectasia. No caput
Pertinent Results:
- CXR 1V ([**2109-4-29**]): Pulmonary vascular congestion which improved
between [**4-26**] and [**4-27**] has returned suggesting a borderline
cardiac decompensation. Right basal consolidation is most
consistent with pneumonia, while left basal abnormality which
has improved since [**4-27**] is probably resolving atelectasis,
although it may be related to aspiration. Heart size is normal.
Lateral aspect of the right lower chest is excluded from the
examination. The other pleural surfaces are normal. Right
jugular sheath ends just above the junction with the right
subclavian vein. Nasogastric tube passes into the stomach and
out of view.
- TIPS ([**2109-4-26**])
- RUQ ultrasound ([**2109-4-26**]): Limited Doppler examination due to
the covered TIPS shunt is causing acoustic shadowing and
preventing Doppler examination of the flow within the TIPS shunt
itself. Indirect evidence suggests TIPS patency with appropriate
direction based on the flow in the main, anterior right common
and left portal veins. Followup ultrasound in one week is
recommended when the TIPS shunt may be interrogated with
ultrasound.
- TIPS ([**2109-4-25**])
- TTE ([**2109-4-25**]): The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Moderate (2+) aortic
regurgitation is seen, secondary to incomplete central leaflet
coaptation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion. IMPRESSION: Normal global and regional
biventricular systolic function. Moderate aortic regurgitation.
Mild pulmonary hypertension.
- EGD ([**2109-4-25**]): Varices at the lower third of the esophagus (4
cords of grade I-II varices); varices at the cardia, injected;
otherwise normal EGD to third part of the duodenum and stomach
antrum.
[**2109-4-29**]
WBC-10.3 Hgb-11.0* Hct-31.0* MCV-88 Plt Ct-71*
PT-17.6* PTT-35.0 INR(PT)-1.6*
Glucose-115* UreaN-22* Creat-0.5 Na-143 K-2.9* Cl-109* HCO3-25
Calcium-8.6 Phos-1.9* Mg-1.8
ALT-492* AST-498* LD(LDH)-289* AlkPhos-113 TotBili-5.0*
Brief Hospital Course:
58 year-old male with cirrhosis secondary to alcohol complicated
by esophageal and gastric varices s/p banding in [**2109-1-27**]
transferred from outside hospital on [**2109-4-25**] with hematemesis.
Patient was admitted directly to the MICU, and transferred to
the medical [**Hospital1 **] on [**2109-4-30**]. Hospital course was as follows.
Hematemesis was most likely secondary to variceal bleeding.
Patient was started on an ocretotide gtt, IV PPI, Ciprofloxacin,
and transfused to keep HCT > 25. Nadolol and Spironolactone
were held in the setting of acute GI bleed. Patient was kept NPO
during admission. Liver team was consulted. They performed an
EGD on the night of admission. EGD revealed large gastric
varix, which was injected 2cc, 6cc, with bleeding (hematemesis).
Bleeding appeared to stop. However NG tube with dark blood,
clots. Patient looked unwell. BP transiently dropped to 80's.
Patient was typed and cross matched and received 2 units of
blood. IR was contact[**Name (NI) **] for urgent TIPS. He was intubated prior
to TIPS, with permission from daughter, his health care proxy.
In procedure, initial porto-systemic gradient of 22. Brought
down to 6 after TIPS. Saw esophageal varices. Pre-TIPS saw
splenorenal shunt. Slower filling after TIPS. They did not
perform any embolization on initial TIPS.
The following morning [**4-26**], patient had a second episode of
hematemesis, 200cc. Vital signs and HCT were stable. IR
performed a redo of TIPS procedure. Patient was extubated on
[**4-27**]. On [**4-28**] patient was started on Ceftriaxone and Flagyl for
aspiration pneumonia seen on chest x-ray. The following day a
meeting was held with the [**Hospital 228**] health care proxy and the
MICU team. The daughter concluded that the patient should have
no more care other than treating his hepatic encephalopathy
(i.e. continuing lactulose, rifaximin, but discontinuing all
antibiotics). Central lines were discontinued, and one
peripheral IV was placed. She did not want further antibiotics,
lab draws, blood products, intubation, or resusitation. Patient
was made CMO, with the exception of treating hepatic
encephalopathy in the event that mental status clears and the
patient does not continue to bleed.
On transfer to the medical service, patient's NG tube fell
out. Per discussion with daughter, the patient would not want
tube replaced. She reported that this was based on lengthy
discussions with her father following recent hospitalizations.
Patient received one dose of lactulose PR. Pain was controlled
with morphine PO; agitation with olanzapine. Patient required
the use of restraints given danger to himself; he made repeated
attempts to get out of bed, and was at risk of falling. He was
alert at times although with limited interaction; he was not
oriented to place or time on discharge. He was hemodynamically
stable on discharge.
Medications on Admission:
Oxycontin 30mg PO Q8
Oxycodone 5mg PO Q6H PRN
Ativan 1mg IV/PO Q4h PRN Anxiety
Albuterol Q2h PRN Wheezing/Dyspnea
Duoneb QID
Pantoprazole 40mg IV BID
Celexa 60mg PO Daily
Aldactone 100mg PO Daily
MVI PO Daily
Nadolol (Both 20 & 40 listed)mg PO Daily
Vit D3 1000 Units daily
Nicotine 21mg TP
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mL PO Q8H
(every 8 hours): Hold for sedation or RR<12.
2. Morphine Concentrate 20 mg/mL Solution Sig: 0.25 to 0.5 mL PO
Q4H (every 4 hours) as needed for Pain: Hold for sedation or
RR<12.
3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 2.5 to 5 mg PO
Q4H (every 4 hours) as needed for Agitation.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) **] family hospice house
Discharge Diagnosis:
Gastric varices
Esophageal varices
Hepatic encephalopathy
Alcoholic cirrhosis
Aspiration pneumonia
Discharge Condition:
Hemodynamically stable. Encephalopathic. Arousable, but unable
to interact. Not orient to place or time.
Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2109-4-25**] with variceal bleeding. The liver team was consulted.
You were initially treated with ocreotide, proton pump
inhibitor, ciprofloxacin, IV fluids, and blood transfusions. An
EGD was performed on the night of admission, which revealed
esophageal varices, and a bleeding gastric varix. You
subsequently had hematemesis (vomiting blood), and had an
emergent TIPS performed. You were intubated for this procedure.
The following morning, you had repeat hematemesis and a redo
tips procedure. After a family meeting with you daughter, your
health care proxy, it was decided to withdraw further
interventions. This included no further blood products, no
ventilation or rescusitations, no lab draws, no IV fluids for
rescusitation. You were initially treated for hepatic
encephalopathy with lactulose and rifaximin, although your
nasogastric tube fell out and was not replaced and after
discussion with your daughter.
You will be going to [**Last Name (un) 59614**] Family Hospice House in New
[**Location (un) **].
Followup Instructions:
You will be cared for at [**Last Name (un) 59614**] Family Hospice House.
Completed by:[**2109-5-2**]
ICD9 Codes: 5070, 496, 4241, 4168, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4042
} | Medical Text: Admission Date: [**2159-3-12**] Discharge Date: [**2159-3-17**]
Date of Birth: [**2115-1-5**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 44-year-old-female
with end-stage liver disease and transjugular intrahepatic
portosystemic shunt who presents with two to three days of
dyspnea on minimal exertion. She has also noticed increasing
abdominal girth, increasing pain, bilateral leg pain (left
greater than right), and worsening problems keeping her
balance. She fell once in her living room yesterday. She
denied head trauma or other significant trauma. No chest
pain. No urinary symptoms. She has a chronic cough. She
denies recent medication indiscretion of illicit drugs. She
has never had similar symptoms before except the dyspnea
which she had last when she had a pleural effusion.
PAST MEDICAL HISTORY:
1. End-stage liver disease secondary to alcohol abuse and
herpes C virus.
2. Status post transjugular intrahepatic portosystemic
shunt.
3. Type 2 diabetes mellitus; poor compliance with
maintaining good glycemic control and frequent episodes of
hyperglycemia.
4. Asthma.
5. Hypertension.
6. Pancytopenia.
7. Status post total abdominal hysterectomy.
8. Tuberculosis that was treated.
9. History of pancreatitis.
10. History of suicide attempts; her psychiatrist is
Dr. [**First Name (STitle) **] at [**Location (un) 669**] Comprehensive.
ALLERGIES: TYLENOL and ASPIRIN.
MEDICATIONS ON ADMISSION: Lithium 300 mg p.o. b.i.d.,
thiamine 100 mg p.o. q.d., trazodone 100 mg p.o. q.h.s.
p.r.n., Humalog sliding-scale, albuterol meter-dosed inhaler
p.r.n., [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 40 mEq p.o. q.d., atenolol 25 mg p.o. q.d.,
lactulose 30 cc p.o. t.i.d., Celexa 10 mg p.o. q.d.,
Lasix 40 mg p.o. b.i.d., Seroquel 25 mg p.o. t.i.d. p.r.n.
(but she has not been taking this), iron gluconate 320 mg
p.o. q.d., insulin 75/25 65 units subcutaneous q.a.m. and
30 units subcutaneous q.p.m. (at dinner time),
Flovent 110 mcg inhaler 4 puffs inhaled b.i.d.,
Protonix 40 mg p.o. q.d., spironolactone 100 mg p.o. q.d.,
Tessalon Perles 100 mg p.o. q.i.d. p.r.n.
SOCIAL HISTORY: She was born in [**Country **] [**Country **] and emigrated to
the United States at the age of eight. She has been married
twice. Her first husband died. [**Name2 (NI) **] second husband she
divorced. She has three children ages 26, 23, and 21; all
are in legal trouble. She has been sober for six months.
She has a history of cocaine and alcohol abuse. She lives
with her son and her son's wife who are both helping care for
her. She has a history of several suicide attempts; most
recently last month.
FAMILY HISTORY: Alcoholism, bipolar disorder, and diabetes
run in her family.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 98.6, blood pressure of 124/82, pulse of 88,
respiratory rate of 22, oxygen saturation of 98% on 2 liters.
In general, she was alert, in no acute distress, lying in
bed. Head, eyes, ears, nose, and throat revealed peripheral.
Extraocular movements were intact. Sclerae were anicteric.
The oropharynx was clear. Mucous membranes were moist. The
neck was supple. Shotty cervical lymphadenopathy. Pulmonary
revealed decreased breath sounds on the right hemithorax and
decreased fremitus on the right hemithorax. The left
hemithorax was essentially clear to auscultation.
Cardiovascular revealed normal first heart sound and second
heart sound. A regular rate and rhythm. A 2/6 systolic
murmur heard at the left sternal border. The abdomen was
distended, diffusely tender, with positive bowel sounds. No
rebound or guarding. The rectal examination was occult-blood
negative in the Emergency Room. The skin was with no rash.
Extremities revealed left lower extremity and right lower
extremity were diffusely tenderness to palpation, left
greater than right. Neurologically, she was alert and
oriented times three. Cranial nerves II through XII were
intact. Deep tendon reflexes were 2+ at the knees and
ankles, biceps, and brachioradialis. There was no
asterixis, and she was not confused.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed Chem-7 with a sodium of 136, potassium
of 4.2, chloride of 104, bicarbonate of 24, blood urea
nitrogen of 6, creatinine of 0.6, blood glucose of 228. The
ALT was 40, AST was 89, alkaline phosphatase was 142, total
bilirubin was 2.6. PT was 15.2, PTT was 33.4, INR was 1.6.
Amylase of 53 and lipase of 144. Complete blood count
revealed a white blood cell count of 3.3 (which is her
baseline), hematocrit of 37.8, platelets of 41 (which is her
baseline). The differential revealed 49% neutrophils,
40% lymphocytes, 6% monocytes, 3% eosinophils).
RADIOLOGY/IMAGING: A chest x-ray showed increased size of
the right-sided effusion. There were loculated components of
the effusion in the upper lung. There was complete right
lung collapse.
Abdominal ultrasound revealed flow in the left portal vein
was reversed from what it should be, status post transjugular
intrahepatic portosystemic shunt. There was increased stent
stenosis compared to prior Doppler performed in [**2159-1-9**].
Electrocardiogram showed nonspecific inferior ST-T changes.
There was no change from [**2158-1-9**]; otherwise, she was
in normal sinus rhythm.
IMPRESSION: This is a 44-year-old-female with end-stage
liver disease and transjugular intrahepatic portosystemic
shunt who presented with increasing dyspnea on exertion,
abdominal pain, and increased abdominal girth.
The patient had transjugular intrahepatic portosystemic shunt
stenosis seen on ultrasound. This caused ascites and
tracking of the ascites fluid into the pleural space, and her
enlarging effusion was responsible for her pulmonary
symptoms.
HOSPITAL COURSE: The Pleural Service was initially
consulted to address the issue of her pleural effusion. The
Pleural Service felt that a thoracentesis would not be
indicated initially until the shunt stenosis was fixed
because the effusion would otherwise accumulate very rapidly
after a tap.
Therefore, the Liver Service was consulted who agreed that
she needed a transjugular intrahepatic portosystemic shunt
revision. The Interventional Radiology Service was
consulted, and after receiving a transfusion of one bag of
platelets, the patient was taken to Interventional Radiology
where she underwent transjugular intrahepatic portosystemic
shunt extension.
Unfortunately, after the transjugular intrahepatic
portosystemic shunt revision, the patient could not be
extubated due to her pleural effusion so she was briefly
admitted the Medical Intensive Care Unit. There, she
underwent thoracentesis with greater than 2 liters of fluid
taken off.
Following this procedure, she was extubated without
complications, and she was transferred back to the General
Medicine Service.
A post procedure ultrasound showed functioning transjugular
intrahepatic portosystemic shunt, and the patient had
complete resolution of her dyspnea and abdominal pain. Her
abdominal girth was decreasing for the last two days of
admission. She had some right upper quadrant pain status
post procedure that was almost certainly due to the stent,
and this pain responded well to Ultram.
We continued her outpatient cardiac regimen as well as her
outpatient diabetes regimen. We also continued lithium,
trazodone q.h.s. p.r.n., and Celexa. She did not request
Seroquel, so this was not given. Her inhalers were also
continued.
DISCHARGE STATUS: Discharge status was to home with [**Hospital6 3429**].
CONDITION AT DISCHARGE: Condition on discharge was good.
MEDICATIONS ON DISCHARGE:
1. Albuterol meter-dosed inhaler 2 puffs q.i.d. p.r.n. for
wheezes.
2. Atenolol 25 mg p.o. q.d.
3. Iron gluconate 320 mg p.o. q.d.
4. Flovent 110-mcg inhaler 4 puffs inhaled b.i.d.
5. Lithium 300 mg p.o. b.i.d.
6. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 40 mEq p.o. q.d.
7. Lactulose 30 cc p.o. t.i.d.
8. Protonix 40 mg p.o. q.d.
9. Spironolactone 100 mg p.o. b.i.d.
10. Tessalon Perles 100 mg p.o. q.i.d. p.r.n. for cough.
11. Thiamine 100 mg p.o. q.d.
12. Trazodone 100 mg p.o. q.h.s. p.r.n. for insomnia.
13. Celexa 10 mg p.o. q.d.
14. Seroquel 25 mg p.o. t.i.d. p.r.n. for anxiety.
15. Furosemide 40 mg p.o. b.i.d.
16. NPH insulin/Humalog 75/25 65 units subcutaneous q.a.m.
and 30 units subcutaneous q.p.m.
DISCHARGE FOLLOWUP: Follow-up appointments were scheduled
with her primary care physician (Dr. [**Last Name (STitle) 36295**] at the [**Hospital6 6613**] for [**3-30**] and with her hepatologist
(Dr. [**Last Name (STitle) **] on [**3-20**].
DISCHARGE DIAGNOSES:
1. Transjugular intrahepatic portosystemic shunt stenosis.
2. Pleural effusion.
3. Ascites.
4. Type 2 diabetes mellitus.
5. Asthma.
6. Hypertension.
7. Depression.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2159-6-13**] 16:52
T: [**2159-6-14**] 11:45
JOB#: [**Job Number 12623**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4043
} | Medical Text: Admission Date: [**2123-10-3**] Discharge Date: [**2123-10-4**]
Date of Birth: [**2123-10-3**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 74748**] is a 3.295
kilogram product of a 39-5/7 week gestation pregnancy born to
a 34-year-old G 4, P 2, now 3 woman. Prenatal screens:
Blood type O+, antibody negative, rubella immune, RPR non-
reactive, hepatitis B surface antigen negative, group beta
strep status negative. The pregnancy was uncomplicated. The
mother was admitted in labor. Rupture of membranes occurred
at 30 minutes prior to delivery. There was no maternal
fever. There was a reassuring fetal heart rate tracing. The
infant was born by normal spontaneous vaginal delivery with
natural childbirth. There was a very tight nuchal cord noted
at the time of delivery. The infant emerged apneic and
hypotonic. There was terminal meconium noted. Positive
pressure ventilation was initiated. The Neonatal Intensive
Care Unit team was called and arrived at 2 minutes to find a
pale, hypotonic infant with a bloodless umbilical cord.
Positive pressure ventilation was continued with spontaneous
onset of respirations at 4 minutes of life. There was cry at
8 minutes of life. Apgars were 2 at one minute and 5 at
five minutes and 7 at 10 minutes. The infant was admitted to
the Neonatal Intensive Care Unit for evaluation and
observation after visiting with the parents.
PHYSICAL EXAMINATION: Weight 3.295 kilograms, length 51.5
cm, head circumference 30 cm. General: Non-dysmorphic, term
female. Head, ears, eyes, nose and throat: Anterior
fontanelle soft and flat. Moderate molding. Normal facies.
Palate intact. Mild flaring. Chest: Breath sounds clear
and equal. Cardiovascular: No murmur. Present femoral
pulses. Abdomen soft, flat and nontender. No
hepatosplenomegaly. Genitourinary: Normal genitalia.
Musculoskeletal: Stable hips. Neurologic: Normal tone,
slightly diminished activity, symmetric Moro.
HOSPITAL COURSE:
1. Respiratory: The infant's oxygen saturations were 100%
on room air. The grunting and flaring noted at the time
of admission resolved within a few hours after
admission. An arterial blood gas was performed with a
pH of 7.31, a partial pressure carbon dioxide of 41.
2. Cardiovascular: Mean arterial pressure upon admission
to the Neonatal Intensive Care Unit was 34. The infant
was treated with two normal saline boluses of 10
ml/kilo, with improvement in blood pressure. At the
time of transfer the baby is stable with a heart rate of
130 to 150 beats per minute with a recent blood pressure
of 60/32 mm of mercury, mean arterial pressure of 42 mm
of mercury. A soft murmur was noted on the second day
of life.
3. Fluids, Electrolytes and Nutrition: The infant began
feeding a few hours after birth and has been breast
feeding well. There has been adequate urine output.
4. Infectious Disease: Due to the birth apnea noted at the
time of delivery, this infant was evaluated for sepsis.
A complete blood count was notable for a white blood
cell count of 9,000 with 45% polymorphic nuclear cells
and 1% band neutrophils. A blood culture was obtained
and remains pending at the time of transfer. She was not
started on antibiotics.
5. Hematological: Hematocrit at birth was 33% with a
reticulocyte count of 5.8%. Repeat hematocrit on the
first day of life was 28.6%. This was felt to be due to
the equilibration of the volume loss at the time of
delivery. The infant was started on iron
supplementation at 6 mg/kilo per day.
6. Gastrointestinal: No issues.
7. Neurology: The infant gradually became more active
during the hours after admission. At the time of
transfer she has a normal neurological examination.
8. Sensory, Audiology: Hearing screening has not yet been
performed but will be prior to discharge.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to the Newborn Nursery. The
private pediatrician will be Dr. [**First Name4 (NamePattern1) 26344**] [**Last Name (NamePattern1) **] with [**Hospital1 **] in [**Hospital1 392**], [**State 350**]. Phone
number [**Telephone/Fax (1) 74749**].
CARE RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Ad lib breast feeding.
2. Medications: Ferrous sulfate 0.8 ml p.o. once daily of
25 mg/ml solution.
DISCHARGE DIAGNOSES:
1. Birth apnea/perinatal depression due to tight nuchal cord.
2. Suspicion for sepsis ruled out.
3. Status post hypovolemia and hypotension due to tight and
early clamping of nuchal cord.
4. Cardiac murmur.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) 74750**]
MEDQUIST36
D: [**2123-10-4**] 16:00:55
T: [**2123-10-4**] 16:29:12
Job#: [**Job Number 74751**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4044
} | Medical Text: Admission Date: [**2187-12-7**] Discharge Date: [**2187-12-19**]
Date of Birth: [**2109-10-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Cough, hoarse voice
Major Surgical or Invasive Procedure:
G/J-tube placement per interventional radiology on [**12-14**].
Intubation
History of Present Illness:
Mr. [**Known lastname 66749**] is a 78 year-old man with a 3-year history of ALS,
for which he receives care at [**Hospital1 18**]. Over the past few months he
has had a progressive cough, but over the past 4 days it has
gotten much more severe, and last night he did not sleep at all
because he was coughing all night. His daughter stayed over at
his house and confirmed this history. He rarely brought up
yellowish-white sputum. He also described feeling a blockage in
his throat. Sometimes this is a little fluid that he has not
been able to swallow, but if he cannot cough up the sputum he
coughs so "you can hear [him] across the block". During these
coughing fits he feels very short of breath and dizzy, but he
describes no fevers or chills. In addition to the cough he has a
sore throat and feels that his voice has gotten more hoarse in
the past few weeks. He has significant dysarthria from his ALS,
but this is a change in the quality of his voice. He takes
guaifenesin to try to loosen his secretions, and recently his
daughter has brought a saline nebulizer home, which seemed to be
helping. According to his daughter, Mr. [**Known lastname 66749**] was recently
seen at the VA, where he was told that his VC was 1.3L. If it
goes down to 1L he will be a candidate for a tracheostomy. He is
on 3L of oxygen continuously at home, and is on a soft food and
thickened liquid diet.
.
In the ED his vitals were T 98.1, HR 77, BP 135/90, RR 20. O2
sat 96%3L, dropped down to 92% on 3L when talking. His NIF was
measured and found to be good at 38. His EKG showed NSR at 81,
RBBB, Q III/F, TWI III/F and V1-V4, with no prior to compare it
to. He recieved an ABG that was normal, a chest x-ray that
showed no signs of acute pulmonary process, V-Q scan was limited
but showed no signs of PE.
Past Medical History:
1. ALS: Mostly bulbar and respiratory troubles, but has been
dependent on a walker for past few months, has had 2 bad falls
in the last month.
2. HTN
3. Cervical stenosis
Social History:
Pt is a former boxer, was in the Navy and worked for the [**Location (un) 86**]
Fire Department for much of his life. He has 10 children and
about 30 grandchildren. He currently lives in his house with his
wife, who is ill with COPD. One of his daughters lives next door
and his a nurse, and she does most of the caretaking. His
granddaughters do the cooking, though Mr. [**Known lastname 66749**] still tries to
do some cleaning around the house.
He has never smoked, never drank, no illicit drugs.
Family History:
Father had lung cancer, does no know any other history of
cancer, diabetes or heart disease. No history of neurologic
disease.
Physical Exam:
Vitals: Tc:97.9 BP:190/98 HR:70 RR:20 O2:99% 3L, resting
General: Awake in bed, alert, no distress
HEENT: head NC/AT, PERRLA (pupils 2->1.5). EOMI, VF intact.
Neck: No palpable lymph nodes, no palpable thyroid
nodules/swelling
Card: nl S1S2, rrr, no m/r/g. PMI non-displaced
Lungs: Expiratory wheezes throughout, inspiratory squeeks in
lower lobes bilaterally, lung volumes decreased, no basilar
crackles.
Abd: +BS, distended, tympanic, non-tender, no masses
Ext: no cyanosis or edema, 2+ pedal pulses.
Neurologic:
Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Severe dysarthria. Language is
fluent with intact repetition and comprehension. There were no
paraphasic errors. Able to follow both midline and appendicular
commands. There was no evidence of neglect.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm OS and 1.5 to 1 mm OD and brisk.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric, though some
weakness of orbicularis oculi bilaterally
VIII: Hearing slightly diminished to finger-rub bilaterally.
IX, X: Palate elevates symmetrically but delayed gag reflex
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline; no fasciculations noted.
Motor: Severe wasting of UEs most notably in intrinsic hand
muscles bilaterally. Fasciculations present in L biceps and
triceps. Spasticity of all 4 ext. No tremor noted.
Delt Bic Tri WrE WrF FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 4+ 5 4+ 5 5- 5 0 2 4 5 5 5 5 4 4
R 4+ 5 4 5 5- 5 0 2 4 5 5 2 5 4 4
Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout.
DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 3 4
R 3 3 3 3 4
3 beats of clonus at bilateral ankles
Plantar response was flexor on the right, extensor on the left.
Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
Gait: Good initiation. Narrow-based, but short, shuffling
stride.
Pertinent Results:
Labs on admission:
ABG: pO2-100 pCO2-41 pH-7.42 calTCO2-28 Base XS-1
Glucose-106* UreaN-29* Creat-2.2* Na-143 K-4.4 Cl-107 HCO3-26
AnGap-14
Calcium-9.3 Phos-2.8 Mg-2.1
WBC-9.7 RBC-4.51* Hgb-13.2* Hct-39.4* MCV-87 MCH-29.3 MCHC-33.6
RDW-14.0 Plt Ct-275
Neuts-73.6* Lymphs-17.1* Monos-4.4 Eos-4.5* Baso-0.3
cTropnT-0.02* Lactate-0.9
[**2187-12-7**] Lung Scan - IMPRESSION: No evidence of interval
pulmonary embolism compared to study of [**2187-3-11**].
[**2187-12-9**] CT HEAD:
1. No acute intracranial hemorrhage.
2. Interval increase in right maxillary and right anterior
ethmoid sinus
mucosal thickening, likely representing chronic inflammatory
disease.
[**2187-12-10**] Video Oropharyngeal Swallow - IMPRESSION:
1. Moderate oral dysphagia.
2. Reflux from the esophagus into the pharynx with subsequent
penetration
into the airway seen.
Brief Hospital Course:
78 year-old man with a 3-year history of ALS who has recently
become more compromised in terms of mobility presents with 4
days of worsening minimally productive cough, sore throat and
hoarse voice without fever or leukocytosis.
#Cough: According to pts report he has had a cough for a few
months, but over the last 4 days it got progressively worse,
with minimal yellow-white sputum production. Pneumonia seemed
less likely in the setting of a normal chest x-ray and no focal
finding on lung exam, as well as lack of fever of leukocytosis.
Considered diagonoses were URI or continued aspiration,
overlying muscle weakness and difficulty clearing secretions.
His home O2 (3L) was continued, as well as his CPAP at night. He
was started on ipratroprium and albuterol nebulizers, as well as
dextromethorphan and codeine for cough suppression. We have IV
fluids, as his daughter reported that he has low PO intake, and
this may have been adding to his thick secretions. IV protonix
40 [**Hospital1 **] was started in case there was an element of
regurgitation. Speech and swallow consult was called to assess
whether he was aspirating more than he had previously.
#ALS: Pt appeared to have decompensated in the past several
months, and it was unclear if this presentation was just a
manifestation of and ALS "exacerbation". Home riluzole and
tizanidine were continued, as well as his previously prescribed
died of soft food and thickened liquidsa. PT consult was
ordered.
.
# CKD: Cr was 2.2 on admission.
.
# HTN: quite hypertensive on admission to floor, but down to 155
systolic after several hours. Continued to monitor BP and give
home metoprolol and terazosin.
.
# PPx: Pt was put on his some bowel regimen; started on a PPI,
and given heparin sc.
.
......
MICU course:
Mr. [**Known lastname 66749**] was transferred to the MICU as a result of
progressive metabolic acidosis and respiratory distress.
.
#ALS - The patient's increased dyspnea and acidosis on transfer
likely represent a progression of his underlying ALS. The
patient was intubated on [**12-18**] so that he could get his affairs
in order after a lengthy discussion with both the patient and
his daughter/HCP and reviewing his goals of care. Efforts to
minimize sedation were made so that the patient could be alert.
The patient self-extubated on the morning of [**12-20**] and
maintained his O2 sats alternating between a face tent and BiPAP
support. The palliative care team continued to follow the
patient and assist him in meeting his goals.
.
#Obstipation ?????? On transfer to the MICU the patient had severe
constipation. He was given an aggressive bowel regimen and
began stooling again. His tube feeds through his GJ tube were
subsequently resumed.
.
#Hypertension - prior to his MICU transfer the patient was
having significant episodes of HTN up to 190's-210, likely
secondary to respiratory distress and holding of his BP meds.
He was continued on hydralazine IV and his regular
antihypertensives were resumed via his GJ tube when his
obstipation resolved.
.
#Anion Gap Metabolic Acidosis ?????? On transfer the patient had an
anion gap acidosis, likely secondary to ketosis and progressive
respiratory muscle fatigue with progression of his ALS. He may
have also had a component of non gap acidosis from receiving NS
IVF. He was given IVF with D5 with 3 amps of sodium bicarbonate
for fluid repletion. His acidosis subsequently resolved.
Medications on Admission:
*Metoprolol Tartrate 25 mg PO twice a day
*MIRALAX PO once a day
*Riluzole 50 mg PO twice a day
*Terazosin 4mg HS
*Tizanidine 2 mg PO twice a day
*Aspirin 81 mg PO once a day
*Docusate Sodium [Colace] 100 mg Capsule PO twice a day
*Guaifenesin 400 mg PO four times a day
*Percocet 1 tab HS
Discharge Medications:
1. Fibersource Liquid Sig: 60 cc/hr PO 24 hours per day:
Please provide 30 day supply with 5 month refills - feed via G/J
tube.
Disp:*180 cans* Refills:*5*
2. Riluzole 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Terazosin 1 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
5. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours).
6. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed.
Disp:*2 bottles* Refills:*5*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
Disp:*2 bottles* Refills:*5*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*2*
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation: hold if having bowel
movements.
Disp:*1 bottle* Refills:*5*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
13. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One
(1) Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
Disp:*60 * Refills:*5*
14. Nebulizer & Compressor For Neb Device Sig: One (1)
Miscellaneous as directed.
Disp:*1 unit* Refills:*0*
15. Nebulizer Accessories Misc Sig: One (1) Miscellaneous
as directed.
Disp:*1 set* Refills:*0*
16. Humidified O2 Sig: One (1) as directed.
Disp:*1 * Refills:*5*
17. Suction equipment Sig: One (1) set Q2-6H as needed.
Disp:*1 set* Refills:*1*
18. face tent Sig: One (1) set as needed.
Disp:*1 set* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Amyotrophic lateral sclerosis
Hypertension
Discharge Condition:
Afebrile, requiring supplemental oxygen to maintain O2 sats.
Discharge Instructions:
You were admitted on [**2187-12-7**] with increased coughing,
difficulty swallowing hence interfering with your nutrition and
weakness. Initially, you were admitted to the medicine service
to rule other possible infection or blood clots that may be
causing your increased coughing but the evaluations were normal
hence you were transferred to neurology service for further
evaluation and treament of your ALS. You were eventually
transfered to the medical ICU service because of worsening
shortness of breath due to progression of your ALS.
After palliative consult and consultation with Dr. [**Last Name (STitle) 66750**]
[**Name (STitle) **], your neurologist at [**Hospital1 18**], you had G-tube placed per
interventional radiology with conscious sedation and without
complications.
You were also intubated briefly to allow you to settle some
legal matters.
Your tube feed has been recommended per nutrition consult and
you are discharged home with home hospice service. Please note
the changes that have been made with your medications.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) 1151**] [**Last Name (NamePattern1) 66751**] at the VA will be contacting you for follow-up.
He has been informed of your admission and plan of care.
Please follow-up with your primary care provider.
ICD9 Codes: 2762, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4045
} | Medical Text: Admission Date: [**2121-5-10**] Discharge Date: [**2121-5-12**]
Date of Birth: [**2067-11-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
R IJ central line placement
History of Present Illness:
Briefly, this is 53 yo M s/p DDRT in [**2111**] who was in his usal
state of health until 2 days prior to presentation when he
develped non-bloody diarrhea and non bloody, non-bilious emesis.
No sick contract, no travel, no abnormal food exposure and no
recent antibiotic exposure. He reports lightheadedness and
dizziness and 2 syncopal episodes.
.
In the emergency department he was found to be hypotensive with
BP 70/40 (baseline SBP = 90-110) with HR = 60s-80s with a
leukocytosis of 16K and acute on chronic renal failure with Cr =
4.0 up from his baseline of 1.9-2.3. Code sepsis was initiated
and he received IVF, stress dose steroids and vancomycin 1 gm,
zosyn 2.25 gm.
.
In the ICU, he was hemodynamically stable and his BP normalized
to SBP 110s without additional IVF nor need for pressors.
.
On the floor the pt feels comfortable, he denies any further LH
or dizziness lying in bed and with ambulation. He denies
abdominal pain, fevers, chills and states that he would like to
go home in the morning.
Past Medical History:
ESRD ?[**3-14**] HTN s/p deceased donor renal transplant in [**2111**]
Gout
HTN
Impaired glucose tolerance
Hyperlipidemia
Social History:
Born in [**Country 6257**], moved to US in [**2091**] at about age 23. He had
worked in electronics but is now on disability. No tobacco,
alcohol or IVDU.
.
Family History:
father who died at 78 of kidney disease, mother who is in her
80s and well. There is no history of diabetes or cancer in the
family. He has one brother and two sisters who are well. He also
has two children, ages 23(a daughter) and 17 (a son) who are
well.
Physical Exam:
T 98.6 BP 106/77 P 94, O2 sat 97% RA
HEENT: NC/AT, PERRL, no scleral icterus noted, MMM,
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Ext: No C/C/E bilaterally, 2+ DP b/l
Skin: no rashes or lesions noted.
Pertinent Results:
[**2121-5-10**] 05:20AM WBC-16.1*# RBC-4.89 HGB-15.2 HCT-44.9 MCV-92
MCH-31.1 MCHC-33.9 RDW-14.5
[**2121-5-10**] 05:20AM NEUTS-78.4* LYMPHS-14.3* MONOS-6.7 EOS-0.4
BASOS-0.2
[**2121-5-10**] 05:20AM PLT COUNT-217
[**2121-5-10**] 05:58AM LACTATE-1.4
[**2121-5-10**] 07:30AM ALBUMIN-3.1* CALCIUM-6.7* PHOSPHATE-3.0
MAGNESIUM-1.9
[**2121-5-10**] 01:37PM freeCa-1.19
[**2121-5-10**] 03:36PM TYPE-MIX PO2-41* PCO2-30* PH-7.27* TOTAL
CO2-14* BASE XS--11 COMMENTS-CENTRAL VE
[**2121-5-10**] 01:37PM TYPE-[**Last Name (un) **] PH-7.24*
.
Admission CXR: no acute process. Right IJ line with tip in the
SVC/RA junction.
.
CT Abd/pelvis:
1. Mild fascial thickening posterior to the transplant kidney.
No evidence of hydronephrosis or perinephric fluid collection.
2. Incompletely visualized coronary artery calcifications.
3. Cholelithiasis without evidence of cholecystitis.
.
Renal transplant U/S:
A transplant kidney is seen in the right lower quadrant and
measures 13.2 cm. There is no hydronephrosis or perinephric
fluid collection. Resistive indices in the upper, mid, and lower
poles are 0.64, 0.72, and 0.69 espectively. The main renal
artery and main renal vein are patent with normal waveforms. A
Foley catheter is in the decompressed bladder. IMPRESSION:
Normal renal transplant ultrasound.
.
CT head: No intracranial hemorrhage or mass effect.
.
Cardiac Evaluation:
[**6-/2115**] ETT - 8.5 METs. No anginal symptoms nor EKG changes.
.
Admission EKG: NSR, LAD, poor R wave progression and first
degree av block. No acute ST changes.
Brief Hospital Course:
53 y.o. M with h/o ESRD s/p deceased donor kidney transplant in
[**2111**] on chronic immunosuppression presents with emesis,
diarrhea, hypotension and acute on chronic renal failure.
.
1. Hypotension: Was likely due to volume loss from diarrhea and
vomiting. Elevated WBC with left shift. Etiology most likely
viral given lack of fever, abdominal pain. He was continued on
IVF with bicarbonate. He received Hydrocortisone 50mg Q8h for
one day, then was placed back on his outpatient dose of oral
prednisone. Pt initially received antibiotics in the ED, none
were necessary anymore after that since his BP remained stable
and he also remained afebrile. He was discharged with stable BP
but off his antihypertensives. He should schedule a followup
appointment with Dr. [**Last Name (STitle) **] within one week after discharge.
At this time, it can be decided if he should continue any of his
antihypertensives.
.
2. Diarrhea: Probably infectious, most likely viral, however
atypical bacterial presentation was initially considered. Also
in this immunosuppressed pt need to consider
crytpo/micropsiridia and CMV. CMV was negative in the past. No
recent antibiotic exposure and presentation not suggestive of C
diff. Extensive stool studies were sent but pending upon
discharge. His diet was advanced and his diarrhea resolved
slowly after admission.
.
3. Non Anion Gap Metabolic Acidosis: Probably secondary to
diarrhea, possible component of RTA in the context of worsening
RF, however, the patient has had normal bicarbonate in the past.
He received IVF with HCO3 and his HCO3 came back up to normal
levels.
.
4. Syncopal Episodes: Unlikely to be cardiac/seizure/stroke,
probably due to orthostatic hypotension secondary to
hypovolemia. CT head was negative. Patient was without focal
neurological signs. He was monitored on telemetry for 24 h.
Hypocalcemia was repleted with IV calcium gluconate as needed.
.
5. ESRD s/p DDRT 10 years ago on neoral and imuran and
prednisone. Renal US was wnl w/o signs of rejection. He was
continued on neoral, imuran and prednisone (except for one day
while being on stress dose steroids instead of his PO
prednisone).
.
6. Acute on chronic renal insufficiency: likely secondary to
hypovolemia, quickly improved with IVF. Back to baseline (around
2.0) on [**2121-5-12**].
.
7. Hypocalcemia: no QT prolongation. Probably secondary to
diarrhea. Repleted with IV calcium gluconate.
.
8. Hypertension: Initially hypotensive. Resolved after IVF. Then
remained normotensive. All antihypertensives were held given
hypotension. They should be restarted as an outpatient.
.
9. Prophylaxis: Tolerating POs, pantoprazole while on steroids,
ISSC while on steroids, SQ heparin
.
10. Access: RIJ was placed on [**2051-5-10**], then pulled the next
day. PIV.
.
11. Code: FULL
Medications on Admission:
COLCHICINE 0.6MG po qd prn gout
HYDRALAZINE HCL 50MG po bid
IMURAN 50MG po q day
LOPRESSOR 100MG po qday
NEORAL 50MG [**Hospital1 **]
PREDNISONE 5MG po qday
PROBENECID 500MG--One by mouth twice a day for gout
VASOTEC 10MG--One by mouth every day
Ranitidine 150mg po bid
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
3. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Probenecid 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Gastroenteritis with hypotension, self-limited, likely viral
2. ESRD s/p deceased donor renal transplant
3. Hypertension
Secondary Diagnosis:
1. Gout
2. Hyperlipidemia
Discharge Condition:
Afebrile. Hemodynamically stable. Ambulating. Tolerating PO.
Discharge Instructions:
You have suffered from a gastroenteritis which was likely caused
by a virus. Your blood pressure was low and you received
intravenous fluids and briefly antibiotics.
.
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
worsening diarrhea, spontaneous bleeding or any other concerning
symptoms.
.
Please take all your medications as directed. You should hold
your blood pressure medications (lopressor, hydralazine and
vasotec) until your next outpatient visit when it will be
decided if you should be restarted on them or not.
.
Please keep you follow up appointments as below.
Followup Instructions:
We have called to schedule you an appointment with [**First Name4 (NamePattern1) 971**]
[**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]. The office will call you with
your appointment time. You should have your blood checked (CBC,
calcium) and follow up with her on your blood pressure
medications and kidney function.
.
In addition, please keep the following scheduled appointments:
.
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2121-7-11**] 9:30
.
Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Date/Time:[**2121-9-15**] 4:10
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
ICD9 Codes: 5849, 5856, 2762, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4046
} | Medical Text: Admission Date: [**2136-11-1**] Discharge Date: [**2136-11-8**]
Date of Birth: [**2057-4-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
1. Intra-aortic balloon pump placement
2. Cardiac catheterization with left main coronary artery bare
metal stent placement
History of Present Illness:
The patient is a 79-year-old male with history of prior CVA,
hypertension, cirrhosis and prior NSTEMI which was treated
medically in [**2136-10-24**] who presents now as a transfer from OSH with a new NSTEMI.
He has been complaining of epigastric pain and "heart burn" for
5 days leading up to this admission. He had associated chest
pain radiating to his jaw and bilateral arms for several days,
almost continuously but waxing and [**Doctor Last Name 688**] in intensity. He
states that he felt better with burping, and his pain worsened
after eating food. He denies any shortness of breath, chills, or
sweats. The patient presented to OSH and was found to have
elevated Troponins to 2.0 with CK of 103. CXR showing mild
pulmonary edema. The patient was treated as an NSTEMI protocol
with heparin, [**Doctor Last Name **], [**Doctor Last Name 4532**] load and he was then transferred to
[**Hospital1 18**] for further management. Aditional review of his EKG at
[**Hospital1 18**] revealed normal sinus rhythm but prominent ST segment
depressions in I, II, aVL, V5-V6
and ST segment elevations in leads aVR and V1. After admission,
the patient was observed on telemetry in preparation for a
cardiac catheterization. He was given ongoing therapy with
[**Last Name (LF) 4532**], [**First Name3 (LF) **], Statin, beta-blocker, and IV heparin. Overnight, he
triggered for hypotension and was given fluid bolus of 500cc x2.
He remained chest pain free initially but had recurrent chest
pain in the early morning hours requiring IV morphine.
In the cardiac cath lab, a right heart catheterization
demonstrated RA Pressure of 19 mmHg,RVEDP 21 mm Hg, PASP 51 with
a mean of 39 mm Hg and PCWP 34 mm Hg. Fluids were discontinued
and Mr. [**Known lastname **] was given 40mg IV lasix. On left heart
catheterization, the LMCA had a distal 90% stenosis at the
trifurcation of the ramus intermedius, LAD, and LCX. The LAD had
mild diffuse disease with a large D1. The LCX had an OM1 with
diffuse 90% proximal stenosis. The RCA was totally occluded
proximally with faint left-right collaterals. Resting
hemodynamics revealed elevated right and left-sided filling
pressures consistent with cardiogenic shock. The cardiac output
was 4.2 l/min with an index of 2.0 l/min/m2 and left
ventriculography was deferred with plan to stabilize patient
with IABP and consider stent or CABG at later time. Ultimately,
the patient underwent stent placement on [**2136-11-2**] with stent
placed across LAD to distal left main coronary artery. Outcome
showed an improvement to 30% obstruction at trifurcation vs.
prior 90% blockage, with a TIMI 3 result.
.
On arrival to CCU, patient was chest pain free and had no
shortness of breath. He was lying flat in bed on 4L NC. He
denied any back, groin pain, LE pain. On review of systems, he
denied any prior history of deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, hemoptysis, black stools or red stools. He denied
exertional buttock or calf pain. All of the other review of
systems were negative.
Past Medical History:
NSTEMI ([**1-31**])
CVA
Gout
Cirrhosis - alcoholic, no biopsy, no known h/o varices or
complications from his liver disease.
Dementia
HTN
OSA
macular degeneration
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
Cardiac History: NSTEMI
Prior percutaneous coronary intervention: none
Pacemaker/ICD:None
Social History:
The patient lives in [**Location **] and is dependent in ADL's and IADL's and
is cognitively very intact. He denies any history of smoking,
current etoh use or any history of drug use.
Family History:
No premature cardiac disease in family, noncontributory family
history.
Physical Exam:
VS - afebrile, T 98.4, IABP Augmented Diastolic BP 105/50, HR
82, SaO2 95% 4L NC, RR 20
Gen: No acute distress, well-developed and well-appearing middle
aged male. Alert and oriented to person, place and time. Mood,
affect appropriate. Speech mildly slurred (without dentures) .
HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma. PERRL, EOMI.
Neck: Thick neck, supine, 8cm JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, balloon pump on 1:1.
Chest: No chest wall deformities, scoliosis or kyphosis.
Respirations were unlabored, no accessory muscle use. CTA
anteriorly, decreased b/s at bases.
Abd: Soft, NTND. No HSM or tenderness. Abdominal aorta not
enlarged by palpation.
Ext: Slightly cool lower extemities with 1+ pedal pulses
bilaterally, no edema. No femoral bruits, R-groin w/o hematoma
or ecchymoses, IABP in place.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: dopplerable DP pulses, faintly dopplerable PT pulses
b/l.
Pertinent Results:
[**2136-11-1**] Admission EKG: sinus rhythm with nml axis, nml
intervals, ST depressions in V4-V6, I, AVL and ST elevation in
AVR. Borderline ST elevation in V1.
.
[**2136-11-2**] Cardiac Cath Report: 1. Successful PTCA and placement
of a 3.0x15mm Vision stent in the distal LMCA and origin LAD
were performed. The stent was postdilated proximally using a
4.5x8mm Quantum Maverick balloon and distally using a 3.5x12mm
Quantum Maverick balloon. Final angiography showed normal flow,
no apparent dissection, and a 30% residual stenosis at the
trifurcation site. (See PTCA comments.)
2. Left femoral arteriotomy closure was performed using an 8
French
Angioseal VIP. FINAL DIAGNOSIS:PTCA and placement of a
bare-metal stent in the distal LMCA to origin LAD.
.
[**2136-11-3**] ECHO :
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-15mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. There is
moderate global left ventricular hypokinesis (LVEF = 40 %).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade III/IV (severe) LV diastolic dysfunction. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened. There
is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. Moderate (2+) mitral regurgitation
is seen. The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
pMIBI at OSH [**1-/2136**]: left ventricular dialtion with diffuse
hypokinesis and reduced EF to 35%. non-transmural inferior wall
perfusion defect on post-stress images. subendocarial ishemia
[**2136-11-1**] 10:42PM PTT-58.0*
LABS PRIOR TO DISCHARGE:
[**2136-11-8**] 05:55AM BLOOD WBC-8.1 RBC-3.14* Hgb-9.3* Hct-28.2*
MCV-90 MCH-29.7 MCHC-33.1 RDW-14.6 Plt Ct-252
[**2136-11-8**] 05:55AM BLOOD Glucose-113* UreaN-45* Creat-1.7* Na-141
K-4.2 Cl-108 HCO3-24 AnGap-13
[**2136-11-5**] 07:00AM BLOOD ALT-26 AST-25 AlkPhos-73 TotBili-0.4
[**2136-11-8**] 05:55AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1
[**2136-11-2**] 01:00AM BLOOD CK-MB-48* MB Indx-11.4* cTropnT-4.06*
proBNP-[**Numeric Identifier 79816**]*
[**2136-11-5**] 04:14PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2136-11-5**] 04:14PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2136-11-5**] 04:14PM URINE RBC-10* WBC-9* Bacteri-FEW Yeast-NONE
Epi-0
Brief Hospital Course:
In summary, the patient is a 79-year-old male with history of
hypertension, s/p NSTEMI [**1-/2136**] who was transferred from OSH
after presenting with 5 days of unstable angina with associated
dyspepsia and found to have NSTEMI with transient ST elevations
in AVR and ST depressions inferolaterally concerning for
significant left
main/proximal LAD disease with relative hypotension.
:
CORONARY ARTERY DISEASE/NSTEMI and CARDIOGENIC SHOCK: The
patient presented to OSH and was found to have elevated
Troponins to 2.0 with CK of 103. The patient was treated as an
NSTEMI protocol with heparin, [**Year (4 digits) **], [**Year (4 digits) 4532**] load and he was then
transferred to [**Hospital1 18**] for further management. Aditional review of
his EKG at [**Hospital1 18**] revealed normal sinus rhythm but prominent ST
segment depressions in I, II, aVL, V5-V6 and ST segment
elevations in leads aVR and V1. CK peaked peaked at 400. Patient
continued [**Last Name (LF) 4532**], [**First Name3 (LF) **], statin and heparin therapy. Patient's
beta blocker held in the setting of severe cardiogenic shock on
admission to CCU. Admission TTE/ECHO [**2136-11-1**] showed moderate
global left ventricular hypokinesis (LVEF = 40 %) and Grade
III/IV (severe) LV diastolic dysfunction. The right ventricle
was mildly dilated with mild global hypokinesis as well. The
patient was stabilized with the assistance of a intra-aortic
balloon pump to help augment BP. The patient was initially
placed on IABP 1:1 and gentle diuresis was given with lasix.
Diagnostic coronary angiography showed 2 vessel and left main
coronary artery disease as patient was found to have 90% L-main
occlusion. Due to significant comorbidities, there was
reluctance to offer CABG as reasonable option. After discussion
with family and patient he elected to undergo an attempt at PCI.
He underwent PTCA and placement of a bare-metal stent in the
distal LMCA to origin of LAD and recovered well with no notable
complications post-procedure.
.
PUMP FUNCTION: ECHO revealed LVEF of 35%. The patient had
initial elevation in BNP of [**Numeric Identifier 79816**] given his acute NSTEMI and CHF
with poor cardiac output. He received post catheterization
diuresis with Lasix and his CXRs showed improvement in his
pulmonary edema throughout his hospital course. The patient's
oxygen saturations were improved to 96 % on room air by time of
discharge and he had no clinical complaints of shortness of
breath and only trace lower extremity edema which had improved
from his initial presentation.
.
RHYTHM : The patient was monitored throughout his stay and per
telemetry he remained predominantly in normal sinus rhythm after
his PCI procedure with very limited PVCs.
.
ANTICOAGULATION: The patient's most recent ECHO revealed
moderate global left ventricular hypokinesis (LVEF =35-40 %)and
the right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. Thus, he was started on IV heparin and
bridged while starting coumadin therapy to reduce his risk of
thrombus and CVAs. The end INR goal being [**2-26**]. At time of
discharge the patient's INR was slightly supratherapeutic at 3.5
and his evening warfarin dose was held prior to his discharge.
.
ACUTE ON CHRONIC RENAL FAILURE : The patient's initial CRF
history was further challenged by his relative hypoperfusion in
the setting of his ACS/NSTEMI and during his cardiogenic shock.
Based on limited OSH records it is unclear what the patient's
true BUN/Cr baseline is. His Cr peaked at 2.4 and came down to
1.6/1.7 by time of discharge. He was given mucomyst pre and
post-procedure and IVFs were given sparingly due to the
patient's CHF/cardiogenic shock.
.
CIRRHOSIS : The patient had a GI consult for pre-op risk
stratification. Unclear if patient has true underlying cirrhosis
but ultrasound revealed a nodular liver. The patient was cleared
for surgery and he had LFTs within normal limits at the time of
discharge. Per GI records the patient had a classification of
Child Class B w/ 30% cirrhosis secondary to alcohol history. He
had no appreciable RUQ tenderness, jaundice, HSM on exam and he
will plan to follow-up with his usual PCP after discharge
regarding his GI management. Hepatitis B/C panels were done and
were all negative.
RECENT PNA : The patient was noted to have had a fever at OSH
and he had recently completed treatment for PNA. He had no
dullness to percusssion on exam and he had no significant cough
or productive sputum during his CCU course. At time of discharge
he had WBC count of 8.1 and was afebrile. Mr. [**Known lastname **] did have
leukocytosis to 19 at OSH but only mildly elevated WBC to 12
here and CXR clear other than mild effusions initially which had
improved to near resolution by time of discharge.
.
DEMENTIA : For the patient's mild dementia he was continued on
his daily Donepezil therapy.
.
URINARY TRACT INFECTION: On [**2136-11-5**] the patient had a routine
UA which revealed bacteria and WBCs and labs were consistent
with a UTI so he was started on Doxycycline for a 7 day regimen.
Follow-up urine cultures were negative. He was through 4/7 days
therapy at time of discharge and had no complaints of dysuria or
frequency.
FLUIDS AND ELECTROLYTES: The patients magnesium and potassium
were repleted on an as needed basis during his hospital stay and
daily electrolytes were monitored. He was started on a full
cardiac diet once he stabilized and he did very well with his
oral input and had a good appetite. IVF were used sparingly in
the setting of CHF.
.
SACRAL DECUBITUS: The patient's sacral stage 1 buttock sore
remained in tact and he had protective cream applied to avoid
any breakdown. Patient stable at time of discharge and will plan
to follow-up with his PCP regarding further monitoring.
.
PROPHYLAXIS: The patient was on anticoagulation for NSTEMI and
thrombus coverage in the setting of his hypokinetic heart and
was therefore covered for DVT prophylaxis as well. PT also
helped the patient to do exercises during his stay to maintain a
fair level of mobility. He was also given 40mg PO daily
Protonix for GI prophylaxis.
.
The patient was maintained as a full code
status for the entirety of his hospital stay. He was asked to
please return to the emergency room or call his primary
cardiologist or PCP as soon as possible if he had any worsening
shortness of breath, chest pain, dizziness or lightheadedness
after discharge.
Medications on Admission:
Home Medications on arrival:
Reglaid
Flonase
Sudafed
Celexa
Colchine
[**Date Range **]
Lopressor
Allopurinol
Aricept
Recently completed levaquin for PNA
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 37**] House Rehab & Nursing Center - [**Location (un) 38**]
Discharge Diagnosis:
Non ST elevation Myocardial Infarction
Acute Systolic Congestive Heart Failure
Urinary Tract Infection
Acute Renal Failure
Discharge Condition:
Stable
Creat: 1.6
BUN: 47
K: 4.2
Hct: 27.9
Stage 1 sacral ulcer
Discharge Instructions:
You had a heart attack and required a bare metal stent to open
one of your heart arteries. You will need to take [**Location (un) **] every
day for the rest of your life. You had some damage to your heart
muscle and now your heart is weak. Because of this, you will
need to follow a low salt diet, weigh your self every day and
call the doctor if you gain more than 3 pounds in 1 day or 6
pounds in 3 days. We changed some of your medicines.
Continue daily [**Location (un) **] to keep the cardiac stent open. Continue
doxycycline for 3 remaining days of therapy for a urinary tract
infection and continue daily Warfarin as prescribed to avoid
blood clots and to decrease stroke risk.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Cardiology: Pt will need follow-up with a cardiologist in [**2-27**]
weeks as a new pt.
Completed by:[**2136-11-8**]
ICD9 Codes: 5849, 5990, 4280, 5859, 2749, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4047
} | Medical Text: Admission Date: [**2128-8-2**] Discharge Date: [**2128-8-12**]
Service: CARDIOTHORACIC
Allergies:
Codeine / Shellfish / Ciprofloxacin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Exertional angina and dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2128-8-2**] CABG x 3(LIMA->LAD, SVG->OM, SVG->PDA)
History of Present Illness:
This is an 85 year old female with prior history of non-hodgkins
lymphoma, s/p Cytoxan in [**2117**] a with recurrence in [**2123**]. Follow
up examinations have found a suspicious left lower lobe finding.
Cardiac workup prior to left lower lobe resection led to cardiac
catheterization which found severe three vessel disease with
[**1-16**]+ mitral regurgitation. She now present for surgical
intervention.
Past Medical History:
Non-hodgkins lymphoma - s/p Cytoxan in [**2117**] and [**2123**], History of
Varicella Zoster with opthalmic lesions, History of Menieres
Disease, GERD, Glaucoma, History of chronic sinusitis, s/p
cataract surgery, s/p TAH and BSO, s/p appendectomy, s/p
bilateral breast reduction
Social History:
Retired RN. Lives alone but family is close. Denies tobacco and
ETOH.
Family History:
Daughter died of MI at age 49.
Physical Exam:
Vitals: BP 160-170/80-84, HR 82, Resp 20
General: Elderly female in no acute distress
HEENT: Oropharynx benign
Neck: Supple, no JVD, no carotid bruits
Chest: Lungs CTA bilaterally
Heart: Regular rate, [**1-18**] holosystolic murmur
Abdomen: Soft, nontender, nondistended
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Nonfocal
Pertinent Results:
[**2128-8-10**] 06:10AM BLOOD WBC-10.9 RBC-3.99* Hgb-12.6 Hct-37.9
MCV-95 MCH-31.5 MCHC-33.2 RDW-13.9 Plt Ct-330#
[**2128-8-10**] 06:10AM BLOOD Glucose-76 UreaN-12 Creat-0.9 Na-141
K-3.5 Cl-104 HCO3-26 AnGap-15
[**2128-8-11**] 06:28AM BLOOD Phenyto-5.5*
Brief Hospital Course:
Mrs. [**Known lastname 63769**] was admitted and underwent three vessel coronary
artery bypass grafting by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1290**]. Of note,
intraoperative transesophageal echocardiogram evaluation showed
only mild mitral regurgitation, so no repair/replacement was
indicated.
Following the operation, she was brought to the CSRU. On
postoperative day one, she was noted to be largely unresponsive
with left hemiparesis. Restlessness with body tremors were also
noted. A stat MRI was notable for multiple abnormal foci
consistent with systemic emboli. These were found in the right
cerebellar, occipital and anterior parietal lobes. The neurology
service was consulted and attributed these findings to
cholesterol emboli. Due to seizure activity, Dilantin was
started. Anticoagulation was not recommended. Over the next
several days, her neurological status slowly improved. She was
eventually extubated without incident. She went on to experience
paroxysmal atrial fibrillation which was initially treated with
intravenous Amiodarone. She concomitantly had loose stools which
were C. diff negative. Her clinical status stablized and she
transferred to the step down unit on postoperative day six. She
remained mostly in a normal sinus rhythm and transitioned to
oral Amiodarone which will need to continue for three months
postop. She tolerated beta blockade which was slowly advanced as
tolerated. She worked daily with physical and occupational
therapy. Her neurological status continued to improve. Acyclovir
was eventually increased from her maintenance dose for a herpes
zoster breakout on her right upper back. In addition, she was
empirically started on Flagyl for persistent diarrhea(despite
negative C. diff cultures), however she developed an additional
rash on her buttocks after the first dose of flagyl, so the
flagyl was discontinued. She developed a urinary tract infection
for which she was started on Bactrim. A foley catheter was
inserted given her mutiple episodes of incontinence that were
adding to skin irritation. On insertion she was found to be
retaining 1400 cc of urine, so the foley catheter was left in.
She continued to make clinical improvements and was cleared for
discharge to rehab on postoperative day 10.
Medications on Admission:
Acyclovir 800 qd, Nexium 40 qd, Lipitor 40 qd, Coreg 6.25 [**Hospital1 **],
Asa 81 qd, Timolol eye gtts, Calcium, MVI, Vitamin C
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever or pain. Tablet(s)
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day). Tablet(s)
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: 400 mg PO daily for 1 week, then decrease to 200 mg
PO daily. Tablet(s)
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Acyclovir 800 mg Tablet Sig: 0.5 Tablet PO 5X/D (5 times a
day) for 5 days: Then decrease dose to 800 mg PO daily.
9. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO BID
(2 times a day).
11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Coronary artery disease - s/p CABG
Varicella Zoster
Postop CVA
Postop Atrial fibrillation
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not lift more than 10 lbs. for 2 months.
Do not drive for 4 weeks.
Call our office for sternal drainage, temp>101.5
No lotions, creams, or powders on wounds.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 6051**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1693**] in neurology clinic for 4
weeks.
Completed by:[**2128-8-12**]
ICD9 Codes: 4240, 9971, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4048
} | Medical Text: Admission Date: [**2191-8-11**] Discharge Date: [**2191-8-17**]
Date of Birth: [**2106-6-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stents x2 to the left
anterior descending artery and balloon procedure to the
diagonal.
History of Present Illness:
Mr. [**Known lastname 656**] is an 85yoM with a h/o CAD, HLD, and bladder cancer
who is s/p cardiac cath last week showing 40% LAD and 40% DI who
is now transferred from [**Hospital3 **] after an episode of
substernal chest pain and EKG e/o anterior STEMI. Patient was
admitted to [**Hospital1 18**] [**2191-8-4**] after an episode of substernal chest
pain and elevated troponin at OSH of 0.54. He had a cardiac
cath which showed 40% LAD and 40% DI. He was discharged with
medical management (ASA and Atorvastatin). Today at 8am
developed [**10-17**] substernal chest pain, called EMS and was
brought to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], where EKG was c/f anterior STEMI. He was
transferred to [**Hospital1 18**] and went to cardiac cath. He received 81
mg ASA, 600mg Plavix, 80mg Lipitor, 3 sublinguals and 6 mg
Morphine. Also received 4000 bolus of heparin followed by 840
units hr gtt. Given 1 liter NS for BP running in the 90s' still
with pain.
Currently, he reports 1/10 chest pain, much improved since cath.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
He denies recent fevers, chills or rigors. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-S/p cath [**2191-8-4**]: mid LAD 40% lesion with an ostial D1 40%
lesion, unchanged from elective cath in [**2188**]
-S/p cath [**2188**]: mid LAD 40% lesion with an ostial D1 40% lesion
3. OTHER PAST MEDICAL HISTORY:
- h/o bladder cancer, currently treated with chemo and
radiation, in mid-cycle, s/p cystoscopic surgery
- h/o herniated disc
- s/p appendectomy
- arthritis
- s/p right rotator cuff surgery
Social History:
-Tobacco history: quit 28 y/a, smoked 1 ppd x 40 years
-ETOH: used to drink about [**2-10**] drinks/day, stopped drinking one
month ago when diagnosed with bladder cancer
-Illicit drugs: denies
-ambulates independently, lives with wife who had a stroke three
years ago
Family History:
No family history of MI, stroke, congestive heart failure.
Father had stomach cancer
Physical Exam:
ADMISSION EXAM:
VS: T=95.6 BP=124/55 HR=77 RR=15 O2 sat= 94%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: No JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: +R femoral bruit (site of previous cath). No c/c/e.
Back: L flank ecchymoses, firm, non-tender, with six inch
abrasion
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE EXAM:
Exam largely unchanged. Afebrile, hemodynamically stable.
Cath sites without hematomas or bruits bilaterally.
Pertinent Results:
PERTINENT LABS
[**2191-8-11**] 06:20PM UREA N-19 CREAT-0.7 SODIUM-139 POTASSIUM-3.7
CHLORIDE-105
[**2191-8-11**] 06:20PM CK(CPK)-3853*
[**2191-8-11**] 06:20PM CK-MB-210* MB INDX-5.5 cTropnT-8.74*
[**2191-8-11**] 06:20PM HCT-28.3*#
[**2191-8-11**] 06:20PM PLT COUNT-173
[**2191-8-11**] 11:42AM TYPE-ART O2-100 O2 FLOW-2 PO2-184* PCO2-38
PH-7.35 TOTAL CO2-22 BASE XS--3 AADO2-503 REQ O2-83
INTUBATED-NOT INTUBA
[**2191-8-13**] 05:14AM CK-MB-14* MB Indx-2.0 cTropnT-3.82*
.
STUDIES
ECG:
Study Date of [**2191-8-5**] 8:18:16 AM
Sinus rhythm. Right bundle-branch block. Non-specific ST-T wave
changes. Compared to the previous tracing of [**2191-8-4**] there is no
significant change
.
CARDIAC CATH REPORTS:
[**2191-8-4**]
1. Single vessel disease. Proximal LAD 40% stenosis, with ostial
Diagonal branch 40% disease. TIMI 3 flow. No significant
stenosis.
2. Findings compare with cardiac cath performed in in [**2188**].
Essentially unchanged.
.
[**2191-8-11**]
1. Limited coronary angiography in this right dominant system
for STEMI
demonstrated total occlusion of the LAD and D1. The LMCA was
patent.
The LAD had proximal calcification and diffuse 50-60% disease
followed
by a total occlusion. D1 also had 100% occlusion at its origin.
The LCx
had mild luminal irregularities but was otherwise patent. The
RCA was
not injected due to recent angiography 7 days prior.
2. Limited resting hemodynamics revealed mildly elevated
systemic
arterial systolic hypertension with an SBP of 131 mmHg.
.
ECHOCARDIOGRAM [**2191-8-12**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with akinesis of the mid-
and distal anterior, septal segments and apex. The remaining
segments exhibit compensatory hyperkinesis and the overall LVEF
is only mildly reduced at 40%. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a trivial/physiologic pericardial effusion.
CT ABDOMEN/PELVIS W/O CONTRAST [**2191-8-12**]:
1. No retroperitoneal bleeding/hematoma.
2. Extensive fat stranding in the soft tissues of the left groin
extending
along the external iliac artery and vein without discrete
hematoma.
3. Cholelithiasis with no evidence of cholecystitis.
4. Diverticulosis of the sigmoid colon with no diverticulitis.
5. Trace amount of bilateral pleural effusion.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION
Mr. [**Known lastname 656**] is an 85 y.o. man with a h/o known CAD, HLD, and
bladder cancer who presented with chest pain and was found to
have an anterior STEMI with cardiac catheterization showed
complete occlusion of the proximal LAD. Pt is now s/p placement
of bare metal sents x 2 to the proximal LAD.
.
ACTIVE ISSUES
# Anterior STEMI:
Patient presented to [**Hospital3 4107**] after an episode of [**10-17**]
substernal chest pain. EKG at [**Hospital1 **] showed an anterior STEMI
and he was transferred to [**Hospital1 18**] where he underwent cardiac
catheterization which showed a complete occlusion of the
proximal LAD. Two bare metal stent were placed with good
restoration of flow.He was placed on an integrelin drip for 18
hr post cath. The patient was continued on aspirin, and
atorvastatin. He was also started on plavix. Patient was
initially hypotensive, and so home antihypertensives were held,
however, at the time of discharge his BP was stable on
lisinopril 2.5mg daily and metoprolol 12.5 mg [**Hospital1 **]. Cardiac
enzymes trended down to 2100, peaking at 3853. ECHO HD # 1
showed mild regional left ventricular systolic dysfunction with
akinesis of the mid- and distal anterior, septal segments and
apex. Overall LVEF is only mildly reduced at 40%. Given apical
akinesis, coumadin was considered but ultimately not given due
to his high risk of bleeding complication with triple
anticoagulation therapy and his recent falls.
# R femoral bruit:
Of note, the patient had a right femoral bruit at the site of
his catheterization from [**2191-8-4**]. Arterial doppler did not show
any evidence of an AVM, fistula or aneurysm. Bruit was no
longer audible at the time of discharge.
.
#Anemia:
Patient reported a fall the day of his cardiac event in which he
fell into [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. On physical exam on HD1, patient had
ecchymosis on bilateral posterior hips without complaints of
tenderness. His hematocrit dropped from 42.0 prior to admission
to 28.3 and then 25.9. Patient was hemodynamically stable and
asymptomatic. He was transfused 1U PRBC and his hematocrit
responded to 29. CT abdomen showed no retroperitoneal bleed or
hematoma. His Hct remained stable and on discharge was 30.7.
# HLD: Patient was continued on high dose atorvastatin during
admission and will continue this medication after discharge.
# Bladder cancer: Stable. Pt receiving chemo/radiation for
localized bladder cancer at OSH.
CHRONIC ISSUES
# H/o herniated disc: His home dose oxycodone was continued as
needed for back pain.
TRANSITIONAL ISSUES
-Patient maintained full code status throughout hospitalization.
-He will need to follow up with his cardiologist and oncologist.
-He should continue ASA 325mg daily indefinitely, and
clopidogrel 75mg daily for at least one year for his BMS
-He should continue atorvastatin, lisinopril, and metoprolol for
post-STEMI
-PT/OT recommended discharge to rehab.
Medications on Admission:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN for chest pain as needed for chest pain: if you
take three and chest pain still has not resolved, please [**Name8 (MD) 138**]
MD.
5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
q6h PRN as needed for nausea.
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 37**] House Rehab & Nursing Center - [**Location (un) 38**]
Discharge Diagnosis:
ST Elevation myocardial infarction
Bladder cancer
Dyslipidemia
Acute Sytolic Dysfunction
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 had a heart attack and needed to have stents placed in your
heart arteries to keep the arteries open. You have done well
since the heart attack and your heart seems to be functioning
well. You will need to take clopidogrel (Plavix) and aspirin for
at least one month and possibly longer. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or
stop taking clopidogrel or aspirin unless Dr. [**Last Name (STitle) **]. [**Doctor First Name **] tells you
to. You risk having another heart attack if you do because the
stent may clot off.
Please weigh yourself every day and call Dr. [**First Name (STitle) **] if you notice
your weight increases more than 3 pounds in 1 day or 5 pounds in
3 days.
.
We made the following changes to your medicines:
1. Start aspirin 325 mg and Clopidogrel 75 mg daily to keep the
stents open
2. Start metoprolol to lower your heart rate and help prevent
another heart attack
3. Start Lisinopril to lower your blood pressure and help your
heart recover
4. Start tylenol to use for the pain in your back
5. Start famotidine to protect your stomach from irritation
Followup Instructions:
Cardiology Appointment: Wednesday,[**9-7**] at 1:30pm
With:[**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 4474**]
Phone: [**Telephone/Fax (1) 4475**]
Hematology/Oncology Appointment: [**Last Name (LF) 2974**],[**8-19**] at 12pm
With:[**Name6 (MD) 251**] [**Last Name (NamePattern4) 4225**], MD
Location: [**Location (un) **] HEMATOLOGY ONCOLOGY
Address: [**Location (un) 10726**], [**Hospital1 **],[**Numeric Identifier 10727**]
Phone: [**Telephone/Fax (1) 10728**]
ICD9 Codes: 4589, 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4049
} | Medical Text: Admission Date: [**2159-4-21**] Discharge Date: [**2159-4-28**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 80-year-old woman
with no past medical history, who was transferred to the [**Hospital1 1444**] with an inferior ST elevation
myocardial infarction. The patient reported the day prior to
admission, she developed indigestion after eating Chinese
food. This did not respond to Tums. The patient went to bed
with continued pain, and woke up in the morning with a
sensation of indigestion as well as chest pressure. She
denied diaphoresis. She had some nausea as well as some
vague discomfort in her left arm.
The patient was subsequently taken to the [**Hospital3 3834**]
[**Hospital3 **], where she was found to have inferior ST elevations.
She was treated with Heparin, Lopressor, and lysed with TNK.
She was transferred to [**Hospital1 69**].
Upon arrival, the patient had continued chest pressure.
Therefore, she was taken to the catheterization laboratory.
In the catheterization laboratory, the right coronary artery
was found to be totally occluded. It was stented x2. There
was an old left anterior descending artery lesion with
collaterals. A left ventriculogram showed an inferior
aneurysm with an ejection fraction of 35%. Her cardiac index
was 1.75, wedge 22, 25.
PAST MEDICAL HISTORY: None.
MEDICATIONS AT HOME:
1. Multivitamins.
2. Aspirin 81 mg po q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has a long history of tobacco.
She denies use of alcohol or illicit drugs.
FAMILY HISTORY: The patient had a father with coronary
artery disease.
REVIEW OF SYSTEMS: The patient describes dyspnea on exertion
as well as chest discomfort while climbing stairs for
approximately 3-4 months.
PHYSICAL EXAMINATION ON ADMISSION: The temperature is 99.7,
heart rate 90, blood pressure 118/46, respiratory rate 20,
and sating 99% on room air. The patient is alert and
oriented times three. Pupils are equal, round, and reactive
to light. Extraocular eye movements are intact. Mucous
membranes are moist. S1, S2 are normal. There is no S3, S4.
There are no murmurs. The heart rate is regular. The chest
was clear to auscultation bilaterally. Abdomen is nontender
and nondistended. The abdomen is soft with positive bowel
sounds. Extremities revealed no clubbing, cyanosis, or
edema. Neurological examination is nonfocal.
LABORATORIES: The white count is 11.5, hematocrit 32.5,
platelets 228, sodium 144, potassium 4.3, chloride 108,
bicarb 23, BUN 19, creatinine 0.9, glucose 134, calcium 10.2,
magnesium 1.6, PTT 150, INR 1.7, PT 16, ALT 55, AST 240, LD
665, CK at 2614, troponin 20.8, alkaline phosphatase is 75,
and total bilirubin is 0.3.
ELECTROCARDIOGRAM: Shows normal sinus rhythm at 100. There
is left axis deviation. There are resolving ST elevations in
II, III, and aVF compared to the electrocardiogram from
before catheterization. There is poor R-wave progression as
well as P-R prolongation.
HOSPITAL COURSE: The patient was initially admitted to the
CCU. She was started on aspirin and Plavix, as well as a
statin. She was initially not started on a beta blocker
given concern for conduction problems with a right
ventricular infarct, but her beta blocker was eventually
started and titrated up. The patient was also started on an
ACE inhibitor, which was also titrated up as tolerated. The
patient was started on a nicotine patch and advised to quit
smoking.
ID: During her hospital stay, the patient developed a
temperature to 101. She was pancultured. The patient also
describes some suprapubic tenderness. Her blood cultures did
show 1/4 bottles with gram-positive cocci. However, this is
felt to be a contaminant as subsequent blood cultures were
negative. She did have one urinalysis that was positive for
leukocyte esterase. Her urine also showed some gram-positive
cocci. The patient was therefore started on levofloxacin for
a seven day course.
Hematology: The patient was noted to drop her hematocrit.
She was transfused 1 unit of packed red blood cells. Studies
revealed that she was iron deficient. She was therefore
started on an iron supplement.
DISCHARGE DIAGNOSES:
1. Inferior ST elevation myocardial infarction, status post
stent to right coronary artery.
2. Ejection fraction 35%.
3. Urinary tract infection.
4. Iron deficiency anemia.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po q day.
2. Plavix 75 mg po q day.
3. Nicotine patch 21 mg transdermal q day.
4. Iron sulfate 325 mg po q day.
5. Pravastatin 20 mg po q day.
6. Toprol XL 50 mg po q day.
7. Lisinopril 30 mg po q day.
8. Levofloxacin 500 mg po q day for seven day course, which
will end on [**2159-5-4**].
DISCHARGE FOLLOWUP: The patient will continue to be followed
by her primary care physician. [**Name10 (NameIs) **] patient will require an
outpatient colonoscopy to investigate her diarrhea. For
cardiology, the patient has a new cardiologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 11493**] at the [**Hospital3 3834**] [**Hospital3 **], phone number
[**Telephone/Fax (1) 11650**]. She will follow up with him on [**5-7**].
The patient will also return to [**Hospital1 **] for T
wave stress test for risk stratification on [**6-5**] at
1:15 pm. She will pick-up a Holter monitor at that time.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2159-4-28**] 12:07
T: [**2159-5-1**] 05:07
JOB#: [**Job Number 49488**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4050
} | Medical Text: Admission Date: [**2165-9-30**] Discharge Date: [**2165-10-9**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
[**2165-10-2**] CABGx3/MV repair
Cardiac Catherization [**2165-9-30**]
History of Present Illness:
Mr. [**Name13 (STitle) 31182**] is an 82 year-old male who was cathed after
presenting to an outside hospital emergency room with exertional
chest pain. This cath revealed a 30% LMCA occlusion, 70% LAD,
and 90% LCx.
Past Medical History:
coronary artery disease and mitral valve disease s/p CABGx3 and
MV repair, prostate cancer, esophagitis, degenerative joint
disease, pulonary embolism and filter placement
Social History:
Mr. [**First Name (Titles) 31182**] [**Last Name (Titles) **] tobacco or alcohol use. He is a retired
mechanic, widowed and lives with his son.
Family History:
Mr. [**Name13 (STitle) 31182**] has no family history of coronary artery disease.
Physical Exam:
At the time of discharge, Mr. [**Name13 (STitle) 31182**] was awake, alert, and
oriented times three. Upon auscultation of his lungs he was
found to be diminished at his bases bilaterally. His heart was
of regular rate and rhythm. His sternum was stable and no
erythema or drainage was noted. His abdomen was soft,
non-tender, and non-distended. He moved his bowels
post-operatively. His extremities were warm and 1+ edema was
noted. His left endovascular vein harvest was clean and dry.
The incisions' steri strips were intact and the left thigh was
ecchymotic. His right anticubital space was noted to be warm
and tender without erythema.
Pertinent Results:
[**2165-9-30**] 06:30PM GLUCOSE-96 UREA N-12 CREAT-0.7 SODIUM-137
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13
[**2165-9-30**] 06:30PM ALT(SGPT)-32 AST(SGOT)-42* CK(CPK)-36* ALK
PHOS-41 AMYLASE-65 TOT BILI-0.9 DIR BILI-0.3 INDIR BIL-0.6
[**2165-9-30**] 06:30PM ALBUMIN-3.6
[**2165-9-30**] 06:30PM WBC-6.4 RBC-4.68 HGB-14.4 HCT-40.5 MCV-87
MCH-30.7 MCHC-35.5* RDW-13.8
[**2165-9-30**] 06:30PM PLT COUNT-215
[**2165-10-9**] 07:30AM BLOOD WBC-9.5 RBC-3.20* Hgb-9.9* Hct-28.4*
MCV-89 MCH-30.8 MCHC-34.7 RDW-14.5 Plt Ct-366
[**2165-10-9**] 07:30AM BLOOD Plt Ct-366
[**2165-10-9**] 07:30AM BLOOD Glucose-109* UreaN-18 Creat-0.9 Na-136
K-4.4 Cl-101 HCO3-26 AnGap-13
[**2165-10-1**] 05:30AM BLOOD ALT-37 AST-42* AlkPhos-45 TotBili-0.9
[**2165-10-1**] 05:30AM BLOOD Triglyc-80 HDL-38 CHOL/HD-2.9 LDLcalc-56
CHEST (PA & LAT) [**2165-10-8**] 3:44 PM
CHEST (PA & LAT)
Reason: pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
82 year old man s/p CABGx3, MV repair
REASON FOR THIS EXAMINATION:
pneumothorax
PA AND LATERAL CHEST
HISTORY: Status post CABG. Mitral valve repair. Prior
pneumothorax.
IMPRESSION: PA and lateral chest compared to [**10-4**] and 7:
Small bilateral pleural effusions have decreased and bibasilar
atelectasis has substantially improved, with a greater residual
on the left. Upper lungs clear aside from borderline vascular
redistribution. The postoperative enlargement of
cardiomediastinal silhouette is stable. No pneumothorax.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications.
Conclusions:
Prebypass: The left atrium is moderately dilated. No atrial
septal defect is
seen by 2D or color Doppler. There is mild regional left
ventricular systolic
dysfunction with LVEF 45=55%.. Resting regional wall motion
abnormalities
include mid anterior and inferior walls. Right ventricular
chamber size and
free wall motion are normal. There are simple atheroma in the
descending
thoracic aorta. The aortic valve leaflets are mildly thickened.
There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. The mitral annular ring appears
well seated and
is not obstructing flow. Moderate to severe (3+) mitral
regurgitation is seen.
The mitral regurgitation jet is eccentric. The posterior leaflet
is mildly
restricted. There is no pericardial effusion.
Post Bypass. Global biventricular function is as prebypass. The
mitral annular
ring appears well seated and is not obstructing flow. There is
no mitral
regurgitation. There is no observed obstruction to flow in the
LVOT. No new
aortic or valvular abnormalities are observed.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mr. [**Name13 (STitle) 31182**] was admitted to [**Hospital1 69**]
for a cardiac catheterization [**2165-9-30**] that revealed an LMCA of
30%, LAD of 70%, and 90% Lcx. A pre-operative echocardiogram
revealed mild to moderate mitral regurgitation.
On [**2165-10-2**] he was brought to the operating room and underwent a
CABGx3/MV repair please see operative report for further
details. He tolerated the procedure well and was transferred in
stable condition to the CSRU. He continued to do well and was
weaned from sedation and extubated. He continued to do well
hemodynamicly and was weaned off all pressors. On postoperative
day 1 was continued to do well and was transferred to [**Hospital Ward Name **] 2.
On postoperative day 2 he developed atrial fibrillation that was
treated with beta blockers and amiodarone. He continued to have
short burst of Afib requiring adjustment of beta blocker. He
was diuresed and anticoagulation was started for atrial
fibrillation. He continued to progress and postoperative day 6
he was ready for discharge. He is in normal sinus rhythm with
Atrial fibrillation rate controlled. Will continue with
physical therapy at rehab. Plan for INR to be checked at rehab
on [**10-11**].
Medications on Admission:
Diltiazem SA 120mg daily
Omeprazole 20mg daily
Oxybutinin 5mg daily
Ultram 50mg TID PRN pain
MVI 1 cap daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
Take 400mg twice a day until [**10-12**] then decrease to 400 mg per
day for seven days and then take 200mg daily .
Disp:*44 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):
please take 3mg [**10-9**], [**10-10**] and have INR checked [**10-11**] - goal
INR 2-2.5 .
15. Outpatient Lab Work
INR as needed
first check [**10-11**] am
Discharge Disposition:
Extended Care
Facility:
[**Hospital 31183**] rehabilitation andNursing Facility
Discharge Diagnosis:
coronary artery disease and mitral valve disease s/p CABGx3 and
MV repair, prostate cancer, esophagitis, degenerative joint
disease, pulonary embolism and filter placement
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, 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
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] in 1 week ([**Telephone/Fax (1) 3183**]) please call for
appointment
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-1**] weeks ([**Telephone/Fax (1) 3183**]) please call for
appointment
Completed by:[**2165-10-9**]
ICD9 Codes: 4240, 4280, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4051
} | Medical Text: Admission Date: [**2176-11-15**] Discharge Date: [**2176-11-21**]
Date of Birth: [**2147-12-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Placement of PICC line
History of Present Illness:
28-year-old Spanish speaking male with a history of etoh abuse
and multiple past seizures for which he was hospitalized at [**Hospital1 2177**]
and [**Hospital1 336**]. He drinks ~l L of vodka/day and has currently has
been abstinant for 2 days until today when he was found down
with emesis and question of seizure. He has had seizures
previously and has been in and out of detox facilities. He does
not recall the events that lead up to him being found down. He
has been having some visual hallucinations recently - seeing men
who are not actually present. He was tremulous and anxious on
admission, and was also complaining of some epigastric pain
without nausea. He has not had any black or bloody stools. He
denies having diarrhea.
ROS: no HA, no cough, no sob, no neck stiffness or photophobia.
+ diffuse body pain/soreness
Past Medical History:
Alcohol abuse
Suspected previousl alcohol withdrawal seziures
Social History:
daily etoh use of one liter of vodka a day
denies other drug use/tobacco
Family History:
unknown
Physical Exam:
PE: vs t 100, bp 140/90, HR 84, RR 16 100%ra
gen: nad, alert and lucid
heent: mild abrasion to face
cvs rrr
resp cta B
abd soft, mild diffuse tenderness
ext no [**Location (un) **]
neuro: no evidence of FND, cn 2-12 intact, moving all 4 limbs.
Pertinent Results:
CXR: Mild pulmonary edema is present accompanied by stable mild
cardiomegaly and progressive mediastinal vascular engorgement.
More focal peribronchial opacification in the right lower lung
could represent a very early pneumonia. There is no
pneumothorax or more than a small right pleural effusion. Tip of
the right PIC line passes as far as the SVC, but the tip is
indistinct, perhaps at the level of the upper right atrium.
[**2176-11-20**] 04:14AM BLOOD WBC-6.4 RBC-3.39* Hgb-11.2* Hct-31.9*
MCV-94 MCH-33.1* MCHC-35.2* RDW-15.7* Plt Ct-190
[**2176-11-20**] 04:14AM BLOOD PT-12.5 PTT-27.5 INR(PT)-1.0
[**2176-11-20**] 04:14AM BLOOD Glucose-84 UreaN-3* Creat-0.7 Na-143
K-3.5 Cl-107 HCO3-24 AnGap-16
[**2176-11-17**] 10:20PM BLOOD ALT-45* AST-142* LD(LDH)-802*
CK(CPK)-4138* AlkPhos-49 Amylase-88 TotBili-1.0
[**2176-11-18**] 02:46PM BLOOD ALT-37 AST-82* LD(LDH)-539* CK(CPK)-2499*
AlkPhos-42 TotBili-0.5
[**2176-11-20**] 04:14AM BLOOD ALT-30 AST-41* CK(CPK)-927* AlkPhos-50
TotBili-0.4
[**2176-11-17**] 10:20PM BLOOD Lipase-137*
[**2176-11-17**] 03:27AM BLOOD CK-MB-22* MB Indx-1.7 cTropnT-<0.01
[**2176-11-17**] 05:46AM BLOOD calTIBC-355 Ferritn-149 TRF-273
[**2176-11-20**] 04:14AM BLOOD VitB12-611 Folate-13.6
[**2176-11-15**] 05:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Over Mr. [**Known lastname 64626**] first 24 hours, he experienced worsening
withdrawal symptoms. He repeatedly removed his IV, and was
demanding very high levels of BZs and constant 1:1 observation.
he was transferred to the [**Hospital Unit Name 153**] for closer observation.
In the [**Hospital Unit Name 153**], Mr. [**Known lastname 13216**] required very high levels of valium
(1500mg over 12 hours), plus ativan, haldol, and versed to
control symptoms per CIWA scale. Elevated AG to 22, attempted to
minimize midazolam and lorazepam since propylene glycol solvent
likely etiology of AG-metabolic acidosis. No urine ketones.
Eventually achieved adquate control of sx's on versed drip, with
monitored daily QTc. Considered starting phenobarb 30mg q6h if
sx's not controlled, but did not have to do so. BZ weaned to
off.
Mr. [**Known lastname 13216**] also was febrile to max 101.8F. CXR showed possible
early RLL PNA. Suspect aspiration as etiology. Was coughing up
brown sputum. Normal wbc, but had pancytopenia, most likely [**1-3**]
marrow suppression [**1-3**] EtOH. Started on 7-day course levo and
flagyl, and was ultimately d/c'ed to complete this course.
PICC line placed. Started on clears on [**11-19**], advanced to
regular diet. Also had evidence of some rhabdo with elevated
CKs, normal trops. Trended down with aggressive hydration.
Creatinine transiently bumpted to 1.3, probably [**1-3**] propylene
glycol or rhabdo, which resolved.
Pt continued to have mild abdominal pain. On PPI, antiemetics.
LFTs elevated, likely fatty liver, which resolved. Guaiac
negative.
Derm consulted for numerous nits visible in scalp and groin
hair. Lice also seen on scalp and groin hair as well as on
clothing in patient's bag. Was treated with Lindane shampoo to
hair-bearing areas - scalp, axilla and groin for two days in a
row, and Lindane lotion applied to. Above regimen was to be
repeated in one week, and he was d/c'ed with the Lindane shampoo
and lotion.
Mr. [**Known lastname 13216**] was transferred to the floor after BZ drips were
tapered to off. He did well on the floor over the next 24 hours,
and did not require any treatment per CIWA scale. He was seen by
case management and social work, and set up to receive free
medications. He was offered lodging at [**Hospital1 **] shelter, but
deferred. He was discharged with multivitamins, the remainder of
his antibiotic course, PPI, Lindane shampoo and lotion, and
contact information for several shelters and substance abuse
centers.
Medications on Admission:
none
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days: Last dose [**2176-11-24**].
Disp:*3 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours) for 3 days: Last dose [**2176-11-24**].
Disp:*9 Tablet(s)* Refills:*0*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Lindane 1 % Shampoo Sig: One (1) application Topical once a
day for 2 doses: Use Lindane shampoo to hair-bearing areas -
scalp, axilla and groin - leave on for 5 minutes daily before
rinsing off, use for two days in a row. Do not apply to
eyelashes if nits become evident here - can simply apply
vaseline to the eyelashes.
.
Disp:*1 bottle* Refills:*0*
8. Lindane 1 % Lotion Sig: One (1) application Topical once a
day for 2 doses: Use Lindane lotion to body - apply, leave on
for eight hours, then wash off.
.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Discharge Condition:
Good. No evidence of withdrawal symptoms, off all withdrawal
meds.
Discharge Instructions:
You have been diagnosed with alcohol withdrawal. You were
treated with medicines to ease your withdrawal. You were also
diagnosed with a possible pneumonia. You are being given three
days more of antibiotics, and should take these medicines as
prescribed.
You also were diagnosed with lice. You were treated with Lindane
shampoo and lotion. It is important that you use these again on
[**11-26**] and [**11-27**] as prescribed.
It is very important for you to cut down on your alcohol intake.
Some resources are listed below. If you feel as though you are
having withdrawal symptoms again, you should return to the ED.
Followup Instructions:
The number for Alcoholics Anonymous in [**Location (un) 86**] is [**Telephone/Fax (1) 11418**].
There is also a Spanish-speaking Alcoholics Anonymous group in
[**Location (un) **], and they can be contact[**Name (NI) **] at [**Telephone/Fax (1) 64627**].
If you reconsider living at [**Hospital1 **] shelter, their phone number
is [**Telephone/Fax (1) 14771**].
ICD9 Codes: 5070, 2762, 2760, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4052
} | Medical Text: Admission Date: [**2141-7-12**] Discharge Date: [**2141-7-21**]
Date of Birth: [**2141-7-12**] Sex: M
Service: NEONATOLOGY
HISTORY: The patient is a 1480 gram product of a 31 week
gestation born to a 31 year old G6, P4-5 woman whose
pregnancy was complicated by maternal asthma, reflux and
occasional smoking.
The mother presented to [**Name (NI) 1474**] Hospital with pre-term labor
at which time she was transferred to [**Hospital1 190**] on the 29th of the month. The patient
received Betamethasone times one on [**7-10**]. The patient
presented the day of delivery with a temperature of 99.5 and
spontaneous rupture of membranes. Mom had received
antibiotics at adequate doses prior to delivery. The
prenatal screen was notable for 0+ antibody negative, Hep
B negative, RPR nonreactive, Rubella immune. The baby was
depressed at delivery, requiring positive pressure
ventilation times several minutes. Apgars 7 and 7.
Upon arrival in Intensive Care Unit, progression of
respiratory distress prompted intubation and the patient was
treated with a dose of Surfactant.
On examination, the patient was pink, nondysmorphic, well
perfused, and well saturated on the ventilator. The skin was
without lesions. The heart was regular rate and rhythm, S1,
S2 were normal and there were no murmurs. Lungs were coarse
bilaterally. The abdomen was benign and the genitalia were
normal. Neurological examination was nonfocal and
the hips were normal.
HOSPITAL COURSE: By systems;
1. Respiratory: The patient was weaned from the conventional
ventilator to C-PAP on hospital day two after receiving only
one dose of Surfactant. The patient weaned off CPAP to room
air by hospital day number three.
On hospital day six, the patient started to have increasing
nasal secretions, had increase work of breathing and was
placed again on a C-PAP of 6 where he remained for two days.
The patient was discontinued from nasal C-PAP to room air 36
hours prior to transfer. The patient is stable on room air
at this time. Initial diagnosis is respiratory distress
syndrome possibly complicated by neonatal pneumonia.
The infant is on caffeine citrate for the management of apnea
of prematurity.
2. Infectious Disease: The patient had an initial CBC that
showed neutropenia (wbc 5.7 - 3 neutrophils, 2 bands, ANC =
285). Follow-up CBC the next day on antibiotics was still
abnormal with a high I:T ratio (wbc 6.0 - 42 neutrophils, 14
bands) A third CBC was finally within normal limits (wbc 16.8
- 44 neutrophils, 4 bands). Based on the initial
presentation, the history of maternal fever, the premature
rupture of membranes, and the persistently abnormal CBCs it
was decided that the patient was to receive at least a 7 day
course of antibiotics with Ampicillin and Gentamicin.
However, on the fourth day of antibiotics, LP was performed
to rule out meningitis. It was a traumatic tap with
excessive number of red blood cells and white blood cells
making it difficult to interpret. Repeat LP's on hospital
days number 6 and 7 both revealed an increased white blood
cell to red blood cell ratio (last LP 250 wbcs-22polys, 28
lymphs, 41 monos; 6425 rbcs, 124 protein, 41 glucose). The
culture and Gram stain on all of the LP's were negative. The
initial culture on the first LP is no growth and final and
the others are no growth and pending.
It was decided, based on the patient's clinical course,
abnormal CBCs, the unreliability of the cultures and the
disproportionate white to red blood cell count in the spinal
fluid to treat for possible meningitis. He is currently on
day number 8 of 21 of antibiotics and has had normal
gentamicin peak and trough levels (trough 1.7/peak 9.0).
3. Cardiovascular. The patient had no cardiovascular issues
during this admission.
4. Fluids, electrolytes and Nutrition: The patient was
initially NPO and maintained on intravenous fluids. The
patient did not have any metabolic or electrolyte
derangements and transition from intravenous fluids to
gavage feeds went well. He is currently receiving 150
cc/kilo of breast milk, 22 Kcal/ounce. The plan to steadily
increase the patient's caloric intake as he tolerates. The
patient has had no other fluid or electrolyte problems this
admission and was stable on full feeds on transfer.
The infant was treated with phototherapy for
hyperbilirubinemia. Peak level was 8.7 on [**2141-7-13**]. Level on
[**2141-7-21**] was 2.9/0.2.
5. Neurology: The patient had a head ultrasound on hospital
day #4 which showed a right Grade 1 intraventricular
hemorrhage. (This may have had some bearing on the results
of the LP.) The ventricles were asyymetric with the left
being larger than the right. The plan was to repeat an
ultrasound of the head in one week's time at day of life #12
or Monday, the 12th.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To a Level 2 nursery at [**Hospital 1474**]
Hospital.
Care Recommendations:
FEEDINGS: gavage feedings at 150 cc/kilo/day of breast milk,
22 Kcal. Increase calories as tolerated.
MEDICATIONS: Caffeine 5 mg/kilo/day.
SCREENING: Repeat HUS Monday [**7-24**]. The infant will need eye
screening monitoring for retinopathy of prematurity. The
patient has not had a car seat or hearing screen yet. He will
need this prior to discharge.
The patient has had two sets of newborn state screens sent.
The patient has not received any immunizations. At 2months or
2 kilograms, he should receive the hepatitis B vaccine.
Other immunizations recommended (besides the routine
immunizations) are Synagis RSV prophylaxis for patient's
discharged [**Month (only) 359**] through [**Month (only) 547**] and are less than 32 weeks,
between 32 and 35 weeks with plans for day care, with a
smoker in the house, or with preschool sibs or patients with
chronic lung disease. The patient falls under the guise of
none of these. Influenza immunization should be considered
annually in the fall for preterm infants with chronic lung
disease once they reach 6 months of age. For this age, the
family and other care givers should be considered for
immunizations against influenza to protect the infant.
PRIMARY CARE PHYSICIAN:
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**]
Pediatric Associates Inc. of [**Hospital1 1474**]
[**Street Address(2) 43830**]
[**Hospital1 1474**], [**Numeric Identifier 8728**]
Phone: [**Telephone/Fax (1) 43831**]; fax: [**Telephone/Fax (1) 43832**]
DISCHARGE DIAGNOSIS: Prematurity, respiratory distress
syndrome, apnea of prematurity, hyperbilirubinemia, right
Grade 1 IVH, suspected sepsis and meningitis.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**First Name3 (LF) 43833**]
MEDQUIST36
D: [**2141-7-21**] 16:30
T: [**2141-7-21**] 16:40
JOB#: [**Job Number 43834**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4053
} | Medical Text: Admission Date: [**2196-10-26**] Discharge Date: [**2196-11-7**]
Date of Birth: [**2127-7-19**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Iodine
Attending:[**First Name3 (LF) 52022**]
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
Right total knee replacement
Central line placement
History of Present Illness:
69 [**Last Name (un) **] woman with h/o PVD, DVT, and OA. complaining of severe,
incapacitating right knee pain. Patient has been complaining of
increasing knee pain over the past few years, now limiting daily
activities.
Past Medical History:
hypertension
renal insuffiency
hx left leg DVT
dementia
schizo-affective disorder
major depressive disorder
osteroarthritis both knees
Social History:
resident of [**Hospital1 **] Seniior Care pf [**Location (un) 55**]
health care proxy : [**Name (NI) 622**] [**Last Name (NamePattern1) **] [**Name (NI) **]( daughter) [**Telephone/Fax (1) 57213**]
ambulates with walker and assistance
history of falls
no history of smoking or alcohol use
Family History:
unknown
Physical Exam:
Gen-Alert/oriented, NAD
VS-98.2, 160/92, 70, 16, 96%RA
HEENT-PERRL
CV-RRR
Lungs-CTA bilat
Abd-soft NT/ND
EXT: RLE-incision clean/dry/intact without evidence of
infection. +[**Last Name (un) 938**]/FHL/AT.
Pertinent Results:
[**2196-10-26**] 11:23PM CK-MB-3 cTropnT-0.04*
[**2196-10-26**] 06:39PM WBC-22.0*# RBC-3.16* HGB-10.5* HCT-29.9*
MCV-95 MCH-33.1* MCHC-35.0 RDW-16.1*
[**2196-10-26**] 12:02PM HGB-11.9* calcHCT-36
Brief Hospital Course:
Patient had been followed by Dr. [**Last Name (STitle) **] in clinic where it had
been recommended that patient have an elective right total knee
replacement. Consent was obtained prior to surgery. Patient was
admitted on [**2196-10-26**] for right total knee replacement. During
surgery patient had significant blood loss because a tourniquet
was not used, due to the fact that patient has severe arterial
insufficiency. Please see op-note [**2196-10-26**]. Post-op patient was
taken to the Medical/surgical intensive care unit for treatment
of hypovolemia. Over the next two days in the unit patient was
stabilized. After three days in the unit patient was transferred
to the orthopedic floor. HCT remained stable at 30. However INR
was elevated at 4.6, Coumadin was held. Patient developed
hypernatremia. Patient was started on D5W for treatment of free
water deficit. Hypernatremia improved with IV fluids,but sodium
remained elevated at 149. Discharge was arrangeded with
geriatric team with the plan that chemistries would be followed
at rehabilitation center. Patient remained afebrile/vital signs
stable. HCT remained stable. Patient was discharged to rehab in
stable condition.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3)
Capsule, Sust. Release 24HR PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig:
One (1) Tablet PO BID (2 times a day).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Per slide scale.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day): PLease hold for SBP <100 or HR <60.
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q4-6H (every
4 to 6 hours) as needed for pain.
16. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
20. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID (3 times a day) for 3
days.
21. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime for 3
weeks: Goal INR 2.0
Please check 2xweekly
-PLease have HO adjust dose to meet goal INR.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Right total knee replacement
hypernatremia
Discharge Condition:
stable
Discharge Instructions:
Please cont with weight bearing as tolerated right leg with a
walker assist. Cont. with physical therapy. Oral pain medication
as needed. Coumadin for anti-coagulation, goal INR 2.0-2.5,
please check INR 2x weekly, please have HO adjust to meet goal
INR. Please call/return if any fevers, increased discharge from
incision or trouble breathing.
Physical Therapy:
Activity: Activity as tolerated
Pneumatic boots
Right lower extremity: Partial weight bearing
Left lower extremity: Full weight bearing
CPM as tolerated
Treatments Frequency:
Please keep incision clean/dry.
-once incision is dry may leave open to air
-Please do not soak or scrub incision
-If incision gets wet, please pat dry.
-staples to be removed at follow-up appt.
Coumadin:
Goal INR 2.0-2.5, please check INR prior to first dose at rehab.
Please check INR 2x weekly, please have HO adjust dose to meet
goal INR.
-once pt is discharge home, please call results to [**Telephone/Fax (1) 9118**]
attn [**Doctor Last Name **] Brown
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 10657**] Date/Time:[**2196-11-11**]
10:45
Please follow-up with PCP:[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 719**] next week.
For follow-up on elevated sodium levels. Please call this week
for appt.
Completed by:[**2196-11-7**]
ICD9 Codes: 2851, 5185, 2760, 5849, 5859, 4439, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4054
} | Medical Text: Admission Date: [**2185-9-2**] Discharge Date: [**2185-9-7**]
Date of Birth: [**2119-10-5**] Sex: M
Service: SURGERY
Allergies:
Penicillins / morphine
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
abdominal pain around umbilicus
Major Surgical or Invasive Procedure:
[**2185-9-2**]
Repair of ventral hernia with mesh.
History of Present Illness:
65M s/p prostatectomy in [**2185**] and most recently 7 wks of
radiation therapy ending in [**Month (only) **] for rising PSA, now presents w/
24 hrs of focal periumbilical pain and a palpable firm mass in
the same location. The pain started suddenly around 6 pm last
night after moving some heavy furniture. He had some nausea and
1 episode of vomiting this morning of stomach contents. He
denies
any fevers or chills. Last BM was yesterday and was normal. He
states that this has never happened before and he has no
knowledge of having an umbilical or ventral hernia.
Past Medical History:
PMH: prostate cancer, s/p prostatectomy in [**2185**] and 7 wks of
radiation ending in [**2185-6-1**], hypercholesterolemia, depression,
colon polyps or colon adenomas.
PSH: prostatectomy [**2185**] at [**Hospital1 112**], arthroscopic R shoulder surgery
Social History:
nonsmoker, drinks 2-3 beers/day, lives in [**State 3914**], home
lighting designer
Family History:
non contributory
Physical Exam:
Temp 98.5 HR 68 BP 153/81 RR 16 O2 sat 99%
GEN: NAD, A&Ox3
Head: NCAT, EOMI, PERLLA
CV: RRR nl S1,S2
Pulm: CTAB
Abd: Firm, tender, 2 inch diameter protrusion under the skin
inch
or so superior and to the right of the umbilicus with no
overlying skin changes. Unable to reduce mass into abdomen. Rest
of abd soft, non-tender, with normal bowel sounds. Voluntary
guarding w/ palpation of mass. No rebound.
Ext: nml strength, no edema
Pertinent Results:
[**2185-9-2**] 06:20PM WBC-13.1* RBC-5.07 HGB-15.8 HCT-44.4 MCV-88
MCH-31.0 MCHC-35.5* RDW-12.7
[**2185-9-2**] 06:20PM NEUTS-90.9* LYMPHS-4.9* MONOS-3.9 EOS-0.1
BASOS-0.2
[**2185-9-2**] 06:20PM PLT COUNT-327
[**2185-9-2**] 06:20PM PT-12.1 PTT-19.5* INR(PT)-1.0
[**2185-9-2**] 06:20PM GLUCOSE-136* UREA N-19 CREAT-1.0 SODIUM-142
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-18
[**2185-9-2**] 06:28PM LACTATE-2.0
[**2185-9-2**] CTA chest/abd/pelvis :
1. High-grade small-bowel obstruction with probable transition
point seen in the mid abdomen, possibly due to adhesion. No
evidence of pneumatosis.
2. No evidence of pulmonary embolism.
3. Bibasilar consolidation, likely atelectasis. The presence of
underlying
aspiration/infection cannot be entirely excluded
Brief Hospital Course:
Mr. [**Known lastname 6323**] was evaluated by the Acute Care team in the Emergency
Room and based on his symptoms and physical exam he had an
incarcerated ventral hernia which required urgent surgery. He
was taken to the Operating Room on [**2185-9-2**] and underwent a repair
of his hernia. He tolerated the procedure well and returned to
the PACU in stable condition. He maintained stable hemodynamics
and his pain was minimal.
Following transfer to the Surgical floor he was able to use his
incentive spirometer and ambulate independently. On POD #2 he
developed nausea and vomiting associated with hypoxia. His
chest Xray showed bibasilar atelectasis and he was transferred
to the SICU for close monitoring. He underwent a CTA of the
chest which revealed bibasilar atelectasis and no pulmonary
embolism. He underwent chest PT and increased use of his
incentive spirometer along with bronchodilators although he
never had wheezing on exam. His O2 requirements gradually
decreased and on 2L nasal cannula he was 95% saturated.
He was transferred back to the Surgical floor on [**2185-9-5**] and
began to make good progress. His diet was gradually advanced to
regular and he tolerated it well. His abdominal wound was
healing well without erythema or drainage and he had minimal
pain. As he quickly improved, he was ambulating without
difficulty and was discharged on [**2185-9-7**]. He will be staying
with a friend in [**Name (NI) 8**] until his follow up appointment as
his home is in [**State 3914**].
Medications on Admission:
lovastatin 40', ASA 81', mvi'
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Incarcerated ventral hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-10**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
Call the Acute care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 2 weeks for staple removal.
Completed by:[**2185-9-7**]
ICD9 Codes: 5180, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4055
} | Medical Text: Admission Date: [**2147-10-17**] Discharge Date: [**2147-10-24**]
Date of Birth: [**2080-11-30**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Sixty-six year old woman with
past medical history of asthma, CHF, sarcoidosis Stage IV
admitted to [**Hospital6 **] [**8-24**] to [**9-7**] for asthma,
CHF with hospital course complicated by lower GI bleed on
[**9-17**]. Was brought into [**Hospital1 69**]
on [**9-21**]. Was revived by transfusion and had a CHF
exacerbation during colonoscopy. Refused rehab and was sent
home with PT.
Patient was able to walk, was doing well in the first few
weeks until four days prior to admission, when she began to
feel weaker. Had some lower extremity edema and started her
Lasix, however, she was having some shortness of breath and
this worsened over the past week. Finally, the patient's
shortness of breath caused her decreased sleep, so she came
to the ED for evaluation. Had not noticed fevers, but has
been having chills over the last three days, plus cough times
a week nonproductive, increased nebulizer use, no headache,
no chest pain, no abdominal pain, no dysuria, no bright red
blood per rectum, no diarrhea, increased lower extremity
edema.
PAST MEDICAL HISTORY:
1. Recent lower GI bleed.
2. Stage IV sarcoidosis.
3. Hypertension.
4. Asthma.
5. Status post bilateral breast implants.
6. Status post right shoulder arthroplasty.
7. CHF, mild diastolic on 1 liter of home O2.
SOCIAL HISTORY: No tobacco and no alcohol. [**Hospital 8735**] medical
assistant.
FAMILY HISTORY: Breast cancer, uterine cancer, diabetes.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Lansoprazole.
2. Verapamil 240 a.m. and 120 p.m.
3. Advair b.i.d.
4. Combivent prn.
5. Lasix 20 prn with increase in weight.
6. Multivitamins.
PHYSICAL EXAMINATION: On physical exam, the patient was
febrile to 101. Sating 96% on 4 liters nasal cannula. CVS:
Tachycardic, 2/6 systolic ejection murmur. Respirations:
lungs are clear to auscultation bilaterally.
ADMISSION LABORATORIES: Significant for a white count of
11.3, normal differential, hyponatremia. Sodium 132,
potassium 5.8, however, sample was hemolyzed, subsequent was
normal.
Chest x-ray showed bilateral apical scarring, left lower lobe
consolidation consistent with pneumonia, bilateral pleural
thickening.
Her recent echocardiogram of [**2145**] showed mild left
ventricular hypertrophy, ejection fraction of 65, left
ventricular outflow tract obstruction, decreased compared to
prior echocardiogram 60 mm Hg [**1-19**]+ MR.
HOSPITAL COURSE: Patient was admitted to the hospital. Was
diuresed with furosemide with good response. However, mild
improvement of her shortness of breath. Patient was also
treated with levofloxacin p.o. 500 q.d. for her pneumonia.
While on the floor, the patient had an acute exacerbation of
her shortness of breath. She was tachypneic, desatting in
respiratory distress. She was ruled out for PE with CTA and
bilateral LENIs. Was transferred to the MICU for noninvasive
BiPAP ventilation. Was started on p.o. prednisone at a dose
of 50 mg p.o. q.d. and improved rapidly. Her levofloxacin
was changed over to 500 IV q.d.
Patient remained in the MICU for three days, and was
subsequently transferred back to the floor with much improved
condition. Her shortness of breath had resolved. She was
started on a prednisone taper.
FINAL DIAGNOSES:
1. Pneumonia.
2. Sarcoid exacerbation.
3. Diastolic congestive heart failure.
4. Left ventricular outflow tract obstruction.
MEDICATIONS ON DISCHARGE:
1. Advair Diskus.
2. Fluticasone.
3. Salmeterol one puff b.i.d.
4. Pantoprazole 40 mg p.o. q.d.
5. Verapamil 240 mg p.o. b.i.d.
6. Bactrim 3x a week.
7. Nasal spray NACL.
8. Albuterol and ipratropium 1-2 puffs q.4-6h. prn.
9. Prednisone taper, rapid taper from 50 mg to 0 over two
weeks with three days of 50, three days of 40, 30, 20, 10, 5,
2.5, and none.
10. Levofloxacin 500 mg p.o. q.d. for the remaining seven
days for a total of 14 day course.
Patient is to check her fingersticks to monitor her blood
sugars which increase when she takes prednisone, however, no
insulin was prescribed.
FOLLOW-UP INSTRUCTIONS: Follow up with Pulmonary with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**University/College 14925**]Medical Center in [**1-19**] weeks
and Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 3510**], her PCP [**Last Name (NamePattern4) **] [**1-19**] weeks.
DISCHARGE CONDITION: Improved and stable. Patient was sent
home on home O2 with VNA services, and home PT, respiratory
therapy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12157**], M.D. [**MD Number(1) 12158**]
Dictated By:[**Name8 (MD) 757**]
MEDQUIST36
D: [**2147-10-25**] 15:48
T: [**2147-10-27**] 07:41
JOB#: [**Job Number 94840**]
ICD9 Codes: 486, 4280, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4056
} | Medical Text: Admission Date: [**2114-1-29**] Discharge Date: [**2114-2-6**]
Date of Birth: [**2039-7-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Demerol
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Mental status change
Major Surgical or Invasive Procedure:
R nephrostomy tube placement
History of Present Illness:
74 yo female with h/o chronic pain, depression, urinary
incontinence and hypothyroidism found in her bed by her health
aide surrounded in "old Urine". Patient was last seen last Thurs
and at that time was not herself. She is usually active and can
do all ADLS, but health aide felt she was not herself. Patient
was alert today when she was found lying supine in bed, but not
oriented. She as also not responding to commands by the aide.
EMS called, and on arrival found the patient to be diaphoretic,
with depressed RR, and constricted pupils. Narcan 0.5mg times 1
given and patient more responsive. Her HR 130 84% RA and SBP
86/42. Patient brought to [**Hospital1 18**]. In the ED, Temp 101.8, HR
130s, 84%RA, RR 32 and BP 129/85. Patient was given 3L NS, and
Levo and Flagyl. SBP < 89/52. LIJ placed and Levophed started.
Patient's c-spine cleared. CXR with LLL PNA. Patient admitted to
the MICU for sepsis.
.
In the MICU, CT Abd showed R hydronephrosis and hydroureter with
9mm stone. Pt had a percutaneous R nephrostomy tube placed with
frank pus draining out. Pt was found to have Ecoli in blood
cxs, and cxs from pus drained from kidney pend. Pt was started
on decadron, weaned from levophed, and continued on Vanco, Levo
and Flagyl to cover from likely source of kidney abscess. Pt
was found to be prerenal and was fluid resuscitated. TTE showed
EF 60%, 1+ MR, 1+ AR, no pulm HTN. EKGs were unchanged. Heme
consult recs thrombocytopenia was in setting of sepsis. Pain
control was maintained without narcotics, of which the patient
has taken high doses for years for severe DJD.
Past Medical History:
1. Falls
2. DJD on chronic pain medications
3. hypothyroidism
4. compression fractures in lumbar spine/chronic low back pain
5. depression
6. ovarian CA- s/p resection
7. hypercholesterolemia
8. osteoporesis
9. urinary incontinence- stress and overflow
10. breast mass-needs repeat mammogram
Social History:
Lives alone, has health aide help, very active and avid
traveller, no TOB, occ ETOH. Pt is noncompliant with medical
care.
Family History:
Brother in [**Name (NI) **] with MI x 2
Physical Exam:
97.4 / 120/82 / 100 / 20 / 98% RA
Gen: Mildly confused, sitting in chair comfortably
HEENT: Hematoma at RIJ (line attempt), LIJ in, JVD cannot be
assessed, no LAD, OP clear, dry mm
Lungs: Bronchial breath sounds L base, quiet rales R base
Heart: RRR, no m/r/g
Abdomen: Soft, +BS, ND, NT
Extr: No c/c/e
Skin: No rashes
Neuro: [**3-21**] motor, 2+ DP pulses bilaterally, CN2-12 intact
Pertinent Results:
CXR:
1. Mild congestive heart failure with left pleural effusion.
2. Left lower lobe pneumonia.
3. Equivocal dilated bowel loops in the upper abdomen.
.
CT HEAD:
Negative for bleed or mass or edema
.
CT C-spine:
DJD, no Fx
.
EKG: sinus tach at 131, no ST elevations, peaked T waves v2-v3
.
CT ABDOMEN:
R hydronephrosis and hydroureter with 9mm stone. Had
percutaneous nephrostomy with frank pus out.
.
[**2114-1-29**] 11:04PM GLUCOSE-84 UREA N-127* CREAT-4.2* SODIUM-149*
POTASSIUM-3.8 CHLORIDE-116* TOTAL CO2-20* ANION GAP-17
[**2114-1-29**] 11:04PM ALT(SGPT)-24 AST(SGOT)-61* LD(LDH)-340*
CK(CPK)-1182* ALK PHOS-312* TOT BILI-2.3*
[**2114-1-29**] 11:04PM LIPASE-33
[**2114-1-29**] 11:04PM CK-MB-20* MB INDX-1.7 cTropnT-<0.01
[**2114-1-29**] 11:04PM ALBUMIN-1.9* CALCIUM-6.3* PHOSPHATE-1.8*
MAGNESIUM-1.7
[**2114-1-29**] 11:04PM WBC-31.3*# RBC-3.45* HGB-9.9* HCT-28.3*
MCV-82 MCH-28.7 MCHC-35.0 RDW-15.6*
[**2114-1-29**] 11:04PM PLT COUNT-18*
[**2114-1-29**] 11:04PM PT-15.3* PTT-22.0 INR(PT)-1.4*
[**2114-1-29**] 11:04PM FDP-10-40
[**2114-1-29**] 11:04PM FIBRINOGE-720* D-DIMER-1576*
[**2114-1-29**] 11:04PM RET AUT-0.3*
[**2114-1-29**] 10:24PM TYPE-ART PO2-87 PCO2-34* PH-7.39 TOTAL CO2-21
BASE XS--3
[**2114-1-29**] 09:07PM TYPE-ART PO2-251* PCO2-33* PH-7.26* TOTAL
CO2-15* BASE XS--11
[**2114-1-29**] 09:07PM LACTATE-1.7
[**2114-1-29**] 09:07PM freeCa-1.01*
[**2114-1-29**] 05:08PM TYPE-[**Last Name (un) **] PH-7.29*
[**2114-1-29**] 05:08PM LACTATE-2.1*
[**2114-1-29**] 05:08PM freeCa-0.90*
[**2114-1-29**] 04:55PM GLUCOSE-149* UREA N-135* CREAT-4.4*#
SODIUM-140 POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-16* ANION
GAP-18
[**2114-1-29**] 04:55PM CALCIUM-6.0* PHOSPHATE-2.4* MAGNESIUM-1.8
[**2114-1-29**] 04:55PM CORTISOL-63.2*
[**2114-1-29**] 04:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2114-1-29**] 04:55PM WBC-9.2# RBC-3.92* HGB-11.7* HCT-32.6* MCV-83
MCH-29.8 MCHC-35.9* RDW-15.5
[**2114-1-29**] 04:55PM PLT COUNT-20*
[**2114-1-29**] 04:55PM PT-15.2* PTT-22.0 INR(PT)-1.4*
[**2114-1-29**] 04:29PM IRON-18*
[**2114-1-29**] 04:29PM calTIBC-163* VIT B12-224* FOLATE-8.1 TRF-125*
[**2114-1-29**] 04:29PM CORTISOL-61.5*
[**2114-1-29**] 03:57PM TYPE-MIX TEMP-36.1 PO2-32* PCO2-37 PH-7.29*
TOTAL CO2-19* BASE XS--8 INTUBATED-NOT INTUBA
[**2114-1-29**] 03:57PM LACTATE-1.6
[**2114-1-29**] 03:57PM O2 SAT-52
[**2114-1-29**] 03:43PM LD(LDH)-253*
[**2114-1-29**] 03:43PM HAPTOGLOB-295*
[**2114-1-29**] 03:43PM CORTISOL-50.0*
[**2114-1-29**] 03:43PM FIBRINOGE-837*#
[**2114-1-29**] 03:43PM RET AUT-0.3*
[**2114-1-29**] 11:30AM LACTATE-3.1* K+-3.4*
[**2114-1-29**] 11:15AM GLUCOSE-100 UREA N-158* CREAT-5.9*#
SODIUM-138 POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-19* ANION GAP-25*
[**2114-1-29**] 11:15AM ALT(SGPT)-15 AST(SGOT)-25 ALK PHOS-635*
AMYLASE-16 TOT BILI-1.6*
[**2114-1-29**] 11:15AM CK(CPK)-354*
[**2114-1-29**] 11:15AM LIPASE-29
[**2114-1-29**] 11:15AM CK-MB-8 cTropnT-0.02*
[**2114-1-29**] 11:15AM ALBUMIN-2.4*
[**2114-1-29**] 11:15AM CALCIUM-7.5* PHOSPHATE-1.9*# MAGNESIUM-2.3
[**2114-1-29**] 11:15AM TSH-1.2
[**2114-1-29**] 11:15AM FREE T4-0.8*
[**2114-1-29**] 11:15AM CORTISOL-84.1*
[**2114-1-29**] 11:15AM CRP-296.1*
[**2114-1-29**] 11:15AM WBC-24.2*# RBC-4.55 HGB-13.6 HCT-37.0
MCV-81*# MCH-29.8 MCHC-36.7* RDW-15.3
[**2114-1-29**] 11:15AM NEUTS-80* BANDS-6* LYMPHS-9* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2114-1-29**] 11:15AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2114-1-29**] 11:15AM PLT SMR-VERY LOW PLT COUNT-26*#
[**2114-1-29**] 11:15AM PT-14.1* PTT-21.9* INR(PT)-1.2*
[**2114-1-29**] 11:15AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2114-1-29**] 11:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2114-1-29**] 11:15AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**2-18**]
Brief Hospital Course:
74 F with PMH chronic pain from DJD, hypothyroidism, urinary
incontinence, now with resolving Ecoli sepsis from R renal
abscess and change in mental status.
.
# Ecoli sepsis / R renal abscess:
In the MICU, pt was in septic shock, with SBP 80-90s. CT Abd
showed R hydronephrosis and hydroureter with 9mm stone. Pt had
a percutaneous R nephrostomy tube placed by IR with frank pus
draining out. Pt was found to have Ecoli in blood cxs, and cxs
from pus drained from kidney also was positive for Ecoli. Pt
was started on decadron, weaned from levophed, and continued on
Vanco, Levo and Flagyl to cover from likely source of kidney
abscess. Pt was found to be prerenal and was fluid
resuscitated. Pt was stabilized, transferred to the medical
floor, where she was continued on Levo only. Likely reason for
pt's changed mental status and being found in "old urine" is R
renal pyogenic abscess, and also narcotic use. Pt will be
following up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] for lithotripsy of R 9 mm
stone. Pt will need to be monitored as outpatient for
resolution of infection.
.
# ARF:
Resolved. Cr 2.2 on admission, baseline 0.9 by discharge.
Likely prerenal and also in setting of R renal abscess, was
fluid resuscitated in MICU. Meds were renally dosed.
.
# Thrombocytopenia:
Resolved. Heme consult stated thrombocytopenia was most likely
in the setting of sepsis. Pt has a history of GIB. Will keep
Hct > 28 and Plt > 10 as long as no signs of bleeding.
.
# Mental status change:
Pt was very confused and was drowsy on and off in the MICU, but
on the floor, pt became completely clear and articulate, able to
communicate. At her baseline, she is functional with full adls.
Benzos and narcotics were minimized, keeping her on methadone
10 [**Hospital1 **] and oxycodone Q6H prn. Pt has history of narcotic abuse.
Pt's mental status on admission was likely due to a combination
of taking too much narcotics and sepsis.
.
# History of urinary incontinence:
Pt has history of urinary incontinence, likely from narcotic
use. Foley will be maintained in place until urology f/u with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**].
.
# Cardiac status:
CXR had shown questionable CHF. Pt was ruled out for MI. Pt
has no history of CHF or cardiac dz. TTE showed EF 60%, 1+ MR,
1+ AR, no pulm HTN. EKGs were unchanged.
.
# Hypothyroidism:
Levoxyl was continued per home regimen.
.
# Chronic pain from DJD / Narcotic abuse:
Pt has a history of chronic narcotic use for DJD pain control.
Narcotics were not given in MICU, for lack of patient's pain,
but pt was placed on flexeril, tylenol RTC, methadone 10 [**Hospital1 **],
oxycodone prn. Pt initially had signs of narcotic withdrawal on
floor (diffuse abdominal pain, restlessness and discomfort) that
had resolved upon discharge.
.
# Nutrition:
Pt was placed on a pureed renal diet.
.
Communication: sons- [**Doctor Last Name 103983**] [**Telephone/Fax (1) 103984**] and [**Name (NI) **] (HCP)-
[**Telephone/Fax (1) 103985**]
Medications on Admission:
1. Ambien 5mg PO QHS: PRN
2. Fosamax 70mg Q WEEK
3. Percocet 1 -2 tabs 4-6H: PRN
4. Methadone 30mg/40mg 30mg
5. Vitamin D 2 tabs QD
6. MVI QD
7. Lipitor 10mg QD
8. Levoxyl 88mcg QD
9. Docusate 100mg [**Hospital1 **]
Discharge Medications:
1. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*4*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Methadone 10 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
8. Heparin
5000 units SC TID until fully ambulatory
9. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
10. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
11. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
Disp:*30 Tablet(s)* Refills:*2*
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
15. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
17. Synthroid 88 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Principal:
1. E.Coli Bacteremia and Septic Shock.
2. Right Pyelonephritis and renal abscess.
3. 9 mm right ureteral stone w/ hydronephrosis and hydroureter.
4. Acute Renal Failure.
5. Left Lower Lobe Pneumonia.
6. Delirium.
7. Cholestasis of sepsis.
8. Thrombocytopenia of sepsis.
9. Vitamin B12 Deficiency.
Secondary:
1. DJD with chronic pain and opioid use.
2. Hypothyroidism.
3. Osteoporosis.
4. Ovarian cancer s/p resection.
5. Urinary incontinence.
6. Depression.
7. Hypercholesterolemia.
8. Hypothyroidism.
9. Urinary incontinence.
10. Hypertension.
11. Abnormal mammogram requiring outpatient follow-up.
Discharge Condition:
Fair, VS stable, pain controlled
Discharge Instructions:
Please return to the emergency room if you experience dizziness,
pain in your flanks, chest pain, shortness of breath, abdominal
pain, or other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 9977**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2114-2-16**]
10:40
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 103986**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2114-3-6**] 1:30
Urology in 1 week.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD
Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2114-2-20**] 9:20
Completed by:[**2114-2-11**]
ICD9 Codes: 486, 2761, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4057
} | Medical Text: Admission Date: [**2168-12-28**] Discharge Date: [**2169-1-3**]
Service:
HISTORY OF PRESENT ILLNESS: This is an 80-year-old Russian-
speaking male with a history of coronary artery disease
(status post coronary artery bypass graft), type 2 diabetes,
and chronic renal failure who presents with two days of
extreme shortness of breath at rest and dull 7/10 chest pain
with radiation to the left shoulder. Positive paroxysmal
nocturnal dyspnea, two-pillow orthopnea, and positive
peripheral edema. The patient has not had any change in his
medications or diet. The patient saw his primary care
physician this morning and was noted to be hypoxic and was
sent to the Emergency Department.
In the Emergency Department, found to have evidence of
congestive heart failure and acute renal failure with a
creatinine of 3.2 (baseline of 2) and ST depressions in V2 to
V4 on electrocardiogram. The patient was given aspirin and
started on a heparin drip. He was given Plavix,
nitroglycerin, and morphine and is now pain free. The
patient was also given one dose of Lasix with minimal
response.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post coronary artery
bypass graft in [**2157**]; status post cardiac catheterization
in [**2168-3-22**] at an outside hospital (no stents
placed).
2. Type 2 diabetes with nephropathy; baseline creatinine of
2.
3. Chronic renal failure.
4. Peripheral vascular disease with right leg
revascularization.
5. Hyperlipidemia.
6. Back pain secondary to spinal stenosis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lasix 20 mg once per day.
2. Atenolol 100 mg once per day.
3. Lisinopril 20 mg once per day.
4. Cardia 30 mg twice per day.
5. Lipitor 40 mg once per day.
6. Aspirin 81 mg.
7. Avandia 8 mg once per day.
8. Acarbose 25 three times per day.
9. Neurontin 300 three times per day.
10. Glyburide 5 mg twice per day.
11. Nitroglycerin as needed.
SOCIAL HISTORY: Healthcare proxy is son. [**Name (NI) **] alcohol,
tobacco, or drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 97,
heart rate was 54, blood pressure was 118/91, breathing at
15, and 90 percent on a nonrebreather. Generally, in no
acute distress. No accessory muscle use. Head, eyes, ears,
nose, and throat examination revealed jugular venous pressure
elevated to the angle of the jaw. The mucous membranes were
moist. Cardiovascular examination revealed a regular rate
first heart sounds and second heart sounds. Positive third
heart sound. No murmurs. The lungs with crackles two thirds
of the way up with diffuse wheezing. Abdomen with positive
bowel sounds and nontender. Mild distention, tympanitic to
percussion. Lower extremities with 2 plus lower extremity
edema bilaterally. Distal pulses were intact bilaterally.
Neurologically, alert. Cranial nerves II through XII were
intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: Notable for
white count of 10.2, hematocrit was 32.5, and platelets were
161. INR was 1.1. Potassium elevated at 5.8, blood urea
nitrogen was 95, creatinine was 3.2, glucose was 352.
Creatine kinase elevated at 1030, MB was 15, and troponin was
0.85. Urinalysis was negative.
PERTINENT RADIOLOGY-IMAGING: A chest x-ray showed evidence
of congestive heart failure with pulmonary edema.
An electrocardiogram showed sinus bradycardia, normal
intervals, T wave inversions in V2 through V4, and ST
depressions in V2 through V4. These were new changes
compared to prior examination.
IMPRESSION: This is an 80-year-old male with coronary artery
disease (status post coronary artery bypass grafting in [**2157**])
here with a non-ST-elevation myocardial infarction and acute
congestive heart failure with hypoxia requiring supplemental
oxygen.
SUMMARY OF HOSPITAL COURSE:
1. CARDIOVASCULAR ISSUES: (a) Coronary artery disease: The
patient was continued on aspirin, Plavix, and statin. The
patient was started on a heparin drip and nitroglycerin
drip. Currently chest pain free. The patient was
ultimately weaned from the nitroglycerin drip. Cardiac
catheterization was considered. The patient continued to
be a good candidate cardiac catheterization; however,
limited by poor renal function. The patient was continued
on aspirin, Plavix, statin, beta blocker, and ACE
inhibitor. His treatments were optimized during hospital
course. Ultimately, the patient did not receive a cardiac
catheterization and will follow up as an outpatient.
(b) Pump: The patient demonstrated an ejection fraction of
30 percent with multiple wall motion abnormalities. ACE
inhibitor was restarted. The patient was initially managed
on a Lasix drip for diuresis; however, was diuresing
adequately off the Lasix drip. Current presentation thought
to be due to decompensated heart failure. The patient was
started on spironolactone. Medications were titrated to
optimize congestive heart failure.
(c) Rhythm: Remained stable on telemetry.
1. PULMONARY ISSUES: The patient with significant diuresis
during the course of hospitalization but still required
oxygen. The patient was given nebulizers and incentive
spirometry. Upon optimization of cardiac regimen, the
patient's oxygen requirement decreased, and oxygen
saturations were stable on room air.
1. ACUTE RENAL FAILURE ISSUES: Thought to be likely due to
congestive heart failure. Initially, diabetic medications
and ACE inhibitor were held; however, creatinine began to
decrease with good diuresis, and ACE inhibitors and
diabetic medications were reinitiated. Creatinine had
improved to better than baseline at the time of discharge.
1. TYPE 2 DIABETES ISSUES: Initially started on a regular
insulin sliding scale. His sugars were elevated. The
patient was ultimately restarted on his home diabetic
medications.
1. MENTAL STATUS ISSUES: The patient demonstrated multiple
onsets of agitation and confusion thought to be secondary
to a communication barrier. The patient was initially
given Haldol and placed in restraints for fear of harm to
self. Per primary care physician assistant, the patient
was started on low-dose Zyprexa and given frequent
reorientation. Family members were present to help calm
and orient the patient. With initiation of his
medication, the patient's mental status improved. The
patient remained calm.
1. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
placed on a cardiac and diabetic diet. His electrolytes
were repleted as needed.
1. PROPHYLAXIS ISSUES: Prophylaxis was with proton pump
inhibitor and bowel regimen.
1. CODE STATUS ISSUES: The patient remained a full code.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to home with services.
DISCHARGE DIAGNOSES:
1. Non-ST-elevation myocardial infarction.
2. Congestive heart failure with acute exacerbation.
3. Hypoxia secondary to pulmonary edema from congestive heart
failure.
4. Anemia.
5. Diabetes.
6. Acute hyperglycemia.
7. Chronic renal insufficiency.
8. Peripheral vascular disease.
9. Delirium.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg one once per day.
2. Plavix 75 mg one once per day.
3. Lipitor 40 mg by mouth at hour of sleep.
4. Gabapentin 100 mg by mouth at hour of sleep.
5. Lisinopril 20 mg by mouth once per day.
6. Lasix 40 mg by mouth once per day.
7. Glyburide one tablet by mouth twice per day.
8. Spironolactone 25 mg by mouth once per day.
9. Acarbose 25 mg by mouth three times per day.
10. Toprol-XL 50 mg by mouth once per day.
DISCHARGE INSTRUCTIONS-FOLLOWUP:
1. Followup is with Dr. [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 1603**] on [**2169-1-11**].
2. The patient was to call the [**Hospital **] Clinic for further
management of diabetes.
3. The patient was to follow up with Cardiology within one to
two weeks.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-426
Dictated By:[**Last Name (NamePattern1) 7898**]
MEDQUIST36
D: [**2169-5-5**] 12:12:48
T: [**2169-5-6**] 12:13:52
Job#: [**Job Number 7899**]
ICD9 Codes: 5849, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4058
} | Medical Text: Admission Date: [**2164-11-16**] Discharge Date: [**2164-11-20**]
Service: MEDICINE
Allergies:
Nitroglycerin / Procardia / Lisinopril / Inderal / Tums Calcium
For Life / Zocor
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 year old female with CAD s/p MI in [**2139**], congestive heart
failure (ECHO [**9-5**] with LVEF = 40%, 3+ mitral regurgitation),
HTN, hypercholesterolemia, s/p pacer, with two prior admissions
to [**Hospital1 **] this fall for pulmonary edema who presents with increasing
SOB x 1 day. She was SOB at her extended living facility and
was found to be hypoxic (79%), by EMS.
.
In ER hypertensive (SBP 170) with bilateral crackles in all lung
fields. She was started on Nitro and Lasix 40 IV x 2 (--> UOP
1.5 L). She subsequently became HYPOTENSIVE and was started on
dopamine and BiPap.
.
She was then admitted to the CCU service.
Past Medical History:
1.CHF- on lisinopril/lasix; Last ECHO [**11-3**]: EF 35%
2.Pacemaker-s/p elective pacer replacement w/ [**Company 1543**] Sigma
DR303B on [**3-5**].
3.h/o dementia- on citalopram 20mg; living in [**Hospital3 **]
dementia unit.
4. CAD- history of MI ('[**39**])
5. HTN- controlled on lisinopril
6. Hypercholesteremia- on statin
7. h/o TIA
Social History:
Lives in [**Hospital3 **] for individuals with
dementia. Son involved with care and has power of attorney;
son??????s name is [**Name (NI) **]: [**Telephone/Fax (1) 41169**] (work), [**Telephone/Fax (1) 41170**] (home).
Family History:
non-contributory
Physical Exam:
Discharge Physical Exam:
Gen: Well appearing in NAD; AAOx3
HEENT: R eye lid lag; well articulated speech
neck: No JVD
Pulm: CTA B/L No crackles or wheezes
Heart: +s1+s LLSB 3/6 SEM
Abd: +BS Soft, NT ND
Ext: no pretibial edema
Pertinent Results:
CXR: [**11-16**]:
IMPRESSION: Diffuse increased interstitial and alveolar
opacities consistent pulmonary edema
.
CXR: [**11-17**]: Post diuresis
IMPRESSION: Overall improvement in pulmonary edema.
.
Admission Lab Results:
[**2164-11-16**] 05:05PM LACTATE-3.0* K+-5.1
[**2164-11-16**] 05:00PM GLUCOSE-207* UREA N-29* CREAT-1.1 SODIUM-134
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-22 ANION GAP-20
[**2164-11-16**] 05:00PM CK(CPK)-110
[**2164-11-16**] 05:00PM CK-MB-4 cTropnT-0.12*
[**2164-11-16**] 05:00PM CALCIUM-9.4 PHOSPHATE-5.3*# MAGNESIUM-2.0
[**2164-11-16**] 05:00PM WBC-6.7 RBC-4.17* HGB-13.3 HCT-40.2 MCV-96
MCH-31.8 MCHC-33.0 RDW-13.9
[**2164-11-16**] 03:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Brief Hospital Course:
Patient is an 86 year old woman who came to ED with symptoms
consistent with acute pulmonary edema and was treated as such
with Lasix 40 IV x 2 and a Nitroglycerin drip. Because of a
subsequent drop in her BP, she was placed on BIPAP and dopamine
for blood pressure support and transferred to the CCU.
.
The admission CXR was consistent with diffuse pulmonary edema.
Post diuresis, this significantly improved. In addition, on
physical exam, crackles present on admission were no longer
audible and she continued to have O2 sats in the mid 90s. She
was then weaned off the dopamine and transferred to the floor.
During her first day on the floor, her home Carvedilol, lasix
and lisinopril were all held since her BP was in the 90s. On the
HOD#4, these were restarted at carvedilol 3.125 [**Hospital1 **], lisinopril
5 and lasix 40 PO. And on HOD#5, she was discharged on her home
regimen.
.
During this admission, we also considered whether a
catheterization would be necessary for this woman given her
frequent hospitalizations with pulmonary edema. However, given
the acute reversal of her symptoms and the fact that she did not
reaccumulate fluid on her lungs or develop any signs of
respiratory compromise and no signs of ischemia on her EKG, we
felt that this could be postponed for now. She did have a
slighly elevated troponin, but this was felt to be [**1-4**] to
stress.
We did not feel that her lasix required uptitrating as she did
not reaccumulate fluid after being off lasix for 2 full days
during the hospitalization. She was discharged on her home
medications. In addition, clopidogrel was added to her regimen
in the event that these events were due to ischemia.
.
Nutrition was asked to educate the patient on the necessity of
adhering to a low salt diet and to restrict her fluid intake to
prophylax against reaccumulating fluid. She was evaluated by
physical therapy and was fit to return to her [**Hospital3 **]
facility. I had a conversation with her son regarding the
possibility that the patient may be at a point where she
requires more intensive care than could be provided by an
[**Hospital3 **] facility and he was in the process of looking
into nursing homes for his mother.
.
Pt is DNR/DNI. Despite this, we felt that a catheterization
would not be unreasonable in the future if she continues to have
these episodes as patient has a fairly good level of
functioning.
Medications on Admission:
Carvedilol 3.125 PO BID
Lisinopril 10 PO daily
Lasix 40 PO daily
ASA 81mg daily
Citalopram 20mg daily
MVI
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]
Discharge Diagnosis:
Acute pulmonary edema
Discharge Condition:
AAOx3
Afebrile, satting well on room air
No crackles in lungs
Discharge Instructions:
Please ensure that you adhere to the medication regimen that we
have listed on this discharge.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet - VERY IMPORTANT
Fluid Restriction: 1.5 Litres per day - VERY IMPORTANT
.
If you find that you are becoming more short of breath,
experiencing increased wheezing or develop increased fluid
retention in your legs, please call Dr. [**Last Name (STitle) **] or call your
cardiologist. In addition, if you develop other concerning
symptoms, please call Dr.[**Name (NI) 30518**] office or go to the emergency
department.
Followup Instructions:
You have the following prescheduled appointment. Please keep it
so that you can be seen to ensure that the medication regimen
that we have you on is sufficient.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1589**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2164-11-22**] 1:00
Completed by:[**2164-11-20**]
ICD9 Codes: 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4059
} | Medical Text: Admission Date: [**2108-1-27**] Discharge Date: [**2108-1-28**]
Service: MEDICINE
Allergies:
Avelox
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patinet is a [**Age over 90 **] year old male with a history of
cardiomyopathy who presented from [**Hospital **] rehab with fevers and
hypoxia. Patient was hypoxic on a NRB to the low 80s in the ED
on a NRB. CXR showed a multilobar pneumonia. He was given
vanc/zosyn in the ED. Given continued hypoxia he was placed on
bipab. The patient developed septic physiology, and was started
on peripheral neo for blood pressure support. He was DNR/DNI,
and family was hesitant about pursuing further invasive care.
He was admitted to the ICU for further manegment.
Physical Exam:
GEN: Frail elderly male, crabbing on BIPAP mask
HEENT: no LAD, no scleral icterus
Chest: upper airway rattle, roughous [**Hospital 1440**] sounds at b/l bases
CV: RRR, no m/r/g, PPM in place
Abd: soft, nt,nd
Pertinent Results:
[**2108-1-27**] 11:02PM LACTATE-3.7*
[**2108-1-27**] 10:56PM WBC-10.6 RBC-5.60 HGB-17.4 HCT-54.0*# MCV-96
MCH-31.1 MCHC-32.3 RDW-14.6
Brief Hospital Course:
Upon arrival to the floor, goals of care were discussed with the
family. They explained that they did not want to have the
patient intubated, and preffered to avoid any invasive
procedures including a central line. The understood that this
would limit out ability to offer optimal care. When discussed
with the patient, he requested to have BIPAP mask removed,
expressing full understanding that this would hasten his death.
The patient and the family agreed to pursue comfort measures
directed care. He was given small doses of IV morphine to treat
air hunger, and passed comfortably, with his family at his side,
within 50 minutes upon arrival to the unit.
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Expired
ICD9 Codes: 0389, 486, 4254, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4060
} | Medical Text: Admission Date: [**2191-10-12**] Discharge Date: [**2191-10-26**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
R subclavian line [**10-12**]
History of Present Illness:
This is a 86 y/o M w/ PMH of diet controlled DM, h/o CVA, and
colon ca s/p colectomy, who presented to OSH on Monday with
altered MS. [**Name13 (STitle) **] had a severe cough and went to the doctor 10 days
prior to admission and was given flonase and the cough subsided
considerably after three days. A week later, went to hospital
because he was acting erratically. He was found to have an O2
sat of 88% on RA and his CXR showed a multiple opacities. He was
initially treated on the medical [**Hospital1 **] with Levofloxacin and he
initially was 94% on 2L. He was somewhat agitated, removed his
mask, and required 50% FM overnight. In the morning, he was
switched to 2 L and was found by the doctor [**First Name (Titles) **] [**Last Name (Titles) 62356**] to be
cyanotic and satting 79%. Though patient was initially DNR/DNI,
this code status was reversed and patient was eventually
intubated for increasing hypoxia and agitation. After being
intubated, patient had significant oxygen requirements and some
hypotension after fentanyl boluses and was transferred to [**Hospital1 18**]
for further ventilator management.
Past Medical History:
1. colon cancer s/p partial colectomy 3 years ago, no chemo
2. CVA [**06**] years ago with residual garbled speech, altered
smell/taste
3. Left occluded carotid
4. glaucoma
5. DM (diet controlled)
6. heart murmur
Social History:
Lives year round with wife on [**Hospital3 4298**]. Retired
production engineer. Smoked remotely for 6 years only. No
significant EtOH use. Does not like to seek medical care or take
medications.
Family History:
NC
Physical Exam:
PE: VS T BP 128/44 HR 103 92%
Vent: AC 550 x 28 PEEP 10 Fi 100%, 1st ABG 7.15/65/72 currently
7.30/43/92
GEN: chronically ill appearing, sedated, intubated
HEENT: PERRL, NCAT
NECK: supple
CV: RRR S1S2 [**5-11**] holosystolic murmur harsh best LUSB, radiates
to carotid, PMI not displaced
LUNGS: course breath sounds bilaterally, L>R
ABD: midline scar, soft, nt, bs+
EXT: 2+ pitting edema, cool bluish extremities but with dps
dopplerable
Pertinent Results:
WBC 18.8 88.3% poly, 0 bands 5.2 lymphs 1.5 monos 4.9 eos
Hct 43.3
Plt 195
inr 1.5 pt 14.8 ptt 31.1
na 141 k 5.3 cl 108 co2 23 bun 45 cr 1.8 glu 174
lactate 1.6
free ca 1.14
alt 18 ast 21 ldh 327 ck 166 alk phos 100 tbili 0.3
ckmb 12 mbi 7.2 tropt .13
CXR: RUL infiltrate, LUL/lingular infiltrate, retrocardiac
opacity
Echo: prelim, LVH, EF 75%-80% hyperdynamic AS, [**Location (un) 109**]<1.0, mean
gradient 40, pulm HTN
OSH lab results:
bnp 213
trop i .18
bun 49
cr 2.0
alb 2.8
ekg sinus 100, LAD, [**Street Address(2) **] dep v5-v6
Brief Hospital Course:
86 y/o M with h/o colon ca s/p partial colectomy 3 years ago,
remote CVA, diabetes, who was transferred from an OSH intubated
with a multilobar pneumonia. Patient was admitted in
respiratory failure, intubated and sedated. His hypotension was
initially fluid responsive, and periodically required presor
support with levophed. He was treated with levofloxacin and
ceftriaxone for pneumonia.
The patient was unable to be weaned from the ventilator as
pneumonia progressed, and secondary to pressor support, also
develop ischemic digits. He also developed a periodic paralysis
likely secondary to steroid admisinstration. After 13 days in
the MICU, the patient's wife and family decided to make the
patient CMO, and he expired one day later.
Medications on Admission:
1. Bitoptic eye drops
2. Naproxen 500 [**Hospital1 **] x 2 weeks
3. ASA rarely
4. flonase
On transfer:
Fentanyl
Versed
Neo gtt
Levofloxacin
Ativan
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Expired.
Discharge Instructions:
None.
Followup Instructions:
None.
ICD9 Codes: 0389, 486, 5849, 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4061
} | Medical Text: Admission Date: [**2107-1-14**] Discharge Date: [**2107-1-24**]
Date of Birth: [**2062-5-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Pedestrian struck
Major Surgical or Invasive Procedure:
1. Application of Halo vest
2. Open reduction and internal fixation of right tibial
plateau fracture with [**Last Name (un) 101**] 5-hole plate.
3. Open reduction and internal fixation of the left medial
malleolar fracture.
History of Present Illness:
44 yo male pedestrian struck by auto; + LOC. He was taken to an
area hospital and found to have a left clavicle fracture,
multiple C-spine fractures, fractures of the right tibia and
left ankle fractures. He received steroids at the referring
hospital and was transferred to [**Hospital1 18**] for continued care.
Past Medical History:
Heart Murmur
Social History:
ETOH
+ tobacco
Married
Family History:
Noncontributory
Physical Exam:
Upon admission:
T100.0, HR89, BP108/70, RR18, Sat99on2L
A+Ox3, Ccollared
EOMI, PERRL, No hemotympanum
L mid clavicular tenderness with ecchymosis
CTA bl.
RRR s1/s2
Soft, NT,ND Nl rectal tone, GUIAC negative
5/5 strength BL U+LE's
No C/C/E
Pertinent Results:
[**2107-1-14**] 07:46PM WBC-6.1 RBC-3.03* HGB-9.4* HCT-28.6* MCV-94
MCH-31.1 MCHC-33.1 RDW-13.9
[**2107-1-14**] 07:46PM PLT COUNT-141*
[**2107-1-14**] 05:50PM PT-12.6 PTT-28.6 INR(PT)-1.1
[**2107-1-14**] 05:27PM GLUCOSE-154* LACTATE-1.5 NA+-136 K+-4.5
CL--110
[**2107-1-14**] 08:26AM LACTATE-1.5
[**2107-1-14**] 04:52AM ASA-NEG ETHANOL-109* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CHEST (PORTABLE AP)
Reason: please assess chest for infiltrate
[**Hospital 93**] MEDICAL CONDITION:
44 year old man with increased secretions, poor cough, hypoxia
REASON FOR THIS EXAMINATION:
please assess chest for infiltrate
INDICATION: Increased secretions, cough, hypoxia. Evaluate for
infiltrate.
COMPARISON: [**2107-1-14**].
PORTABLE CHEST RADIOGRAPH
PORTABLE CHEST: Study is limited by overlying hardware related
to halo fixation device. Cardiac and mediastinal contours appear
stable. Pulmonary vascularity remains within normal limits. No
new focal consolidations are seen. No evidence of pleural
effusion.
IMPRESSION: No evidence of acute cardiopulmonary process.
CT C-SPINE W/O CONTRAST
Reason: Assess for fracture, repair stability and alignment.
Please
[**Hospital 93**] MEDICAL CONDITION:
44 year old man pedestrian struck s/p ORIF
REASON FOR THIS EXAMINATION:
Assess for fracture, repair stability and alignment. Please do
3mm cuts. Thanks.
CONTRAINDICATIONS for IV CONTRAST: None.
CT OF THE CERVICAL SPINE: Comparison is made with [**2107-1-14**].
The patient is status post interval anterior fusion from C3
through C5. There is partial corpectomy of the C4 with a bone
strut fusion at this level. There is satisfactory appearance of
surgical hardware. Alignment is satisfactory. There is widening
of the fracture line involving the dens extending to the left
aspect of the body of C2. There is fracture of the right C2
lamina extending to the inferior articular process, unchanged.
There is a fracture of the right C4 lamina extending to the
articular pillar and subluxation of the facet joints, unchanged.
There is an unchanged nondisplaced fracture of the C6 spinous
process. There are unchanged nondisplaced fractures of the C5
and C6 right anterior tubercles of the foramen transversaria.
There is no bony retropulsion noted within the canal. The
evaluation of the canal content is limited by artifact and
surgical hardware, however, no large hematoma is seen.
IMPRESSION: Status post C3 through C5 fusion and partial
corpectomy of C4 with placement of a bony strut. Alignment is
satisfactory.
Slightly increased distraction at the fracture line of C2.
A wet read was provided into CCC by the resident at the time of
exam completion.
Cardiology Report ECG Study Date of [**2107-1-14**] 2:08:22 PM
Normal sinus rhythm, rate 85. No diagnostic abnormality. No
previous tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 160 102 394/436.14 65 68 63
MRA NECK W&W/O CONTRAST
Reason: evaluate fractures & cord, evaluate for arterial
dissection
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
44 year old man pedestrian stuck with multiple c-spine
fractures, neuro deficit in RUE with absent biceps
REASON FOR THIS EXAMINATION:
evaluate fractures & cord, evaluate for arterial dissection
The study done on [**2107-1-14**], 6:14 a.m., was available for
interpretation at on [**2107-1-14**] at 2:30 p.m.
INDICATION: 44-year-old man, pedestrian struck, with multiple
C-spine fractures, neural deficit in the right upper extremity,
to evaluate for cord, arterial dissection.
PRIOR STUDY: CT of the C-spine done on the same day, earlier.
TECHNIQUE: Contrast enhanced MR angiogram of the neck vessels,
including fat sat _sequences performed.
FINDINGS:
The origins of the arch vessels for patent. Bilateral vertebral
arteries, including the origins and the intracranial segments
are patent and normal in caliber with no abnormal foci of signal
intensity on the T1 fat saturated images. There is no evidence
of vertebral artery dissection.
Bilateral common carotid, cervical intra- and extracranial
carotid arteries are patent and normal in caliber.
IMPRESSION:
No evidence of arterial dissection in the neck vessels.
Brief Hospital Course:
He was admitted to the Trauma service. Repeat CT imaging was
performed which confirmed extensive cervical spine fractures
involving C2, C4, C5 and C6. There is retropulsion of C4
fragments into the central spinal canal, and disk or hematoma at
C4-5 compressing the cord. Additionally, Oblique fracture of the
proximal right tibial metaphysis and Fracture of the left medial
malleolus. He was admitted to the TSICU for close observation
and was taken to the OR with Dr. [**Last Name (STitle) 363**] for C4 corpectomy and
C2-C5 anterior fusion. A Halo was placed at the bedside without
incident.
Orthopedics was consulted for his extremity fractures. He was
taken to the operating room returned for open reduction and
internal fixation of right tibial plateau fracture with [**Last Name (un) 101**]
5-hole plate and open reduction and internal fixation of the
left medial malleolar fracture.
He was extubated on HD 3 and remained in TSICU through HD 4,
requiring CIWA scale for ETOH withdrawal at approx 10mg/hour;
otherwise no active issues during his ICU stay. He did initially
require 1:1 sitter for close observation because of delirium;
the sitters were eventually discontinued. His mental status
improved significantly.
On HD 6 his serum sodium found to be low and urine lytes were
checked, a Renal consultation was ordered. Diagnosis of mild
SIADH due to either surgical stress or episodic Haldol dosing
made per Renal and plan for monitoring for resolution. He was
placed on a 1 liter free water fluid restriction.
A Speech and Swallow evaluation was ordered and he was cleared
for an oral diet. Physical and Occupational therapy were also
consulted and have recommended short term rehab.
Medications on Admission:
none
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
Disp:*60 injection* Refills:*2*
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
7 days.
Disp:*14 Capsule(s)* Refills:*0*
4. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for SBP <100; HR <60.
8. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain.
9. Milk of Magnesia 800 mg/5 mL Suspension Sig: [**9-5**] ML's PO
twice a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
s/p Pedestrian Struck
C2,C4 vertebral body fractures
C5,C6 Transverse process Fractures
C6 spinous process fracture
R tibial plateau fracture
L medial malleolar fracture
Discharge Condition:
Stable
Discharge Instructions:
DO NOT put any weight on either of your lower extremities.
Followup Instructions:
Follow up With Dr. [**Last Name (STitle) 363**] regarding the Halo and the fractures
of your cervical spine the number is ([**Telephone/Fax (1) 11061**].
You will need to follow up with Dr. [**Last Name (STitle) 1005**] regarding the
fractures of your legs in 2 weeks. The number is ([**Telephone/Fax (1) 2007**].
Completed by:[**2107-1-24**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4062
} | Medical Text: Admission Date: [**2141-7-15**] Discharge Date: [**2141-8-8**]
Date of Birth: [**2095-11-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Originally admitted to medicine with chief complaint of
constipation/ileus. [**Hospital **] transferred to
Neuromed/epilepsy service for seizures/LTM/medication
adjustment. Required brief stay in MICU for desaturation,
tachypnea in setting of likely mucous plugging.
Major Surgical or Invasive Procedure:
PICC placement
Lumbar Puncture
History of Present Illness:
45 year old female, nonverbal at baseline [**2-3**] severe MR.
Presents with constipation x 3d. Per caretaker pt has not had BM
since Tuesday, is passing flatus. No n/v. The patient did have
some abdominal distention but the abdominal exam was nonfocal.
The patient did not have fevers or chills in the group home.
Of note patient was recently seen in [**Hospital1 18**] ER on [**2141-7-11**] for
refractory seizures thought secondary to patient taking generic
zonisamide.
ED course: KUB large amount of stool no volvulus, no si of
obstruction other than stool. Disimpacted in ER with [**Male First Name (un) 1658**]
consistency stool.
At time of transfer, she was in NAD, nonresponsive at baseline,
alert.
On the floor she was in NAD, nonresponsive at baseline, alert.
Was disimpacted for a moderate amount of [**Male First Name (un) 1658**] stool.
Past Medical History:
Her seizure history is significant, as she has had frequent
episodes of breakthrough seizures. Most recently, she had her
Zonegran increased to 400 mg daily, on top of Keppra 1500 [**Hospital1 **].
Aphasic at baseline, history of severe mental retardation.
S/p CCY
History of thrombocytopenia
Social History:
Lives in group home, home health aide available.
Family History:
Initially unavailable. Subsequently discovered that visiting
sister also has seizure disorder, but does not have MR.
Therefore unclear if Seizure D/O related to MR [**First Name (Titles) **] [**Last Name (Titles) **]
predisposition unrelated.
Physical Exam:
T:98.4 P:70 R:18 BP:98/doppler SaO2:96%RA
General: Patient was seen in a chair with head tilted to the
right, drooling, incontinent of stool, seizing - see below.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally.
Seizure like activity - patient has head turned to her right,
eyes closed, right hand shaking - 4-6hz, not suppressable.
Incontinent of stool.
Neurologic:
-Mental Status: Patient unresponsive on physical exam. Her
alertness fluctuated from eyes open and possibly attending the
examiner to eyes closed and grunting. She didn't appear to
follow any comands.
-Cranial Nerves: Olfaction not tested. Very difficult to test
CNs as patient seizinig and alternately postictal. She blinked
to threat. No obvious facial droop. She looked from side to
side. She was drooling.
-Motor: Normal bulk, unable to assess tone, unable to assess
strength.
-Sensory: unable to assess strength.
-Coordination: Unable to assess coordination.
-DTRs:unable to test.
Plantar response flexor.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
[**2141-8-8**] 05:52AM BLOOD WBC-6.1 RBC-2.92* Hgb-10.2* Hct-30.6*
MCV-105* MCH-34.8* MCHC-33.3 RDW-14.1 Plt Ct-338
[**2141-8-2**] 05:25AM BLOOD Neuts-75.7* Lymphs-20.2 Monos-2.5 Eos-1.2
Baso-0.4
[**2141-8-8**] 05:52AM BLOOD Plt Ct-338
[**2141-8-3**] 01:30PM BLOOD PT-12.0 PTT-32.5 INR(PT)-1.0
[**2141-8-3**] 01:30PM BLOOD Ret Aut-2.6
[**2141-8-8**] 05:52AM BLOOD Glucose-83 UreaN-11 Creat-0.6 Na-141
K-3.8 Cl-109* HCO3-23 AnGap-13
[**2141-7-14**] 10:30PM BLOOD ALT-15 AST-21 AlkPhos-79 Amylase-66
TotBili-0.3
[**2141-8-3**] 01:30PM BLOOD TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2141-7-14**] 10:30PM BLOOD Lipase-42
[**2141-7-25**] 04:42AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2141-7-24**] 07:27PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2141-8-5**] 04:30AM BLOOD Calcium-9.8 Phos-3.2 Mg-2.0 Iron-60
[**2141-8-5**] 04:30AM BLOOD calTIBC-238* VitB12-934* Folate-GREATER
TH Ferritn-57 TRF-183*
[**2141-8-3**] 01:30PM BLOOD Hapto-119
[**2141-7-24**] 07:27PM BLOOD TSH-0.57
[**2141-7-31**] 08:54AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.019
[**2141-7-31**] 08:54AM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
[**2141-7-31**] 08:54AM URINE RBC-0 WBC-8* Bacteri-OCC Yeast-NONE Epi-5
AEROBIC BOTTLE (Final [**2141-8-7**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2141-8-7**]): NO GROWTH
URINE CULTURE (Final [**2141-8-1**]): NO GROWTH
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA
CAMPYLOBACTER CULTURE (Final [**2141-7-27**]): NO CAMPYLOBACTER
FOUND
FECAL CULTURE (Final [**2141-7-26**]): NO SALMONELLA OR SHIGELLA
FOUND
CT ABDOMEN:IMPRESSION:
1. No evidence for retroperitoneal bleed.
2. Retained fecal material with heterogeneous density within
the distal
rectum, likely stool. Clinical correlation is advised.
CXR:
FINDINGS: AP single view of the chest obtained with patient in
supine
position is analyzed in comparison with a similar preceding
study of [**2141-8-1**]. Noted is the placement of a right-sided
PICC line which is seen to terminate overlying the SVC at the
level of the carina. This line was not present on the preceding
examination. A previously present NG tube, however, has been
removed. There is no pneumothorax. There is now markedly
increased haze around the pulmonary vasculature on the left side
which was not present on the preceding examination. The same
increase most likely is also present in the right side but less
well seen because of the patient's partial rotation. When
comparing this findings with the next preceding study, the most
likely explanation is that the patient has become overhydrated.
Otherwise, the possibility of pulmonary congestion must be
entertained. There is, however, no evidence of pleural effusion
as the lateral pleural sinuses remain free. No new discrete
parenchymal infiltrates are identified.
VIDEO SWALLOW:IMPRESSION: Moderate oropharyngeal dysphagia,
with penetration and aspiration with thin liquids.
Brief Hospital Course:
Ms. [**Known lastname **] is a 45 yo female with a seizure disorder who came in
on [**2141-7-15**] with constipation refractory to medical therapy.
1. Constipation:
Ms. [**Known lastname **] was manually disinpacted x 2 on [**2141-7-15**] with removal
of moderate amounts of [**Male First Name (un) 1658**] stool. Serial KUB showed improving
impaction. Her interaction improved to closer to baseline
according to her sister. She had a negative c.diff toxin assay
x 2. With aggressive medical management in addition, including
bisacodyl, lactulose, and senna, and an NG tube to help with PO,
she began to stool on her own. She was transfered with
bisacodyl pr, lactulose pr prn, and docusate standing [**Hospital1 **].
2. Seizures:
Ms. [**Known lastname **] was noted to have seizure activity on [**2141-7-16**]. Neuro
was consulted and recommended making her Zonegran brand name and
giving her TID low dose Ativan with prn. On [**2141-7-17**], continued
seizure activity was noted per Neuro and patient was transferred
to the Neuro service. The patient's zonegran and keppra were
maintained at pre-transfer/at home doses. The ativan was
increased to a maximum of 3mg 5 times/day until her seizures
finally abated. Doses twice had to be held for low blood
pressure. The ativan was then slowly withdrawn. At discharge,
the patient is now off the standing ativan order and only has
ativan ordered for breakthrough seizures. She has been seizure
free on her regimen for over 10 days. Her hypotensive episodes
also resolved once the Ativan was stopped. She did have one [**1-11**]
second breakthrough seizure the night prior to discharge, but
this is her baseline even with the current regimen prior to
admission. Her Neurologist and PCP are aware of these seizures.
3. Neutrophilic Leukocytosis:
Patient remained afebrile and her leukocytosis resolved. She
had a negative UA on [**2141-7-15**]. No antibiotic therapy was
started. After transfer to the neurology service the patient
had two episodes of fever. Numerous urine and blood cultures,
stool studies and a CSF culture were negative. A chest xray
revealed a left lower lobe consildation which likely represented
an aspiration pneumina or hospital acquired pneumonia. The
patient was tachypneic and had oxygen desaturations which
required high flow O2 on a facemask. The patient did not
require intubation durin her hospital course. She was started
on vancomycin and zosyn, and she was able to wean off the O2 and
her fevers and leukocytosis improved. By discharge, she had
remained afebrile and completed a course of IV antibiotics to
cover for both hospital acquired and aspiration pneumonia.
4. At the peak of the patient's ativan dosing she became
tachypneic, with pulse oxygen desaturations into the mid 70s.
She required a nights stay in the MICU. The patient's
respiratory status resolved with suction alone, so the leading
hypothesis explaining the patient's respiratory diseress was
mucous plugging initially. Later, she was found to have the
pneumina likely from aspiration due to the high doses of ativan.
5. The patient required numerous [**Last Name (un) **]-gastric tubes, as she was
too somnolent to feed herself. At the time of discharge, the
patient was off oxygen and was tolerating a PO soft diet.
6. Patient will need to be discharged to a
rehabilitation/nursing facility for monitoring and
rehabilitation to get her back to her baseline. Prior to
admission, she was capable of walking on her own, and peforming
some of her ADLs by herself or with assistance. She will have
occupational and physical therapy followup in the rehabilitation
facility.
Medications on Admission:
- Bactrim 800mg [**Hospital1 **] x5 days (completed am [**7-4**])
- Zonisamide 300mg QD (incr'd to 400mg QD on [**2141-7-7**])
- Keppra 1500mg [**Hospital1 **]
- Benadryl 50mg Q6H PRN (dc'd [**2141-7-7**])
- MVI
- Lactulose 30cc [**Month/Day/Year 4962**]
- Folic acid 1mg [**Name (NI) 4962**]
- MOM 30cc QPM
- Senna [**Hospital1 **]
- Desitin oint [**Hospital1 **]
- Peridex 15cc [**Hospital1 **]
- Citracal +D [**Hospital1 **]
- Robitussin PRN
- Motrin PRN
- Fleet enema PRN
- Biscodyl PRN
- Tylenol PRN
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation: titrate to 1 BM daily.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation: give if no stool>24 hrs.
8. Zonegran 100 mg Capsule Sig: Two (2) Capsule PO [**Hospital1 4962**]: Must be
brand name.
9. Zonegran 100 mg Capsule Sig: Four (4) Capsule PO at bedtime:
Must be brand name.
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
15. Lactulose 10 g/15 mL Solution Sig: Three Hundred (300) ML PO
PRN (as needed) as needed for constipation: ENEMA.
16. Ativan 2 mg/mL Syringe Sig: [**1-3**] units Injection PRN as
needed for Seizure: Administer if seizure for more than 5
minutes or more than 3 seizures in 1 hour.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 16662**] - [**Street Address(1) **]
Discharge Diagnosis:
Primary Diagnosis: Constipation
Secondary Diagnosis: [**Hospital **]
Hospital Acquired Pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please see to it that the patient is placed on commode for at
least 15 minutes after every meal to provide her with the
opportunity to move her bowels without relying on a diaper. It
was felt that chronic diaper use may have contributed to the
patient's constipation. The patient had a protracted hospital
course which included a hospital acquired vs aspiration
pnumonia, seizures requiring increased benzodiazepines which
were eventually tapered, and hypotension which resolved once the
benzodiazepines were stopped.
Please take all medications as prescribed and follow up with
your PCP as scheduled.
If you develep any of the following symptoms, please call your
PCP or go to the ED: fevers, chills, seizures, worsening
constipation, or decreased urine output and low blood pressures.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 17798**], MD Phone:[**Telephone/Fax (1) 3506**]
Date/Time:[**2141-9-5**] 10:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-8**]
8:50
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
ICD9 Codes: 486, 2762, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4063
} | Medical Text: Admission Date: [**2192-1-8**] Discharge Date: [**2192-1-13**]
Date of Birth: [**2145-9-30**] Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
dyspnea/ chest pain
Major Surgical or Invasive Procedure:
Pericardiocentesis, pericardial drain placement and removal
[**2192-1-8**]
History of Present Illness:
Mr. [**Known lastname 24927**] is a 46 year old male transferred from OSH with
pericardial effusion. Patient has experienced both dull and
sharp chest pain, centered around left chest, but radiating to
substernal area and left shoulder, for past 5 weeks. Pain was
sometimes so severe that he had to take vicodin to relieve it.
Pain is also associated with shortness of breath that comes and
goes, with no specific alleviating or exacerbating factors.
Patient was seen 5 weeks ago when he first experienced the pain
at OSH. The pain was [**Known lastname **] but did worsen at times. He had
an extensive work up at OSH including a CTA which excluded
aortic dissection, pericardial effusion and pulmonary embolus.
He was seen in the ED by a cardiology attending who thought
there was a very low probability of atherosclerotic CAD. He was
ruled out by 3 cycles of cardiac enzymes, all of which were
negative, and he was discharged. Since then, he has seen his
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] dyspnea, gotten several CXR
at OSH all of which were negative for abnormality, and has been
prescribed flovent and albuterol, and recently a Zpack, none of
which have provided any relief. His left sided chest pain was
assessed to be MSK by an orthopedist, and he has been receiving
muscular massages by a massage therapist, as well as taking
vicodin for his pain. He presented to OSH today with similar
symptoms, was found to be febrile to 102.7F and on Echo was
found to have a pericardial effusion. He was transferred to the
[**Hospital1 **] for further evaluation.
On ROS, patient notes extreme fatigue and loss of appetite. He
does not believe he's lost weight, but his wife does. [**Name2 (NI) **]
endorses frequently feeling fevers/chills, but until today has
not taken his temperature. He has drenching night sweats at
times. He has also had some upper respiratory symptoms
including cough, white phlegm production and sore throat. He
denies lightheadedness, dizziness, confusion, abdominal pain or
distension, changes to his bowel habits, dysuria or frequency,
muscular weakness or sensory changes besides pain in left
shoulder and extreme fatigue. He denies easy bruising, bleeding
while brushing his teeth or overt bleeding from elsewhere in his
body. He denies rashes, joint swelling, or joint pain. He
denies cold intolerance, proximal muscle weakness, or weight
gain.
.
Cardiac review of systems is notable for absence of chest
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
In the ED, patient was found to have pulsus 10. Cardiology
fellow bedside echo confirmed pericardial effusion and early
tamponade physiology. He received 1L NS and levaquin for fever
and pleural effusion. He received tylenol for his fever.170cc
fluid taken out during pericardiocentesis and drain left in
place.
Most Recent Vitals prior to transfer: 99.1 101 121/71 18 98%2L
Past Medical History:
hand surgery for tendon release
sebaceous cysts on his head
borderline hypertension, hyperlipidemia
Social History:
He works as a contractor and has had asbestos exposure in the
past, but always with a mask. He has also worked with various
plumbing solvents and has had exposure to dust in atticks.
- Tobacco history: 15 pack-year smoking hx
- ETOH: rare
- Illicit drugs: none
Family History:
Father had an MI at age 56 and died during CABG at age 72. Uncle
had MI in late 50s. Grandmother had GI cancer. Daughter has
mild ebstein's anomaly and accessory pathways - treated with
ablation. History of DM. No hx of autoimmune or rheumatologic
conditions.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: T=98.9 BP=137/75 HR=109 RR=27 O2 sat=100(RA)
GENERAL: NAD. Orientedx3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis or petechia of the oral mucosa.
oropharynx without erythema or exudate. No cervical or axillary
lymphadenopathy. No thyroid enlargement or goiters.
NECK: Supple with JVP of 13 cm, no Kussmaul's sign.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. +friction rub. no murmurs.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: normoactive bowel sounds, soft, nondistended. pain in
epigastrum with abdominal pressure. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or rashes.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
PHYSICAL EXAM ON DISCHARGE:
Vitals - Tm/Tc: 97.2/97.5 HR:59-85 BP:99-123/57-84 RR:18 02
sat:100% RA
GENERAL: 46 yo M in no acute distress
HEENT: mucous membs moist, no lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR, no rubs.
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: wwp, no edema.
NEURO:5/5 strength in U/L extremities.
PSYCH: A/O
Pulsus [**7-13**]
Pertinent Results:
Labs on Admission:
[**2192-1-8**] 04:45PM BLOOD WBC-12.1* RBC-3.94* Hgb-11.5*# Hct-34.1*#
MCV-87 MCH-29.2 MCHC-33.7 RDW-12.7 Plt Ct-320
[**2192-1-8**] 04:45PM BLOOD Neuts-74.1* Lymphs-19.5 Monos-6.2 Eos-0.1
Baso-0.2
[**2192-1-8**] 04:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Spheroc-OCCASIONAL Burr-1+
[**2192-1-8**] 04:45PM BLOOD PT-19.8* PTT-29.2 INR(PT)-1.9*
[**2192-1-8**] 04:45PM BLOOD Fibrino-904*
[**2192-1-8**] 10:15PM BLOOD FDP-40-80*
[**2192-1-9**] 05:02AM BLOOD ESR-83*
[**2192-1-8**] 04:45PM BLOOD Ret Aut-1.6
[**2192-1-8**] 04:45PM BLOOD Glucose-117* UreaN-17 Creat-1.3* Na-135
K-3.8 Cl-99 HCO3-24 AnGap-16
[**2192-1-8**] 04:45PM BLOOD ALT-21 AST-14 LD(LDH)-208 AlkPhos-74
TotBili-0.6
[**2192-1-8**] 04:45PM BLOOD Lipase-71*
[**2192-1-8**] 04:45PM BLOOD cTropnT-<0.01
[**2192-1-9**] 05:02AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
[**2192-1-8**] 04:45PM BLOOD Albumin-3.6 UricAcd-4.6
[**2192-1-8**] 10:15PM BLOOD Iron-14*
[**2192-1-8**] 04:45PM BLOOD Hapto-445*
[**2192-1-8**] 10:15PM BLOOD calTIBC-196* Ferritn-934* TRF-151*
[**2192-1-8**] 04:45PM BLOOD TSH-1.6
[**2192-1-8**] 04:48PM BLOOD Lactate-1.1
Cardiac Cath [**1-8**]:
FINAL DIAGNOSIS:
1. Pericardial Tamponade with sucessful removal of 160 cc of
bloody
pericardial fluid via a sub-xiphoid approach.
2. Reduction in pericardial pressure from 25 mmHg to 13 mmHg
after
pericardiocentesis.
TTE [**1-8**]:
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%), although there is beat
to beat variation in the ejection fraction due to abnormal
septal motion. Right ventricular chamber size and free wall
motion are normal. The aortic valve is not well seen. The mitral
valve leaflets are structurally normal. No mitral regurgitation
is seen. There is a moderate sized pericardial effusion. There
is brief right ventricular diastolic collapse and significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, consistent with impaired ventricular filling and early
tamponade physiology.
IMPRESSION: Moderate circumferential pericardial effusion with
early tamponade physiology. Normal biventricular function with
abnormal septal motion.
TTE [**1-8**]:
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. There is abnormal
septal motion/position. There is a very small pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. There are no
echocardiographic signs of tamponade.
IMPRESSION: Small residual pericardial effusion without
echocardiographic signs of tamponade.
Labs on Discharge:
[**2192-1-13**] 06:55AM BLOOD WBC-6.3 RBC-4.41* Hgb-12.5* Hct-37.7*
MCV-86 MCH-28.3 MCHC-33.1 RDW-12.7 Plt Ct-466*
[**2192-1-13**] 06:55AM BLOOD Glucose-101* UreaN-18 Creat-1.0 Na-141
K-5.1 Cl-105 HCO3-29 AnGap-12
[**2192-1-13**] 06:55AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.3
Brief Hospital Course:
Primary Reason for Hospitalization:
Mr. [**Known lastname 24927**] is a 46M with no signficant PMH who is transfered
from an OSH for evaluation of a pericardial effusion and found
to have tamponade physiology.
.
# PERICARDIAL EFFUSION: Patient has had intermittent chest pain
since [**Month (only) 404**]. At that time, there was no EKG evidence of
pericarditis or low voltage suggestive of effusion. He was
observed and sent home after three set of negative cardiac
enzymes. He now represents with dyspnea and chest pain, this
time found to have effusion with early tamponade physiology.
Pulsus was 10 in ED. Patient was sent directly to cath lab for
fluoro-guided pericardiocentesis. He drained 160 ccs of
pericardial fluid, after which his drain was pulled. Repeat echo
on HD#2 showed increase in pericardial effusion, pulsus 12. His
chest pain was initially managed with IV dilaudid and tylenol.
He then underwent ASA desensitization (given h/o eye swelling
with ASA), after which he was started on indomethacin and
colchicine for pericarditis. His symptoms improved significantly
with these treatments. DDx for pericardial effusion included
viral, TB, post-MI, uremia, hypothyroidism, malignancy or
collagen vascular disease. Initially most concerned for either
malignancy (given recent weight loss, fatigue, night sweats, new
anemia) or viral (given recent URI, fever, leukocytosis with
left shift). Pt ruled out for MI. Pericardial fluid cell count
had 12:1 ratio of RBC:WBC, with left shift. Pericardial fluid
cytology negative for malignant cells. Pericardial fluid culture
(including acid fast) and gram stain were negative. [**Doctor First Name **], anti-DS
DNA and complement panel were checked to screen for lupus and
other collagen vascular diseases. [**Doctor First Name **] and anti-DS DNA were
negative. C3 and C4 were mildly elevated at 191 and 59. ESR was
markedly elevated at 83 (ref range 0-15). CT chest/[**Last Name (un) 103**]/pelvis
with contrast was performed to work up for occult malignancy,
and showed mild non-pathologic mediastinal lymph node
enlargement more concerning for infection. HIV test was
negative. TSH WNL. Other viral cultures checked were negative.
Based on these studies and clinical picture, it was found that
pericardial effusion was most likely due to a viral etiology.
Patient received a cardiac MRI that showed some restrictive
physiology.
.
# Elevated INR: Patient's INR was 1.1 in [**Month (only) 404**], now 1.9.
Patient does not take coumadin. PTT is not prolonged.
Differential includes nutritional deficiencies, liver synthetic
dysfunction, DIC. After receiving vitamin K 5mg on HD#2, INR
remained elevated at 2. LFTs are not significantly elevated,
nor is albumin low, to suggest liver synthetic dysfunction. DIC
labs negative. Blood smear showed no schistocytes. INR came
down by itself to 1.3 by discharge.
.
# Anemia: Patient's Hct was 44 in [**Month (only) 404**], but now is 34,
signifying a 10 pt drop within the last month. Patient has
pericardial effusion, but otherwise has no overt evidence of
bleeding. Hemodynamically stable. His iron studies shows
possible anemia of chronic disease, but extremely elevated
ferritin levels are difficult to interpret in the setting of
high inflammation (acute phase reactant). Hemolysis labs
signify no hemolysis.
.
# [**Last Name (un) **]: Cr 1.3, up from baseline 1.0. Differential includes
pre-renal vs. intrinsic renal failure from systemic disease.
After IV fluids, creatinine improved to 0.9, indicating
pre-renal etiology.
.
# Fevers: Differential includes infectious, malignant, vs.
auto-immune. Patient's history and CXR with effusions does not
make it seem infectious; therefore azithromycin was
discontinued. Bloody pericardial effusion, night sweats, and
fatigue were concerning for malignancy, although CT
chest/abdomen/pelvis did not show any gross evidence of
malignancy. Auto-immune disease also a possibility, but not
consistent with patient's clinical picture; also ESR elevated
but [**Doctor First Name **], anti-DS DNA and C3/C4 were normal. Patient remained
afebrile starting HD#3.
Transitional Issues:
Patient was discharged to rehab.
He will continue indomethicin for 2 weeks and colchicine for 2
years.
His oxygen levels were noted to be low overnight, so he was
recommend to obtain an outpatient sleep study to evaluate for
sleep apnea.
Medications on Admission:
tylenol prn pain
flovent prn dyspnea (stopped bc not helping)
albuterol inhaler prn dyspnea (stopped bc not helping)
azithromycin 250 daily (today is day [**1-6**])
vicodin prn pain
Discharge Medications:
1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
2. indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) for 1 weeks.
Disp:*42 Capsule(s)* Refills:*0*
3. indomethacin 25 mg Capsule Sig: One (1) Capsule PO three
times a day for 1 weeks.
Disp:*21 Capsule(s)* Refills:*2*
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial Effusion
Anemia
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a pericardial effusion or a collection of fluid in the
sac around your heart. We think this is because of a virus and
we have sent many tests to make sure it is not for another
reason. All of these tests are negative and a few cultures are
still not finalized. You had a cardiac MRI top further assess
your heart and the fluid. There is still some fluid that we hope
will be absorbed over time. You have been started on some
medicines, indomethicin and colchicine to help decrease the
inflammation of the lining around your heart and help to prevent
the fluid from reaccumulating. You should take the indomethicin,
50 mg (2 25 mg tablets) three times a day for one week and then
decrease to 25 mg (1 pill) three times a day for one week. At
that time, you will see Dr. [**First Name (STitle) **] again and can discuss
your medicines. Colchicine will be taken twice daily for at
least one year. You will also take prilosec (omeprazole) twice
daily as these medicines can irritate your stomach. Please call
Dr. [**First Name (STitle) **] if your chest pain worsens and call the Heartline
for any urgent symptoms you may have at home.
You will get an echocardiogram during the appt with Dr.
[**First Name (STitle) **] on [**1-26**].
You had a low blood count or anemia during your hospital stay.
You should have your blood studies rechecked in a few weeks to
see if there is any need to treat or do further testing.
Your kidneys function declined but have now normalized.
Followup Instructions:
PCP [**Name Initial (PRE) **]:Wednesday, [**Month (only) 956**] the 15th at 11am
With:[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],MD
Location: [**Hospital **] MEDICAL ASSOCIATES, P.C.
Address: [**Location (un) 21638**], [**Location (un) **],[**Numeric Identifier 21639**]
Phone: [**Telephone/Fax (1) 21640**]
Department: CARDIAC SERVICES
When: THURSDAY [**2192-1-26**] at 11:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
Completed by:[**2192-1-14**]
ICD9 Codes: 5849, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4064
} | Medical Text: Admission Date: [**2149-5-8**] Discharge Date: [**2149-5-17**]
Date of Birth: [**2075-10-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Bactrim / Ciprofloxacin / Clindamycin / Dilaudid /
Percocet / Oxycontin / Ceftin / Vicodin / Morphine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**2149-5-12**] - CABGx2 (Left internal mammary->Left anterior descending
artery, Vein graft->Diagonal artery).
[**2149-5-8**] - Cardiac Catheterization
History of Present Illness:
73 y/o with a PMH of HTN, HLP, CHF with preserved EF (EF 80% on
C Cath on [**5-8**] @ [**Hospital1 1474**]), paroxysmal A fib (not on coumadin)
who was admitted to [**Hospital 1474**] hospital 2 weeks ago with CHF and
AF. At that time she had a nucler stress that showed apical
ischemia. Cardiac Catheterization was recommended, but she
refused and was discharged to home on medical managment. Then
she re-preseneted to [**Hospital1 1474**], continuing to complain of
shortness of breath. On [**5-8**] she underwent elective cath
showing LAD 90% lesion and she was transferred to [**Hospital1 18**] for PCI
(dye load=116cc). Upon arival, prior to C Cath, pre-procedure
creat was noted to be 1.8 (basline 1.1-1.3) so she was given
mucomyst and sodium bicarbonate. Cardiac Catheterization at
[**Hospital1 18**] showed 80-90% lesion in the mid LAD with unsuccessful PCI
attempt of the mid LAD despite multiple attempts. Dr. [**Last Name (STitle) 2230**] was
called, and plan for surgical revascularization of the LAD with
a LIMA after plavix washout.
Past Medical History:
Hypertension
Hyperlipidemia
CHF with normal EF (EF 80% on [**2149-5-8**] C Cath)
GERD
TIA
GOUT
CRI (basline creat 1.1-1.3)
PAF
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
Positive family history of premature coronary artery disease
(brother with CAD in his 40s), no fhx or sudden death.
Physical Exam:
VS - Tc 98.7, Tm 98.4, 150/75 (128-150/52-80), 81 (76-96), R20,
O2 94%RA
Gen: elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: Right groin site with no hematoma, clean dressing, No
c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
[**2149-5-8**] 10:50PM PT-17.1* PTT-34.7 INR(PT)-1.5*
[**2149-5-8**] 09:43PM PT-20.1* PTT-66.1* INR(PT)-1.9*
[**2149-5-8**] 09:43PM THROMBN-150*
[**2149-5-8**] 09:30PM POTASSIUM-4.1
[**2149-5-8**] 09:30PM CK(CPK)-36
[**2149-5-8**] 09:30PM CK-MB-NotDone
[**2149-5-8**] 09:30PM PLT COUNT-231
[**2149-5-8**] 07:55PM GLUCOSE-150* UREA N-55* CREAT-1.5* SODIUM-137
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14
[**2149-5-8**] 07:55PM estGFR-Using this
[**2149-5-8**] 07:55PM ALT(SGPT)-13 AST(SGOT)-10 ALK PHOS-76 TOT
BILI-0.3
[**2149-5-8**] 07:55PM ALBUMIN-3.5
[**2149-5-8**] 07:55PM %HbA1c-5.5
[**2149-5-8**] 07:55PM HBc Ab-NEGATIVE
[**2149-5-8**] 07:55PM WBC-5.6 RBC-3.79* HGB-12.5 HCT-34.5* MCV-91
MCH-33.0* MCHC-36.2* RDW-12.6
[**2149-5-8**] 07:55PM PLT COUNT-208
[**2149-5-8**] 07:55PM PT-44.5* PTT-150* INR(PT)-5.0*
.
.
Studies:
EKG demonstrated NSR@64 nml axis, nml intervals, Q in III, TWI
in aVL, no ST elevations/deprssions.
.
2D-ECHOCARDIOGRAM performed in [**4-17**] @ [**Hospital **] Hospital: with
reported EF 55-60% [**First Name8 (NamePattern2) **] [**Hospital 1474**] Hospital D/C summary.
.
Percutaneous coronary intervention, on [**5-8**] at [**Hospital **] Hospital
anatomy as follows:
RHC:
nml RA pressure, elevated pul artery pressure (40/15 mean 23),
PCWP nml, Shows evidence of pulm artery htn.
Left Heart Assessment:
EF 80%, LV chamber size small. Elevated lv systolic pressure.
Nml lv end diastolic pressure. LVEDP 15 mmHg. No mitral
stenosis. Grade 1 MR. [**First Name (Titles) **] [**Last Name (Titles) **] calcification. Normal LV wall
motion. Hyerkinetic LV contractility.
Cononary Angiography:
Right dominant.
Left main: no sig stonosis
LAD: 99% focal mid stenosis after 1st diag branch
LCX: mild intimal irreg without sig stenosis
RCA: mild intimal irregularities without sig stenosis
.
Percutaneous coronary intervention, on [**5-8**] at [**Hospital1 18**] anatomy as
follows:
1. Initial angiography revealed a 80-90% lesion in the mid
LAD.The LM coronary artery was normal. The LAD was as above. The
distal LAD was normal. The LCx was normal. The RCA was not
engaged.
2. Limited hemodynamics revealed a central aortic pressure of
142/73
3. Unsuccessful PCI attempt of the mid LAD despite multiple
attempts.
[**2149-5-12**] ECHO
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The descending thoracic aorta is tortuous. The aortic valve
leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-11**]+) mitral regurgitation is seen.
Tricuspid regurgitation is present but cannot be quantified.
POSTBYPASS
Biventricular systolic function is preserved. MR remains mild to
moderate. The study is otherwise unchanged compared to
prebypass.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2149-5-8**] via transfer from
[**Hospital 1474**] Hospital for a cardiac catheterization and angioplasty.
This revealed an 80% stenosed left anterior descending artery
which was unamenable to angioplasty or stenting. The cardiac
surgery service was consulted and Ms. [**Known lastname **] was worked-up in the
usual preoperative manner. As she had a history of atrial
fibrillation and poor compliance with coumadin, it was decided a
concommittant MAZE procedure would also be performed. The
psychiatry service was consulted for assistance with her care as
she was at times unagreeable and argumentative. Through further
evaluation, she was found to be at her baselne however no
conclusion of her decision making ability was made. A 1:1 sitter
was maintained and social work was consulted. Plavix was allowed
to wash out over the next several days. On [**2149-5-12**]. Ms. [**Known lastname **] was
taken to the operating room where she underwent coronary artery
bypass grafting to two vessels and a MAZE procedure. Please see
operative note for details. Postoperatively she was transferred
to the intensive care unit for monitoring. By postoperative day
one, she had awoke neurologically intact and was extubated. She
developed rapid atrial fibrillation which was treated with
amiodarone. She was transfused with packed red blood cells for
postoperative anemia. Coumadin, aspirin and beta blockade were
resumed. Chest tubes were removed. She was transferred to the
floor by POD#3 and wires were removed and she did well. She was
discharged to rehab on [**2149-5-17**].
Medications on Admission:
Lisinopril 40 mg daily
Plavix 75 mg daily
Protonix 40 mg daily
Lipitor 20 mg daily
Primadone 50 mg HS
Lopressor 75 mg [**Hospital1 **]
Lasix 60 mg daily (took 80 mg as 1 lb. wt. gain)
Colchicine 0.6 mg daily
ASA 325 mg daily.
Norvasc 5 mg daily
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. Insulin Lispro 100 unit/mL Solution Sig: AS DIRECTED AS
DIRECTED Subcutaneous ASDIR (AS DIRECTED).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
12. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO BID
(2 times a day): HOLD for K>4.5.
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day): HOLD for SBP<100, HR<60.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
15. Furosemide 20 mg IV Q12H
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses: Please check INR daily and dose Warfarin daily.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
CAD s/p CABGx2
HTN
Hyperlipidemia
CHF
GERD
TIA
Gout
AF
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 78538**]
Follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] 2 weeks. [**Telephone/Fax (1) 8725**]
Follow-up with Dr. [**Last Name (STitle) 16004**] in 2 weeks. [**Telephone/Fax (1) 3183**]
ICD9 Codes: 5849, 4280, 2749, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4065
} | Medical Text: Admission Date: [**2102-8-14**] Discharge Date: [**2102-8-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
In for elective coronary catheterization and PCTA
Major Surgical or Invasive Procedure:
Right Heart Catheterization
Coronary Angiography
Percutaneous Transluminal Coronary Angiioplasty with Cypher
Stenting
of Left Main, Left Anterior Descending, and Right Coronary
Artery
History of Present Illness:
86 y/o male with PVD and history of abnormal ETT (pMIBI [**2102-7-19**])
who presents for elective cardiac cath. He has significant LE
clauidication for 3-4 years with discomfort at 10-25 feet of
walking. He was referred for peripheral noninvasive testing. Had
right ABI 0.76 which went to 0.52 with exercise and left ABI
1.01 which went to 0.74 with exercise.
Past Medical History:
Peripheral Vascular Disease with Claudication
Hiatal Hernia
Hypercholesterolemia
Degenaerative Joint Disease
Social History:
Former Smoker
Family History:
No known history of Heart Disease
Physical Exam:
No significant findings on exam.
Pertinent Results:
Admission Labs:
[**2102-8-14**] 08:00AM BLOOD UreaN-11 Creat-0.9 K-4.3
[**2102-8-14**] 12:30PM BLOOD CK(CPK)-42
[**2102-8-14**] 09:33PM BLOOD CK(CPK)-92
[**2102-8-15**] 04:46AM BLOOD CK(CPK)-73
[**2102-8-15**] 05:10PM BLOOD CK(CPK)-71
[**2102-8-14**] 12:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2102-8-15**] 04:46AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.7
[**2102-8-14**] 09:33PM BLOOD Plt Ct-108*
[**2102-8-14**] 08:00AM BLOOD Hct-39.6*
Cardiac Cath [**2102-8-14**]
1. Selective coronary angiography of this right dominant system
demonstrated left main and two vessel coronary artery disease in
the
left coronary system. The LMCA had a proximal 80% lesion. The
LAD had a
midvessel 70% lesion. And the LCx had a 90% midvessel lesion.
2. Limited resting hemodynamics revealed normal central blood
pressures
of 129/62 mmHg. Post-procedure the mean PCWP was 10 mmHg.
Cardiac index
was 4.5 L/min/m2 by Fick.
3. Successful placement of 3.0 x 8 mm Cypher drug-eluting stent
(DES) in
the LMCA postdilated with a 3.25 mm balloon. Final angiography
demonstrated no residual stenosis, no angiographically apparent
dissection, and normal flow (See PTCA Comments).
4. Successful placement of four overlapping Cypher DES in the
LAD (from
proximal to distal a 3.0 x 13 mm, a 3.0 x 8 mm, a 2.5 x 23 mm,
and a
2.5.x 8 mm). The first two stents were placed initially. The
last two
stents were placed after development of slow flow and concern
for a
dissection after the LCx stent was placed. Final angiography
demonstrated no residual stenosis, no angiographically apparent
dissection, and normal flow (See PTCA Comments).
5. Successful placement of 2.5 x 18 mm Vision stent in the
mid-LCx with
a 3.0 x 8 mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 64218**] and more proximally in the
proximal
LCx. Final angiography demonstrated no residual stenosis, no
angiographically apparent dissection, and normal flow (See PTCA
Comments).
FINAL DIAGNOSIS:
1. Multivessel coronary artery disease.
2. Normal central blood pressure.
3. Normal cardiac index.
4. Successful treatment of LMCA with drug-eluting stent.
5. Successful treatment of LAD with drug-eluting stents.
6. Successful treatment of LCx with stents.
Cardiac Cath [**2102-8-15**]
1. Coronary angiography of this right dominant system
demonstrated
multivessel coronary artery disease. The LMCA had no
angiographically
apparent, flow-limiting disease and a widely patent stent. The
LAD had a
proximal 30% mild lesion with the remainder of the newly stented
vessel
free of angiographically apparent, flow-limiting disease. The
LCx had no
angiographically apparent, flow-limiting disease with the newly
placed
stents. The RCA had a tubular 40% midvessel lesion as well as a
distal,
tortuous 50% lesion. The r-PDA had a 90% focal lesion.
2. Limited resting hemodynamics revealed a normal central blood
pressure
of 129/59 mmHg.
3. Successful placement of a 2.5 x 8 mm Cypher drug-eluting
stent in the
r-PDA. Final angiography demonstrated no residual stenosis, no
angiographically apparent dissection, and normal flow (See PTCA
Comments).
FINAL DIAGNOSIS:
1. Multivessel coronary artery disease.
2. Planned, staged intervention of r-PDA.
3. Normal central blood pressure.
4. Successful placement of drug-eluting stent in r-PDA.
Brief Hospital Course:
86 y/o Male with severe 3VD (including 80% LMCA, 99% RPL, 60%
pLAD, 80% mLCX) presented for elective cath.
.
1. CAD: Severe 3VD. Not a surgical candidate for Peripheral
surgery so he underwent two phases of staged percutaneous
intervention. First had 1 LMCA stent, 3 LAD stents (with LAD
dissection), and 2 LCx stents. Second stage included Cypher
drug-eluting stent in the r-PDA. First cath complicated by LAD
disection with TIMI 1 flow. LAD Restented. Other complications
included bradycardia and hypotension after haveing femoral
sheaths removed. He received atropine and IV fluid with good
resolution of hemodynamics. Treated with asa/plavix/statin/BB.
Monitored on Telemetry throughout stay. Recovered excellently
after procedures.
.
2. PVD: Will have percutaneous intervention of Lower extremtiy
in the future. R ABI 0.7 --> 0.52 c exercise. L ABI 1.01 -->
0.74 c exercise.
.
3. Thrombocytopenia: Chronic. Not worked up during stay. Needs
follow up.
Medications on Admission:
Lipitor 40 mg QD
Plavix 75 mg QD
Atenolol 25 mg QD
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease (3 Vessel Disease)
Discharge Condition:
Good, without chest pain.
Discharge Instructions:
Please call your doctor or come to the emergency room if you
have any chest pain or concerning symptomes.
Please follow up with Dr. [**First Name (STitle) **] in the next two weeks. Please
call him at [**Telephone/Fax (1) 920**] to make an appointment.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2102-12-19**] 4:00
Completed by:[**2102-8-19**]
ICD9 Codes: 9971, 2875, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4066
} | Medical Text: [** **] Date: [**2151-11-9**] Discharge Date: [**2151-11-12**]
Service: MEDICINE
Allergies:
Protonix
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Black Stools
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
[**Age over 90 **] yo M h/o gastric bleeding from Dieulafoy lesion in [**2148**] p/w 5
days black stools. He has been having 1 BM per day for the last
5 days which has been black. He reports dizziness on standing up
and walking associated with fatigue. He denied any CP, SOB,
nausea, vomiting, diarrhea, abdominal pain.
.
ED: His vitals were stable. He was frank guiac pos. His HCT was
down to 26.2 from 34.7 in [**December 2150**]. He refused NG lavage. GI
consulted who decided to scope him in the ICU.
.
*EGD [**12-12**]: Polyp in the fundus, Mild gastritis
*EGD [**7-11**]: An oozing gastric Dieulafoy lesion was seen in the
fundus. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis
successfully.
Past Medical History:
1. HTN
2. CV ***Echo- [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. Nl LVSF. Mild dilated
ascending
aorta. [**12-8**]+ AR. mod-sever MR.
3. Flailed of a posterior mitral valve leaflet
4. PVD with critical carotid stenosis on Left side
5. glaucoma
6. macular degeneartion
7. hyperlipidemia
8. BPH
9. h/o TIA in [**7-11**]
10. GIB-[**1-11**], [**7-11**] with Dielafoy's lesion and blood in the
antrum
11. Sleep apnea
12. h/o epistaxis
13. GERD in remission
14. Claustrophobia
Social History:
Social History: Pt is retired from the textile industry. He
lives at home with his wife. Quit smoking in [**2106**]. Smoked 1.5
ppd x 20 years. Drinks 4 oz bourbon per day.
Family History:
Non contributory
Physical Exam:
97.9, 70, 145/53, 17, 100%/2L
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RRR, S1, no S2 heard, [**3-12**] holosystolic murmur at apex and
LSB
ABD: distended, tympanic, non-tender, no HSM
EXT: no c/c/e, warm, good pulses
SKIN: xerosis
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
RECTAL: guaiac positive
Pertinent Results:
[**2151-11-9**] 01:05PM BLOOD WBC-3.9* RBC-2.85*# Hgb-8.5*# Hct-26.2*
MCV-92# MCH-29.7 MCHC-32.4 RDW-13.1 Plt Ct-264
[**2151-11-9**] 02:35PM BLOOD WBC-4.0 RBC-2.89*# Hgb-8.6* Hct-26.4*
MCV-91 MCH-29.9 MCHC-32.7 RDW-13.9 Plt Ct-307
[**2151-11-10**] 02:22AM BLOOD WBC-3.9* RBC-3.19* Hgb-9.8* Hct-28.5*
MCV-90 MCH-30.6 MCHC-34.2 RDW-13.2 Plt Ct-231
[**2151-11-9**] 02:35PM BLOOD Neuts-58.7 Lymphs-31.8 Monos-5.8 Eos-3.6
Baso-0.1
[**2151-11-9**] 01:05PM BLOOD Plt Ct-264
[**2151-11-9**] 02:35PM BLOOD PT-13.3 PTT-37.8* INR(PT)-1.1
[**2151-11-9**] 02:35PM BLOOD Glucose-104 UreaN-58* Creat-1.8* Na-139
K-4.6 Cl-108 HCO3-21* AnGap-15
[**2151-11-9**] 01:05PM BLOOD ALT-10 AST-11 AlkPhos-100
[**2151-11-9**] 02:35PM BLOOD Calcium-8.2* Phos-3.2 Mg-2.6
.
EGD:
Esophagus:
Lumen: A small size hiatal hernia was seen.
Stomach:
Contents: Red blood was seen in the fundus.
Flat Lesions A large clot and pool of blood was seen in fundus.
After extensive suctioning and rolling of patient to other side,
an oozing Dieulafoy lesion was seen. 10 1 cc.Epinephrine 1/[**Numeric Identifier 961**]
injections were applied for hemostasis with success.
Duodenum: Normal duodenum.
Impression: Small hiatal hernia
Dieulafoy lesion in the fundus (injection)
Blood in the fundus
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
[**Age over 90 **] yo M h/o gastric bleeding from Dieulafoy lesion in [**2148**] p/w 5
days black stools due to upper GIB. An EGD was performed in the
ICU on [**11-10**]; an oozing Dieulafoy lesion was identified and
injected with epinephrine until hemostasis was achieved. He
received 2 units of PRBCs. His hematocrit remained stable for
36 hours following the procedure. H Pylori serologies were
negative. He resumed a normal diet without complication. He
will follow up with his PCP on discharge, he will hold his
aspirin until he follows up with his PCP.
.
Code Status: DNR/DNI. Communication: Patient and Son [**Name (NI) 382**]-
[**Telephone/Fax (1) 22948**].
.
Medications on [**Telephone/Fax (1) **]:
Diovan 40 mg QD
Aspirin 40 mg QD
Lasix 20 mg QD
Metoprolol 50 mg QD
Terazosin 10 mg QD
Finasteride 5 mg QD
Timolol eye drops
Tobradex
Fish oil
Ambien 10 mg QHS
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tobramycin-Dexamethasone 0.3-0.1 % Drops, Suspension Sig: One
(1) Drop Ophthalmic [**Hospital1 **] (2 times a day).
3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
8. Terazosin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI Bleed due to Dieulafoy lesion
Discharge Condition:
Hemodynamically stable, stable hematocrit, tolerating POs.
Discharge Instructions:
During this [**Hospital1 **] you were treated for bleeding in your
stomach.
Please continue to take all medications as precribed; call your
primary care doctor with any questions regarding your
medications.
Please come to the ED immediately if you experience recurrent
black or bloody stools, or vomiting blood or black liquid; if
you experience chest pain or shortness of breath, or of you
develop any other concerning symptoms.
We have started a new medication called omeprazole. We have
stopped your aspirin--please DO NOT restart your aspirin until
you see you PCP [**Last Name (NamePattern4) **] [**11-22**].
Followup Instructions:
You have the following appointment with your PCP: [**Name Initial (NameIs) 2169**]:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2151-11-22**]
9:30
.
Follow up with GI if you have any recurrent symptoms: black or
bloody stool, black or bloody vomit, or abdominal pain. Call
for an appointment. Your GI doctors [**First Name (Titles) **] [**Last Name (Titles) **] were [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 174**], MD [**First Name (Titles) **] [**Last Name (Titles) **] [**Name8 (MD) **], MD (fellow). The phone number for
the [**Hospital **] clinic is ([**Telephone/Fax (1) 22346**].
ICD9 Codes: 2859, 4019, 4439, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4067
} | Medical Text: Admission Date: [**2150-5-18**] Discharge Date: [**2150-5-21**]
Date of Birth: [**2087-6-30**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Latex
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left arm and leg weakness
Major Surgical or Invasive Procedure:
IV tPA
History of Present Illness:
The pt is a 62 year-old right-handed man with a PMH of DM, HTN.
HLD and a reported prior stroke who was BIBA after awakening at
3am with L sided weakness. His last known well time was around
2am when he went to sleep, and he recalls having no deficits at
the time. His wife last saw him well at 11pm when she went to
sleep. Mr. [**Known lastname **] [**Last Name (Titles) 5058**] at 3am and wanted to get up to go
urinate, however he was unable to get out of bed. He therefore
called his wife and she attempted to help him stand but he and
she were unable to support his weight and he fell to the ground.
He was weak on the left side and mildly dysarthric per his wife,
but she was not sure if the later symptom was due to the fact
that he was not wearing his dentures.
She called 911 and in the field, EMS noted a BS of 165 and a
pressure of 208/100 with a HR of 130. Their exam revealed a L
facial droop and L arm and leg weakness. He did not receive meds
in the field.
In the ED he remained hypertensive initially to 160/90's but
then increased to 200/100. His exam was remarkable for a L
facial droop, mild dysarthria and a L hemiplegia. He was taken
to CT/CTA and the preliminary review of these studies showed
extensive calcification of bilateral MCA's but no clear loss of
grey/white differentiation or obscuration of the insular ribbon.
His CTA
showed atherosclerotic disease but no occlusion of the ICA or
MCA's.
His INR was 0.9 and his platelets were 425. He met no exclusion
criteria for tPA, therefore the decision to give IV tPA was made
as he was still in the therapeutic window. His BP was elevated
however at SBP 200/100's. He was treated with labetalol IV
without successful reduction in BP and was therefore started on
a labetalol and nicardipine drip. The tPA is on hold until the
blood pressure is controlled given concern for HTN increasing
the risk of ICH.
ROS: denied headache, loss of vision, blurred vision, diplopia,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denied difficulties producing or comprehending
speech. Denied CP, SOB, N,V, or fevers/chills.
Past Medical History:
-DM
-HTN
-HLD
-prior stroke
-R eye blindness
-prior MVA
-chronic venous stasis
-stenosis (pt thinks in the lumbar distribution)
-heart murmur
-prior L Caudate infarction / encephalomalacia on CT
Social History:
-married, lives with his wife
-denies tobacco or drugs
-drinks socially
Family History:
There is a history of CAD in a grandfather and CHF in his
father. Mother died of emphysema. No family history of
diabetes.
Physical Exam:
Vitals: T: 98.7 P: 106 R: 19 BP: 166/126 SaO2: 98% on 2L
General: Awake, cooperative, NAD.
[**Last Name (Titles) 4459**]: thick neck, no bruit appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: harsh systolic ejection murmur, best heard over the R
sternal border
Abdomen: soft, obese, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: bilateral hyperpigmentation L>R with 3+ edema.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
CN
I: not tested
II,III: VFF to confrontation, Pupil 3-2mm bilaterally, fundi
normal but limited exam due to need to expide CT scan
III,IV,V: [**Last Name (Titles) 3899**], but baseline esotropia of the R eye. no ptosis.
No nystagmus
V: sensation intact V1-V3 to LT
VII: L facial droop, symm forehead wrinkling
VIII: hears voice bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**4-20**] bilaterally
XII: tongue protrudes midline, mild dysarthria
Motor: Normal bulk and tone; L arm and leg have no spontaneous
movement; the L arm flexes at the deltoids with nox stim and the
L leg has trace contracture of the IP with nox stim. R arm and
leg are antigravity
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0--------------> Extensor
R 0--------------> Extensor
-Sensory: No deficits to light touch. No extinction to DSS.
-Coordination: + R sided intention tremor, no ataxia; L side is
plegic as above
-Gait: deferred given likely acute stroke
Pertinent Results:
BUN 24 Cr 1.1
Na:139
K:3.4
Cl:93
TCO2:34
Glu:161
freeCa:1.11
Lactate:2.0
pH:7.44
Hgb:14.0
CalcHCT:42
Fibrinogen: 492
[**Doctor First Name **]: 102
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
11.5 \13.6/ 425 MCV 82
PT: 10.8 PTT: 21.4 INR: 0.9
EKG: ST, rate of 106, LBBB, new from ECG in [**2146**]
A1c [**2150-5-18**] 6.5
Lipids [**2150-5-21**]: Chol 207 Triglycerides 221 HDL 41 LDL 122
Radiologic Data:
NCHCT/CTA/CTP [**5-18**]:
IMPRESSION:
1. No definite evidence of acute large vascular territory
infarction is seen on CT or CT perfusion. Small infarct cannot
be excluded and an MRI may be performed if clinically indicated.
2. Atherosclerotic plaques with calcifications noted in the
carotid bulbs,
with mild-to-moderate right and mild left internal carotid
narrowing at their origins.
3. 9-mm left thyroid nodule.
4. Mildly displaced, likely subacute first left rib fracture.
<br>
MRI Head [**5-18**]:
IMPRESSION: Acute/subacute ischemic changes noted on the
posterior aspect of the caudate nucleus on the right with
extension to the right external capsule as described above. The
areas of ischemia _____ hyperintensity signal on the DWI
sequence and low signal in the corresponding ADC maps.
Limited examination secondary to motion artifact. Multiple
subcortical
hyperintensity areas suggesting chronic microvascular ischemic
changes.
Prominence of the pituitary gland detected on the sagittal
image, correlation with dedicated MRI of the sella turcica is
recommended if clinically warranted.
<br>
MRA Head [**5-18**]:
IMPRESSION: Significant limited examination secondary to motion
artifact;
apparently there is evidence of vascular flow in both internal
carotids as
well as the vertebrobasilar system; however, the anatomical
detail is obscured by the motion artifact, please consider
repeating this examination under conscious sedation if
clinically warranted.
<br>
NCHCT [**5-19**]:
IMPRESSION:
1. Infarct involving the right corona radiata with extension to
the right
subinsular region is more conspicuous compared to the prior CT
study, and
correlates with findings seen on MR. [**Name13 (STitle) **] region of new infarct
and no new
hemorrhage seen.
Transthoracic ECHO [**2150-5-20**]:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is probably normal (LVEF>55%).
Inferior hypokinesis is suggested but not confirmed. Transmitral
Doppler and tissue velocity imaging are consistent with Grade II
(moderate) LV diastolic dysfunction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are severely thickened/deformed. There is
moderate aortic valve stenosis (area 1.0-1.2cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
CXR [**2150-5-18**]:
The diaphragms are in normal position. The size of the cardiac
silhouette is within normal range. The transparency and
structure of the lung parenchyma is unremarkable. There is no
evidence of focal parenchymal opacities suggestive of pneumonia.
The right hilus appears slightly bigger than left, but this is
unchanged as compared to the previous radiograph from [**2147-9-17**]. There is no evidence of pleural effusions.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the Neuro ICU for close monitoring
following administration of IV tPA in the Emergency Department.
The decision was made to administer IV tPA based on the clinical
appearance of a significant R MCA stroke. Later on the day of
admission, an MRI was obtained that demonstrated an acute
infarct of the right caudate nucleus and external and internal
capsules, likely involving a lateral lenticulostriate vessel.
Etiology is likely a small artery occlusion (so-called
"lacunar"). He remained neurologically stable for 24 hours after
tPA and repeat head CT at 24 hours after tPA showed no
hemorrhage. He was transferred to the floor.
Fasting lipid panel revealed LDL 122 and HDL 41 after continuing
on a statin in house. Hb A1c was 6.5. His blood sugars were
well-maintained on insulin-sliding scale while in the hospital,
and he will be discharged on his oral hypoglycemics prior to the
hospitalization. Cardiac TTE was obtained and did not reveale
evidence for a cardioembolic mechanism.
He was started on Aggrenox for secondary stroke prevention, as
he had been on aspirin at the time of the event. A baby aspirin
was added to the aggrenox just prior to discharge. Furthermore,
the Aggrenox should be increased to [**Hospital1 **] dosing on [**2150-5-22**].
It was noted that his CK was markedly elevated (max 1813),
without corresponding increase in MB; troponin was
insignificantly elevated. As such, this was attributed to a
myositis. The patient was continued on a statin and his CK
trended downward daily thereafter (610 on discharge).
While in the ICU, he developed a leukocytosis without fever, so
this was followed. He continued to have a low grade
leukocytosis (12 on day of discharge) without evidence of
infection.
The patient's anti-hypertensives were initially held in the
setting of stroke, but were gradually added back during the
hospitalization as the patient remained hypertensive between the
150s-190s. Half his home dose of hydrochlorothiazide and and
terazosin were resumed on the final day of the hospitalization.
Please increase as necessary to optimize blood pressure control.
Medications on Admission:
- labetalol 600 mg [**Hospital1 **]
- terazosin 1 mg daily
- HCTZ 50 mg daily
- lovastatin 10 mg daily
- metformin 1000 mg [**Hospital1 **]
- nifedipine 30 mg [**Hospital1 **]
- Cozaar 100 mg daily
- Glyburide 10 mg [**Hospital1 **]
Allergies: PCN
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO DAILY (Daily): Please increase to twice
daily on [**2150-5-22**].
9. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
10. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for insomnia.
12. Nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours). Capsule(s)
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Terazosin 1 mg Capsule Sig: One (1) Capsule PO once a day.
15. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
16. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
17. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Right subcortical stroke - posterior aspect of the caudate
nucleus and porterior putamen on the right with extension to the
right external capsule
Discharge Condition:
Stable, has dense left face and left hemibody weakness.
Discharge Instructions:
Please take your medications as prescribed and follow up with
your appointments as prescribed. You have had a stroke. If you
have any new, worsening, or concerning symptoms (such as new
weakness, numbness, tingling, visual change or trouble
speaking), please contact your neurologist at [**Hospital1 18**], Dr. [**First Name8 (NamePattern2) 2530**]
[**Name (STitle) **] at [**Telephone/Fax (1) 44**] or the on-call [**Hospital1 18**] neurologist at
[**Telephone/Fax (1) 2756**], or head to the nearest emergency room.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2150-7-6**] 2:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4068
} | Medical Text: Admission Date: [**2114-10-23**] Discharge Date: [**2114-10-30**]
Date of Birth: [**2069-8-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Hypotension and altered MS
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
45 y.o male with end stage liver disease presented to OSH from
Hospice with altered MS [**First Name (Titles) **] [**Last Name (Titles) 7186**] of breath with hemoptysis.
Pt transfused 2 units PRBC at OSH with HCT up to 25. Transfered
to [**Hospital1 18**] after family reversed code status for further care. In
ED found to be hypotensive and tachypneic with hemoptysis. Pt
intubated and NG lavage performed which was positive for coffee
ground material. Cleared after 700cc. GUIAC negative in ED.
.
Per brother pt has been hospitalized numerous times since his
diagnosis. Approx 2 weeks ago and was treated at [**Hospital1 2177**] for upper
GI bleed and had EGD at that time, unknown findings.
.
Pt found to have elevated WBC to 27, Lactate 2.7, >50 WBC in
urine. Received Zosyn, Flagyl and Vanco in the ED. GI service
consulted for GI bleed and pt started on Sepsis protocol. Pt
received 5 liters NS in ED. No blood products.
Past Medical History:
Etoh abuse
Hep C
Social History:
Pt was living with his brothers when he became increasingly ill
and they were unable to care for him at home. Brothers told that
there was a place that could take care of him, were not informed
that this place was hospice.
Family History:
Unable to obtain.
Physical Exam:
VS: 96.8 ax, HR 107, BP: 100/42 (on Levophed) 100% (500/16, Peep
5, FiO2 0.4)
GEN: Intubated and sedated, jaudiced.
HEENT: Pupils at 3mm bilaterally and reactive, no roving eye
movements, scleral icterus, scleral edema.
CV: tachy, regular, no murmur.
CHEST: Coarse BS throughout, no wheeze appreciated.
ABD: Mildly distented, no fluid wave, soft, no masses
appreciated. Difficult to palpate liver edge.
EXT: Jaudiced, warm to touch, 2+ pulses, 1+ pedal edema, palmar
erythema.
NEURO: Sedated, unresponsive.
Pertinent Results:
[**2114-10-23**] 09:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2114-10-23**] 09:35PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-FEW
EPI-0-2 TRANS EPI-0-2
[**2114-10-23**] 09:35PM URINE HYALINE-0-2
[**2114-10-23**] 08:47PM LACTATE-2.7*
[**2114-10-23**] 08:30PM GLUCOSE-140* UREA N-46* CREAT-2.3* SODIUM-138
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-16
[**2114-10-23**] 08:30PM ALT(SGPT)-47* AST(SGOT)-53* ALK PHOS-257*
AMYLASE-83 TOT BILI-5.6*
[**2114-10-23**] 08:30PM ALBUMIN-2.0* CALCIUM-6.5* PHOSPHATE-4.7*
MAGNESIUM-1.6
[**2114-10-23**] 08:30PM NEUTS-95.8* BANDS-0 LYMPHS-2.2* MONOS-1.9*
EOS-0.1 BASOS-0
[**2114-10-23**] 08:30PM PLT SMR-LOW PLT COUNT-149*
[**2114-10-23**] 08:30PM PT-20.1* PTT-42.7* INR(PT)-2.9
.
Head CT: FINDINGS: There is no evidence of acute intracranial
hemorrhage, mass effect, shift of normally midline structures,
hydrocephalus, or major vascular territorial infarcts. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. The cisterns and
sulci are maintained. The visualized portions of the paranasal
sinuses and mastoid air cells are normally aerated. The patient
is intubated.
IMPRESSION: No acute intracranial pathology, including no
evidence of acute intracranial hemorrhage.
.
CXR: IMPRESSION:
1. ET tube in satisfactory position.
2. NG tube with its tip in the mid esophagus.
3. Abnormal lung findings could be due to aspiration with
partial atelectasis of the left lower lobe, multifocal pneumonia
or pulmonary edema.
Brief Hospital Course:
45 y.o male with end stage liver disease presents with GI bleed
and sepsis.
.
1) Sepsis: Pt started on sepsis protocol in ED for elevated WBC
(27 with no bandemia) and respiratory compromise. Lactate 2.7.
Possible sources include urosepsis given >50 WBC in urine, PNA
given resp failure, vs abd source [**3-14**] translocation from GI
bleed. Stool became positive for c.diff colitis and was started
on broad spectrum abx in ED; Zosyn, Vanco and Flagyl for
coverage of GI flora and staph. Eventually change in goal to
comfort only and so antibiotics were stopped.
.
2) Resp failure: Likely secondary to sepsis and mental status
changes. CXR shows prominence of the pulmonary vasculature as
well as patchy consolidation in the left lower lobe. Possible
PNA vs pulm edema given low albumin and fluid rescusitation.
Hemoptysis likely secondary to upper GI bleed, however cannot
rule out lung process. He was eventually extubated with change
in goals of care to comfort.
.
3) GI bleed: EGD here with evidence of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear.
Supported with blood products and coagulopathy reversed until
change in goal of care.
.
4) Liver failure: Pt has hx of ETOH abuse and Hep C cirrhosis.
Pt was apparently diagnosed only 4 months ago. Has received all
of his care at [**Hospital1 2177**]. Not on transplant list that we can tell.
Last Etoh was 4 months ago, on diagnosis. Extent of disease is
evident by INR 2.9 and albumin 2.0. Was seen by liver team with
elevated MELD score and not a transplant candidate and again
supportive measures only were taken.
.
5) Renal failure: Likely secondary to hepatorenal syndrome. Low
urine output throughout stay.
.
6) Altered MS: Likely multifactorial. End stage liver disease
causing hepatic encephalopathy, renal failure causing uremia and
sepsis. Head CT negative for bleed. However mental status only
improved marginally to the point where he recognized family
memebers, but never back to baseline.
.
7) Code: Famiy was not aware iniitially of patient's wishes for
Hospice and comfort care only. Once discussed with his
physicians and his wishes made known, they agreed in change of
care to comfort care only and all medications and procedures
were stopped except morphine drip and prn ativan and scopolamine
patch. He was then transitioned to equivalent dose of fentanyl
patch and prn concentrated morphine solution for pain control.
Medications on Admission:
Unknown
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
c. diff sepsis
[**Doctor First Name 329**] [**Doctor Last Name **] tear resulting in gastrointestinal bleed
hepatic failure from hepatitis C and alcoholic cirrhosis
acute renal failure
altered mental status
Discharge Condition:
deceased
Discharge Instructions:
--
Followup Instructions:
--
Completed by:[**2114-10-31**]
ICD9 Codes: 0389, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4069
} | Medical Text: Admission Date: [**2162-10-24**] Discharge Date: [**2162-11-3**]
Date of Birth: [**2091-1-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Acute headache and left hemiplegia
Major Surgical or Invasive Procedure:
[**10-25**]: Right craniotomy for hemorrhage evacuation
History of Present Illness:
71-year-old pt who presented with acute headache and left
hemiplegia, found to have ICH. He was engaged in intercourse
with his wife around 9:15 am today when he had a sudden
right-sided headache, maximal at onset. He immediately then was
unable to move his left side. His wife called EMS, who arrived
in 5 minutes or so and brought him to [**Hospital6 3105**].
There, a head CT showed a large R parietal intraparenchymal
hemorrhage. He complained of nausea. He received 8 mg of Zofran
at [**Hospital1 487**]. He was transferred to [**Hospital1 18**] for
further evaluation and definitive treatment
Past Medical History:
HTN
Hypercholesterol
CAD s/p MI 5-6 years ago
Social History:
Smokes [**12-9**] ppd x 50 years. Drinks 2 beers/day. Married, lives
with wife. [**Name (NI) **] illicit drugs, including cocaine. Retired defense
planner.
Family History:
No known history of strokes.
Physical Exam:
On Admission:
General: Arouses to voice, oriented to person only, in NAD.
PERRL 4 to 3mm and brisk bilaterally, EOMI without nystagmus,
facial sensation intact to light touch. 5/5 strength in trapezii
and SCM bilaterally, Tongue protrudes midline, smile
symmetrical.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 0 0 0 0 0 0 0 0 0 0 0 0 0 0
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
On Discharge:
AOx2-3, occasionally missing the year. PERRL, EOMI without
nystagmus. Unable to perform pronator drift due to dense left
sided hemiplegia. Left neglect. Speech appropriate, follows
commands.
Pertinent Results:
Labs on Admission:
[**2162-10-24**] 09:51PM OSMOLAL-294
[**2162-10-24**] 11:50AM PT-12.8 PTT-27.3 INR(PT)-1.1
[**2162-10-24**] 11:50AM WBC-14.3* RBC-4.75 HGB-14.6 HCT-40.6 MCV-86
MCH-30.8 MCHC-35.9* RDW-12.8
[**2162-10-24**] 11:50AM GLUCOSE-149* UREA N-14 CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
Labs on Discharge:
[**2162-11-1**] 05:03AM BLOOD WBC-14.9* RBC-3.55* Hgb-11.2* Hct-30.9*
MCV-87 MCH-31.6 MCHC-36.3* RDW-13.1 Plt Ct-296
[**2162-11-1**] 05:03AM BLOOD Plt Ct-296
[**2162-11-1**] 05:03AM BLOOD Glucose-99 UreaN-25* Creat-0.7 Na-142
K-3.9 Cl-109* HCO3-24 AnGap-13
[**2162-11-1**] 05:03AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0
Imaging:
Head CT [**10-24**]:
IMPRESSION: Large mixed attenuation right parietal lobe finding
with
associated mass effect including compression of the right
lateral ventricle. Possible hematocrit level suggests this is
hemorrhagic in etiology, but an underlying mass cannot be
excluded and MRI should be considered.
ADDENDUM AT ATTENDING REVIEW: There is moderate right lateral
ventricular
blood, and a small amount of blood sedimenting in the left
occipital [**Doctor Last Name 534**]
region.
Head CTA [**10-25**]:
IMPRESSION:
Large right frontal intraparenchymal hematoma. No definite
aneurysm or AVM is seen. Please note that a small AVM can be
compressed by the hematoma and not be detectable on CTA.
Pathology:
EXTENT OF INVASION
Clinical: Parietal hematoma.
Gross: The specimen is received fresh in two parts, both
labeled with the patient's name, "[**Last Name (LF) 81488**], [**Known firstname 3065**]" and the
medical record number.
Part 1 is additionally labeled "right sided lesion, frozen
section." It consists of multiple fragments of blood clots
admixed with thin strands of tan white soft tissue measuring 1.4
x 1.1 x 0.5 cm in aggregate. Intraoperative consultation was
obtained smear and frozen section was performed on
representative areas. The frozen section and smear diagnosis by
Dr. [**Last Name (STitle) 28411**] is "blood clot and blood vessels. The vascular
malformation or congophilic angiopathy. No obvious tumor, but
would permanents to be definite. Dr. [**Last Name (STitle) **] will culture just in
case. The rest will wait for permanent section." The specimen
is entirely submitted as follows: A = frozen section remnant #1,
B = frozen section remnant #2, C = remainder of specimen.
Part 2 is additionally labeled "right sided lesion." It consists
of multiple fragments of dark red hematoma and soft tissue
measuring 8 x 3.8 x 1.5 cm in aggregate. The specimen is
entirely submitted in D-I.
MRI Head [**10-26**]:
IMPRESSION:
1. Evolving large right parietal intraparenchymal hematoma. No
evidence of
extension of hemorrhage. No evidence of associated mass.
CTA [**10-29**] of Head:
IMPRESSION:
1. Subarachnoid hemorrhage and intraventricular blood with
postoperative
changes in the right frontoparietal region with small amount of
blood products at the surgical site. The blood products may not
have significantly changed since the MRI of [**2162-10-25**].
2. Mild vascular displacement and diminished and delayed filling
of the
frontoparietal arterial branches could be secondary to mild
swelling and
postoperative change in this region. No arteriovenous
malformation is seen. No sinus thrombosis is identified.
EKG [**10-24**]:
Sinus rhythm. Borderline intraventricular conduction delay. Left
atrial
abnormality. Non-specific ST segment and T wave changes. No
previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
66 166 98 [**Telephone/Fax (2) 81489**] 68
Brief Hospital Course:
Pt presented to ED from an OSH with headache and left
hemiplegia. Pt was transferred to the ICU where pt was
intubated. CT without contrast showed large mixed attenuation
in the right parietal lobe with associated mass effect including
compression of the right lateral ventricle, mod right lateral
ventricular blood, and a small amount of blood sedimenting in
the left occipital [**Doctor Last Name 534**] region. [**10-25**] pt went to OR for right
crani, evacuation & duraplasty, and kept intubated overnight.
Pt was extubated on [**10-26**], and a dobnoff was placed, tube feeds
were started. Pt found to be hypertensive to 160's, and was
given prn labetalol with effect. [**10-28**] pt was pan-cultured for
a temp of 101F, which future work up was negative. [**10-30**] pt
pulled dobhoff, which was replaced and tf's restarted. He again
pulled out his dobhoff tube. Because of his continually
improving mental status, a speech and swallow consult was again
attempted, and patient was able to pass, negating the need to
pursue permanent tube placement. Patholgy was returned on the
clot that was evacuated, and was consistant with blood products,
and not obvious vascular abnormality was identified. On [**11-2**],
his wound staples were removed, and wound was clean dry and
intact. He was seen by physical and occupational therapy and
determined to be an appropriate candidate for rehabilitation.
He was discharged to said facility on [**11-2**].
Medications on Admission:
Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day):
Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed for htn.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Sodium Citrate-Citric Acid 500-300 mg/5 mL Solution Sig:
Thirty (30) ML PO QID (4 times a day) as needed for heartburn.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day): Hold for HR<60 of SBP<100.
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
as needed for htn.
11. Famotidine 20 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day.
12. LeVETiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right parietal lobar hemmorhage
Discharge Condition:
Neurologically Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair, as your staples have been removed.
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Do not take any anti-inflammatory medicines such as Motrin,
aspirin, Advil, Ibuprofen etc.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing in 7 days
and fax results to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
You have already had your staples removed in the hospital.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
Completed by:[**2162-11-2**]
ICD9 Codes: 431, 4019, 2724, 412, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4070
} | Medical Text: [** **] Date: [**2109-2-8**] Discharge Date: [**2109-2-19**]
Date of Birth: [**2050-5-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis
History of Present Illness:
58 year old F with Multiple Sclerosis with repeated admissions
this month for AMS who was admitted to [**Location **] [**2-6**] for
confusion after a fall and found to have UTI and bil DVT and is
now transffered to us primarily for continuous EEG monitoring
d/t continued AMS.
.
At baseline pnt is mostly wheelchair bound, but is able to walk
a few steps with a walker and transfer independently, mentates
normally and is able to care for her affairs.
.
She was recently admitted to [**Hospital3 1196**] ON
[**2109-1-24**] for UTI and became delirious at that point. However,
her delirium did improve and she was alert and oriented upon
discharge. transferred to [**Hospital **] Rehab on [**2109-1-23**]. She was
at for less than a day, at which point she was transferred back
to [**Hospital3 1196**] with altered mental status where
she was discharged on [**1-26**] back to rehab. Details of this
[**Month/Year (2) **] are unclear. She then presented [**2-6**] to [**Hospital3 **]
from nursing home due to a fall which she said was [**3-14**] to
neglecting to lock her wheelchair when she was trying to get off
it. She fell backwards and sustained a occipital scalp
hematoma, there was no loss of consciousness, no incontinence,
tongue [**Last Name (un) 20694**] or limb movements. Per nursing home report, the
patient was confused after the fall.
.
At [**Hospital3 **] was reported to have intermitent confusion with
peridos in which she is able to converse and cooperate. Kepra
was started overnight for ? of seizures. Today she became
progressively more lethargic to the point of awakening only to
noxiuous stimuli. Noncontrast head CT showed atrophy but no
acute findings. MRI scan was limited d/t movement and showed
[**Known lastname 1007**] matter findings consistent with multiple sclerosis, but
could not absolutely r/o infarction. EEG show generalized
slowing and some high-amplitude sharp activity which was felt to
be consistent with an encephalopathy, although seizure could not
be ruled out. All centerally acting medications including
baclofen and keppra. She was given IV acyclovir empirically on
day of transfer. LP was performed prior to transfer, initial and
showed: gluc 63, prot 47, gram stain neg, RBC 2140 1st tube 20
4th tube, no xanthrchromia, WBC = 5, 5.
.
.
She also reported increased swelling bilaterally in her lower
extremities over past few months left > right, limiting her
mobility. She denied any chest pain, shortness of breath,
nausea, vomiting, headache, focal numbness or weakness. LENI
demonstarted DVT in the left common femoral and proper femoral
veins + clot was also seen in the right common femoral vein.
She has no family or personal h/o DVT. She denied any CP or SOB.
VQ scan was was interpreted as very low probability for
pulmonary embolism. Echo showed mild-mod TR and minimal PHTN
(28mmHg) w/o RV strain. IV heparin was started + coumadin. Then
reversed for LP and IVC filter was placed.
.
Also UTI was diagnosed per dirty UA, patient received 3 days of
ciprofloxacin which was stopped d/t AMS. Unkown if positive
cultures.
.
Past Medical History:
Osteoporosis
- multiple sclerosis, wheelchair bound with indwelling Foley, -
hyperlipidemia
- frequent urinary tract infections
- myelopathy
- chronic pain syndrome.
Social History:
She lives in a skilled nursing facility. A brother is
healthcare proxy. She has never smoked. She does not drink
alcohol.
Family History:
Mother had multiple sclerosis and father had hypertension and
depression.
Physical Exam:
[**Known lastname **] Exam:
General: awake but not alert, non-verbal, not following
commands, answers in repeated monosylabals, no acute distress,
very thin and wasted.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: bil air entery, no wheezes, rales, ronchi
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no organomegaly
GU: foley in place
Ext: +3 edema bil left > rt, left distal LE is cool with
motelling and cyanosis in toes, DP are however 2+ bilaterally.
Neuro: limited exam: CN's grossly intact, mild spacticity in 4
limbs w/o contracturs, able to move 4 limbs, symetric reflexes
bilaterally, gait deferred
.
Discharge Exam:
VS: T 97-98 BP 120-130/70-90 HR 100-120 RR 20 O2 Sat 97% RA
GEN: Elderly woman in NAD, cachectic.
Neck: Supple
CV: Tachycardic, regular. No m/r/g.
PULM: CTAB, diminished BS at the bases bilaterally. No increased
WOB. No wheezes, rales or rhonchi.
ABD: Firm and slightly distended, NABS. No rigidity, rebound or
guarding.
EXT: 2+ pitting edema to the thighs. DPs 1+, BLEs are WWP.
NEURO: A/O x2.
Pertinent Results:
[**Known lastname **] Labs:
[**2109-2-9**] 12:04AM BLOOD WBC-6.4 RBC-3.30* Hgb-10.3* Hct-30.5*
MCV-92 MCH-31.1 MCHC-33.7 RDW-12.9 Plt Ct-375
[**2109-2-9**] 12:04AM BLOOD Neuts-94.5* Bands-0 Lymphs-10.0*
Monos-5.2 Eos-0.3 Baso-0.2
[**2109-2-9**] 08:51PM BLOOD PT-28.6* PTT-36.9* INR(PT)-2.8*
[**2109-2-9**] 02:50PM BLOOD PT-27.0* PTT-77.9* INR(PT)-2.6*
[**2109-2-9**] 07:37AM BLOOD PT-26.8* PTT-105.3* INR(PT)-2.6*
[**2109-2-9**] 12:04AM BLOOD Glucose-109* UreaN-22* Creat-1.1 Na-137
K-4.2 Cl-100 HCO3-25 AnGap-16
[**2109-2-9**] 12:04AM BLOOD ALT-17 AST-19 LD(LDH)-382* AlkPhos-78
TotBili-0.2
[**2109-2-9**] 09:30AM BLOOD T4-7.9 Free T4-1.6
[**2109-2-9**] 12:04AM BLOOD TSH-4.7*
[**2109-2-9**] 09:30AM BLOOD calTIBC-173* VitB12-769 Folate-16.6
Hapto-271* Ferritn-324* TRF-133*
[**2109-2-9**] 09:30AM BLOOD [**Doctor First Name **]-PND
[**2109-2-9**] 12:04AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs:
[**2109-2-18**] 04:56AM BLOOD WBC-10.4 RBC-2.90* Hgb-9.2* Hct-27.2*
MCV-94 MCH-31.7 MCHC-33.7 RDW-14.7 Plt Ct-377
[**2109-2-17**] 04:49AM BLOOD Glucose-89 UreaN-29* Creat-1.2* Na-133
K-4.8 Cl-101 HCO3-21* AnGap-16
[**2109-2-14**] 05:48AM BLOOD CA125-2614*
.
CT Chest/Abd/Pelvis ([**2109-2-12**]):
1. Large pelvic masses that are mainly composed of soft tissue
but have some cystic components within them. Bilateral
hydronephrosis is detected secondary to external compression of
the ureters by the pelvis masses.
Omental caking and peritoneal seeding are seen along with
malignant ascites. These findings are most probably related to
primary ovarian carcinoma.
.
2. IVC filter is well positioned, filling defects that are
compatible with
DVT are seen in the right common iliac vein. The right external
iliac vein is obliterated. Filling defects are seen in the left
common femoral vein and left superficial femoral vein. The left
iliac veins are not well visualized.
.
Paracentesis ([**2109-2-14**]): Technically successful ultrasound-guided
diagnostic paracentesis Preliminary Reportwith 850 mL of clear
serous fluid removed. No immediate complication. Cytology
consistent with adenocarcinoma.
Brief Hospital Course:
Primary Reason for [**Month/Day/Year **]: 58 year old F with Multiple
Sclerosis with repeated admissions this month for AMS who was
admitted to [**Location **] [**2-6**] for confusion after a fall and
found to have UTI and bilateral DVTs transferred for continuous
EEG monitoring d/t continued AMS found to have widespread
ovarian cancer.
.
Active Problems:
.
# AMS/Delirium: Likely toxic metabolic encephalopathy given
marked improvement with antibiotics and EEG consistent with
generalized encephalopathy and no e/o seizure or epileptiform
activity. She was initially A/O x0, arousable but minimally
verbal, only responsive with echolalia. After initiating
appropriate antibiotic therapy for enterococcus UTI, her mental
status rapidly improved. There was initially concern for
bacterial/viral meningitis/encephalitis and LP was performed at
[**Hospital3 **]. CSF showed Tot Protein 47, Glucose 63, RBC 2140
(Tube 1), RBC 20 (Tube 4), likely representative of a traumatic
tap. HSV PCR and Cryptococcal antigen were negative. Bacterial
cultures were negative and antibiotics were narrowed and
acyclovir was discontinued. MRI was also performed at [**Hospital3 2568**]
and showed periventricular [**Known lastname **] matter changes consistent with
MS. On the floor her mental status rapidly improved, though she
contined to wax and wane with occasional hallucinations and
inappropriate responses to questioning, intersperced with
periods of lucidity consistent with delerium. RPR was negative
and TFTs were normal. At the time of discharge, she was A/Ox3
and able to engange in conversation, though occasionally
confused.
.
# DVT: Pt with b/l DVTs, for which she was started on Heparin
gtt and Warfarin. She also had an IVC filter placed at [**Hospital3 10959**], as she needed to be reversed for urgent LP. CT C/A/P was
performed due to concern for malignancy or IVC clot and showed a
large pelvic mass with widespread peritoneal metastases
consistent with advanced ovarian cancer. Warfarin and Heparin
were stopped and she was placed on therapeutic doses of Loveonx.
She should be continued on Lovenox shots as prescribed for at
least the next 6 months with consideration given to lifelong
anticoagulation given her known hypercoagulable state.
.
# Ovarian Cancer: Large pelvic mass with associated ascites,
omental caking peritoneal seeding and pleural effusion were seen
on CT scan. Ultrasound guided paracentesis was performed and
cells were sent for cytology. Ca-125 was 2614. Ascitic fluid was
exudative, consistent with peritoneal carcinomatosis. Cytology
showed adenocarcinoma and Heme/Onc was consulted. She will
follow up as an outpatient for management of her malignancy.
Final staining for pathology is pending at discharge.
.
# Bleed: Pt's HCT dropped 28->23 s/p paracentesis in the setting
of anticoagulation with Lovenox. For this she was transfused 1U
pRBCs with appropriate response in her HCT from 23->28. Her HCT
remained stable for the remainder of her hospital course.
.
# UTI: She was found to have UTI at [**Hospital3 2568**] and placed on
Cipro, which was stopped after 3d due to worsening mental
status. At [**Hospital1 18**] she was given Ceftriaxone; urine culture grew
enterococcus sensitive to Ampicillin and Ceftriacxone was
stopped and she was given a 7d course of Ampicillin. Ampicillin
was continued due to her recurrent UTIs and hospital admissions
for AMS; she will require lifelong Ampicillin prophylaxis and
should continue q6h straight cath for her neurogenic bladder.
.
# [**Last Name (un) **]: Pt with elevated Cr. Initial concern was for pre-renal
failure given poor PO intake and she was given IVF without
improvement. CT C/A/P was then performed and showed a large
pelvic mass compressing the bilateral ureters and mild bilateral
hydronephrosis. Her Cr and electrolytes were monitored and her
Cr remained stable (1.2-1.3) throughout her course.
.
# Atonic Bladder: At baseline pt straight caths herself for
atonic bladder due to MS. [**First Name (Titles) **] [**Last Name (Titles) **] to [**Hospital1 18**] she had an
indwelling foley. This was d/c'ed upon arrival to the floor and
she was straight cath'ed q6h for the remainder of her hospital
course.
.
# Tachycardia: Likely [**3-14**] hypermetabolic state given widespread
ovarian cancer. She was most tachycardic immediatley prior to
her Metoprolol doses. Given this, her Metoprolol was changed
from 50mg po bid to 37.5mg po tid with imprvement in her
tachycardia.
.
# Malnutrition: Nutrition was consulted and recommended Ensure
supplements with meals. As her mental status improved, her PO
intake also improved. At the time of discharge she was
tolerating POs and eating 3 full meals per day.
.
Chronic Problems:
.
# MS: Current presentation unlikely due to MS flare.
.
Transitional Issues: Pt was d/c'ed with Heme/Onc and GYN/Onc
follow up. Her brother, [**Name (NI) **] is involved in her care and will
be present at her appointments to facilitate discussion of her
options moving forward.
Medications on [**Name (NI) **]:
Tylenol 650 mg p.o. q.6h as needed for pain or fever
Colace 100 mg p.o. b.i.d.
Prozac 20 mg daily
Provigil?
folic acid 1 mg daily
HCTZ/triamterene 37.5/25 mg daily
MiraLax 17 grams daily as needed
Toprol-XL 75 mg daily
milk of magnesia 30 mL p.o. as needed for constipation
Dulcolax 10 mg rectally as needed.
Fosamax 70mg Qweek
ibandronate 150mg Qmonth
Modafinil (provigil) 400mg QD
Baclofen 10mg QID
Discharge Medications:
1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for yeast infection.
5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. modafinil 100 mg Tablet Sig: Two (2) Tablet PO qday ().
7. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
8. ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours).
9. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for fever or pain.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
12. Miralax 17 gram Powder in Packet Sig: One (1) PO once a
day.
13. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
14. ibandronate 150 mg Tablet Sig: One (1) Tablet PO once a
month.
15. baclofen 10 mg Tablet Sig: One (1) Tablet PO four times a
day.
16. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Village - [**Location 4288**]
Discharge Diagnosis:
Primary Diagnosis:
Toxic Metabolic Encephalopathy
Secondary Diagnosis:
Ovairan Cancer
Recurrent UTIs
Multiple Sclerosis
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 Ms [**Known lastname 1007**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for altered mental status,
which we feel was due to your urinary tract infection. For this,
we gave you antibiotics, which you should continue taking
indefinately. Unfortunately, we also found that you have cancer.
We had the Oncologists evaluate you, and we have arranged for
you to see an Oncologist as an outpatient. At this appointment,
you and your brother should discuss how you would like to
proceed in managing your cancer.
Please note the following changes to your medications:
STARTED Ampicillin 500mg by mouth 4 times a day
CHANGED Metoprolol to 37.5mg by mouth three times a day
STOPPED HCTZ/Triamterene 37.5/25mg by mouth daily
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2109-2-21**] at 3:30 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2109-2-21**] at 3:30 PM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5990, 5849, 5119, 4168, 2851, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4071
} | Medical Text: Admission Date: [**2115-4-5**] Discharge Date: [**2115-4-11**]
Date of Birth: [**2046-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Atenolol / Codeine / Enalapril / Inderal
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
59-year-old with postintubation tracheal
stenosis to evaluate the airway patency.
Major Surgical or Invasive Procedure:
flexible and rigid bronchoscopies
History of Present Illness:
69F s/p trach [**10-6**] during hospitalization for COPD/asthma
exacerbation. In coma x5wks and trached -> weaned over ~3months.
[**12/2114**] developed cough and progressive SOB, treated for PNA in
[**2-6**] and has been hospitalized 4-5 times since [**2-6**] for
respiratory distress. Ct scans showing tracheal stenosis down to
0.9cm from 1.6cm prox/distal.
Past Medical History:
COPD, CHF, vocal cord polyps, GERD, HTN, dyslipidemia, macular
degeneration
PSHx: s/p trach [**2111**], s/p hysterectomy, s/p ccy, s/p wedge
resection
Social History:
100 pk year smoker-quit 4 yrs ago
lives independently
Family History:
non-contibutory
Physical Exam:
PE: 97.7-84-133/72, 97% 3L
Sitting comfortably in bed in NAD.
Chest: CTA. able to talk in full sentences.
COR: RRR S1, S2
ABD: soft, NT, ND, +BS.
extrem: LE warm, no edema.
nauro: alert and oriented x3
Pertinent Results:
CXR [**4-9**]: Heterogeneous opacification at the base of the left
lung has improved. This may represent either residual
atelectasis or aspiration, and acute pneumonia is certainly not
excluded. Lungs are otherwise clear. Heart size is normal.
Narrowing of the lower cervical trachea is better evaluated by
recent chest CT.
BAL [**2115-4-8**]: Staph coag positive mod growth.
Brief Hospital Course:
Pt was admitted on [**2115-4-5**] w/ tracheal stenosis mainatined on
steriods. Noted to have thrush-placed on fluconazole, nystatin
and PPI's. Placed on BIPAP. Airway CT done consistent w/
Moderate upper tracheal stenosis, severely malacia. Severe
generalized tracheobronchomalacia, main, right upper, and
intermediate bronchi. Nonincarcerated, subsegmental,
post-thoracotomy transthoracic lung hernia, anterior segment,
left upper lobe. Moderate to severe centrilobular emphysema.
Flexible bronch done on HD#3 w/ thickened 2nd/3rd ring;
triangular shaped stenosis immed distal and posterior-micro and
path sent. Old tear also noted at left posterior-lateral gutter.
CT trachea w/ focal narrowing to 9mm at 3cm below the cordsand
distal malacia. Post bronch pt became acutely SOB and required
ICU admit for CPAP. Pt improved w/ positive pressure
ventilation. Taken to the OR on HD#4 for silicone stent (16x20)
placement.
BAL [**2115-4-8**] staph coag postive-started on levoflox for 2 week
course.
Medications on Admission:
prednisone, norvasc, crestor, prilosec, meprobamate, mvi,
citrucel, quinine sulfate, albuterol, combivent, pulmicort,
advair, singulair, flonase, spiriva
Discharge Medications:
1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for wheezing.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
9. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily).
12. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) as
needed for gerd.
15. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for copd.
16. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
17. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
18. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
19. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) as needed for oral / laryngeal [**Female First Name (un) **] for 9 days.
20. Levofloxacin 25 mg/mL Solution Sig: Five Hundred (500) mg
Intravenous once a day for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
fractured second and third tracheal rings
- subglotic narrowing
- left lower lobe pneumonia
- inflamed vocal cords
- h/o COPD, CHF, vocal cord polyps, GERD, HTN, dyslipidemia,
macular degeneration
- s/p trach '[**11**], hysterectomy, cholecystectomy
Discharge Condition:
deconditioned
requires CPAP prn
Discharge Instructions:
you should eat a regular diet
- you should be up and moving daily
- you should gradually increase your activity as tolerated
- you should take pain medication as needed
- every day you take pain medication you should take a stool
softener: colace, senna, or dulcolax are all good options
- you may shower
- call the interventional pulmonology office at ([**Telephone/Fax (1) 73295**]
if T>101.5, chills, nausea, vomiting, chest pain, shortness of
breath, productive cough -> with colored sputum or blood,
abdominal pain, swelling in extremities, or any other concern
Followup Instructions:
*it is very important to make/keep the following appointments*
- you should call and schedule a follow-up appointment with the
interventional pulmonology service in 6 weeks for bronchoscopy.
Please call the office at ([**Telephone/Fax (1) 73296**] to make this
appointment.
- you should schedule a follow-up appointment with your primary
care physician as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 41081**] visit. This will be
important to re-evaluate your chronic medicaitons and overall
health.
**you will need to call and confirm all appointments**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2115-4-17**]
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4072
} | Medical Text: Admission Date: [**2103-2-5**] Discharge Date: [**2103-2-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Cardiac catheterization
Intubation
History of Present Illness:
89 yo F hx CAD s/p NSTEMI [**2103-1-19**] treated medically presents with
acute onset dyspnea. Pt was brought in by EMS from home for
respiratory distress, found seated in bathroom, AAOx3, in resp
distress with pink forthy sputum, given 40mg IV lasix, nitro
spray, progressively lethargic and ashen, intubated in the field
(nasal intubation x1 unsucessful), BP initially 200/140,
bradycardic to 36. Initially seen at OSH, where EKG revealed a
previously known LBBB, CXR demonstrated pulmonary edema, labs
notable for CK 153, MB 11.0, Trop I 0.28 (nl 0-0.03), INR 1.0.
She was started on heparin drip with 5,500U bolus, drip at
1,000U/hr, lasix 40mg IV x2, ASA 650mg, plavix 300mg,
nitropaste, transferred to [**Hospital1 18**] for further care.
Urine output thus far 800cc. On arrival notable for intermittent
bradycardia to 30's, BP stable, bleeding from nares b/l, packing
placed. Transferred to CCU for further care.
On arrival pt intubated, sedated.
Past Medical History:
CAD s/p MI [**2103-1-19**] treated medically
Hypothyroidism
HTN
Hyperlipidemia
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: NSTEMI [**2103-1-19**] treated medically
Social History:
Pt has daughter who is involved in her care. Smoking hx unknown.
Physical Exam:
VS - 95.8, BP 103/46, HR 40, RR 16 on AC 100%/450/14/5
Gen: elderly female, inbutated sedated, unresponsive, pupils 2mm
b/l minimally reactive.
HEENT: anicteric, OP with dry blood, nares with packing and dry
blood.
Neck: Supple with JVP to jaw
CV: RRR nl s1, s2, no murmur auscultated.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Femoral 2+ DP 2+ PT 2+
Left: Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2103-2-5**] 03:45AM BLOOD WBC-7.5 RBC-4.50 Hgb-12.7 Hct-38.7 MCV-86
MCH-28.1 MCHC-32.8 RDW-13.3 Plt Ct-321
[**2103-2-7**] 02:45AM BLOOD WBC-11.0 RBC-3.05* Hgb-8.7* Hct-25.3*
MCV-83 MCH-28.5 MCHC-34.3 RDW-14.0 Plt Ct-248
[**2103-2-8**] 05:16AM BLOOD WBC-9.6 RBC-3.35* Hgb-9.8* Hct-27.9*
MCV-84 MCH-29.4 MCHC-35.2* RDW-13.9 Plt Ct-228
[**2103-2-5**] 03:45AM BLOOD PT-66.5* PTT-150* INR(PT)-8.1*
[**2103-2-8**] 05:16AM BLOOD PT-11.7 PTT-30.4 INR(PT)-1.0
[**2103-2-5**] 03:45AM BLOOD Glucose-316* UreaN-29* Creat-1.4* Na-137
K-3.5 Cl-100 HCO3-27 AnGap-14
[**2103-2-8**] 05:16AM BLOOD Glucose-141* UreaN-63* Creat-1.8* Na-146*
K-4.1 Cl-110* HCO3-25 AnGap-15
[**2103-2-5**] 03:45AM BLOOD ALT-56* AST-118* LD(LDH)-311*
CK(CPK)-643* AlkPhos-72 TotBili-0.3
[**2103-2-5**] 03:51PM BLOOD CK(CPK)-565*
[**2103-2-6**] 04:15AM BLOOD CK(CPK)-368*
[**2103-2-7**] 02:45AM BLOOD CK(CPK)-226*
[**2103-2-5**] 03:45AM BLOOD cTropnT-1.01*
[**2103-2-5**] 03:51PM BLOOD CK-MB-76* MB Indx-13.5* cTropnT-3.01*
[**2103-2-6**] 09:06AM BLOOD CK-MB-21* MB Indx-6.4* cTropnT-2.16*
[**2103-2-7**] 02:45AM BLOOD CK-MB-8 cTropnT-1.88*
[**2103-2-6**] 04:15AM BLOOD Calcium-7.5* Phos-4.5 Mg-1.6
[**2103-2-8**] 05:16AM BLOOD Calcium-8.2* Phos-4.6* Mg-2.5
[**2103-2-5**] 02:00PM BLOOD Free T4-0.97
[**2103-2-5**] 02:00PM BLOOD TSH-3.2
.
Cardiac Cath [**2-5**]
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal left and right ventricular diastolic function.
3. Moderate pulmonary arterial hypertension.
4. Successful bifurcation stenting of the LAD and D1 with
Culotte
technique with Endeavor DES
.
Echo [**2-6**]
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50-55%). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened with trivial mitral regurgitation. The pulmonary
artery systolic pressure could not be determined. There is an
anterior space which most likely represents a fat pad.
IMPRESSION: Suboptimal image quality. Low normal left
ventricular systolic function. Preserved right ventricular
systolic function.
.
CT Head [**2-7**]
IMPRESSION:
1. No CT evidence of acute vascular territorial infarction. If
this is of significant clinical concern, further evaluation with
MRI with diffusion- weighted imaging is suggested as this is
more sensitive for ischemia.
2. Opacification and fluid levels of the paranasal sinuses may
be related to intubation.
.
CT neck [**2-7**]
IMPRESSION:
1. Presence of the endotracheal tube which somewhat distorts
normal anatomy of the airway, limits evaluation for airway
narrowing, although none is definitely seen.
2. Dependent consolidation of both upper lungs may represent
aspiration or pneumonia.
3. Extensive atherosclerotic calcification of the aortic arch
Brief Hospital Course:
Patient presented with respiratory distress and was nasally
intubated in the field, no reported chest pain, however
concerning for ACS given positive cardiac enzymes. She was
taken to the cardiac cath lab where she had bifurcation stenting
of the LAD and D1. Medical treatment included aspirin, plavix,
heparin drip, and statin. She was not given a beta-blocker
because of bradycardia. Echocardiogram did not show
significantly depressed cardiac function.
In the setting of nasal intubation patient had nasopharyngeal
bleeding. ENT was consulted and she was changed to oral
intubation with nasal packing. Plans for extubation were
complicated by lack of consistent cuff leak. She was given
steroids and had a CT scan of the neck which was difficult to
interpret with the ET tube in place. After course of steroids,
she was extubated successfully but family chose to make patient
DNR/DNI understanding the risk of not reintubating patient.
Soon after she was made CMO. She was maintained on mask oxygen
and was initially hypoxic after extubation however O2 sat
recovered. In the evening after extubation patient became
asystolic and passed away.
While patient intubated as well as post-extubation, patient
exhibited right-sided hemiparesis. This was concerning for CVA.
A head CT without contrast and CT neck did not show hemorrhage
or large ischemia to explain these findings. An MRI was not
pursued given patient's clinical instability and lack of
therapeutic options.
Medications on Admission:
Plavix 75mg daily
Atenolol 25mg daily
Lisiopril 10mg daily
Lipitor 10mg daily
Synthroid 50 mcg daily
Imdur 30mg daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
Stroke
STEMI
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 4280, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4073
} | Medical Text: Admission Date: [**2179-8-5**] Discharge Date: [**2179-8-13**]
Date of Birth: [**2179-8-5**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 74151**] is a 655 gram
product of an IVF gestation with an EDC of [**2179-11-22**],
born to a 39-year-old, gravida 9, para 0-1 mother, with
prenatal screening was a blood type of A+, antibody negative,
RPR nonreactive, rubella immune and GBS unknown. The mother
was transferred to [**Hospital1 18**] from [**Hospital1 2177**] because the NICU was full.
She had been at bedrest at [**Hospital1 2177**] for 3 weeks prior to delivery.
She had a cerclage in place at 13 weeks. She was
betamethasone complete 1 week prior to delivery. Rupture of
membranes was just a few hours prior to delivery. Mother was
treated with 1 dose of antibiotics prior to transfer from [**Hospital1 2177**]
and a dose of antibiotics at [**Hospital1 18**]. This infant was born by
cesarean section because of changes in the cervix and
footling breech. He was given positive pressure ventilation
and intubated in the delivery room. His Apgars were 6 at one
minute and 8 at five minutes.
FAMILY HISTORY: Mother has had multiple losses. In [**2164**], a
normal spontaneous vaginal delivery at 24 weeks in [**Country 74152**].
In [**2168**], she also had a normal spontaneous vaginal delivery
at 26 weeks which was a neonatal death. In [**2174**], she had a
neonatal spontaneous vaginal delivery at 22 weeks. She also
had SAB x6 prior to 24 weeks and a history of fibroids.
SOCIAL HISTORY: The family is from [**Country 74152**]. The parents are
married. The patient has denied alcohol, tobacco or drugs.
PHYSICAL EXAMINATION AT TRANSFER: In general, active,
nondysmorphic, postmenstrual age, 26 week infant. HEENT:
Anterior fontanelle open and soft. Ears appears normal.
Nose appears normal. Palate is intact. Respiratory: The
infant remains orally intubated on a vent with a 2.5 ET tube.
Breath sounds are equal, coarse and tight. CV: No audible
murmur on exam, quiet precordium, regular rate and rhythm.
The infant also has generalized edema on exam. Abdomen is
soft and round with hypoactive bowel sounds, no
hepatosplenomegaly. He has a patent anus. GU: Normal
preterm male genitalia. Testes undescended bilaterally.
SUMMARY OF HOSPITAL COURSE BY SYSTEM: Respiratory: The
infant was treated with 3 doses of Cafergot, initially on a
conventional ventilator due to worsening gases on day of life
#1, placed on hi-fi. On day of life #7, with continued
desaturations on hi-fi, the infant was transitioned back to
conventional ventilator with current vent setting of 30/5 at
a rate of 35 with an FIO2 of 55% with an ABG of 7.33, 57, 81,
31 and 1. Chest X-ray on [**2179-8-11**] showed diffuse
opacity throughout both lungs, likely representation of
increasing fluid associated with patent ductus arteriosus.
Cardiovascular: The infant initially was on Dopamine for 24
hours after birth for mean BPs in the low 20s. The infant
was successfully weaned off of Dopamine on day of life #1 and
has been hemodynamically stable with mean BPs of greater than
25. Echocardiogram on day of life #1 showed a small PDA, PFO
and mild biventricular dysfunction. The infant has received
2 course of indomethacin and followup echocardiogram on
[**2179-8-12**] revealed a 1 mm patent ductus arteriosus with
bidirectional flow, only 6 mm Hg left to right gradient.
Qualitatively good left ventricular systolic function. The
infant has a left aortic arch by report and of note, some
images suggest there is a vessel located posteriorly that
drains superiorly but this not well seen and should be
reimaged in the future. The infant is sent to [**Hospital3 18242**] for a PDA ligation.
Fluids, electrolytes and nutrition: The infant has remained
NPO and has been maintained on intravenous fluids. The
infant's current total fluids are at 130 mL per kilo per day
of parenteral nutrition by way of a double lumen UVC with
current electrolytes on [**2179-8-13**], which is day of life
#7, with a sodium of 148, potassium 4.3, chloride 111,
bicarbonate 28, BUN 19 and creatinine 1.1.
Infectious disease: Blood cultures and CBC with differential
obtained on admission: Initial white count was 5.7 with 21
polys and 4 bands. Repeat CBC with differential on day of
life #1 showed a white count of 16.6, 40 polys and 2 bands.
The infant was treated with antibiotics for 48 hours with a
negative blood culture.
Gastrointestinal: The infant has required treatment for
unconjugated hyperbilirubinemia. His peak bilirubin level
was on day of life #1 which was 5.5/0.4. The infant has
remained under phototherapy with a current bilirubin on day
of life #7 of 2.5/0.3.
Hematology: Hematocrit and platelet count on admission to
NICU was a hematocrit of 47.5 with a platelet count of
117,000. Repeat hematocrit of 36 with a platelet count of
142,000 on day of life #1. The infant's blood type is A+.
The infant has received 3 blood transfusions during his NICU
admission. His current hematocrit is 29.3 on day of life #7,
for which he is currently being transfused 20 mL per kilo of
packed red blood cells. He has also received platelet
transfusion on day of life #6 for a platelet count of 89,000.
His current platelet count on day of life #7 is 140,000. He
has also received FFP x3 for abnormal PT/PTT and fibrinogen.
His current PT is 14.3 with a PTT of 46.7 and a fibrinogen of
133, which was done on day of life #6, which he has received
FFP for.
Neurology: Head ultrasound on day of life #1 showed no
intraventricular hemorrhage. Head ultrasound on [**2179-8-11**], day of life #6, showed a small right sided germinal
matrix hemorrhage.
Ophthalmology: The infant has not been examined. The
patient is due to his first exam at 6 weeks of age.
Psychosocial: [**Hospital1 18**] social worker involved with the family.
The contact social worker can be reached at [**Telephone/Fax (1) 8717**].
CONDITION AT TRANSFER: Guarded.
DISCHARGE DISPOSITION: [**Hospital 86**] [**Hospital3 1810**].
PRIMARY PEDIATRICIAN: Has not been identified at this time.
CARE AND RECOMMENDATIONS: The infant is current NPO. The
only medication is vitamin A 5000 units which he receives
every Monday, Wednesday and Friday.
SCREENING: State newborn screening has been sent per
protocol and results are pending. The infant has not
received immunizations.
DISCHARGE DIAGNOSES:
1. Prematurity at 24-6/7 weeks gestation.
2. Respiratory distress syndrome.
3. Sepsis.
4. Patent ductus arteriosus with 2 course of indomethacin.
5. Intraventricular hemorrhage on the right with right
germinal matrix hemorrhage.
6. Anemia.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2179-8-13**] 05:23:26
T: [**2179-8-13**] 09:03:26
Job#: [**Job Number 74153**]
ICD9 Codes: 769, 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4074
} | Medical Text: Admission Date: [**2132-1-30**] Discharge Date: [**2132-2-2**]
Date of Birth: [**2069-2-2**] Sex: M
Service: MICU [**Location (un) **]
REASON FOR ADMISSION: Status post seizure with aspiration
pneumonia, intubated.
HISTORY OF PRESENT ILLNESS: This is a 62-year-old male with
multiple medical problems found down in his assisted-living
facility seizing in bed. Of note, the patient had just been
discharged on the [**8-31**] from [**Hospital6 **]
after an unrevealing five day workup for abdominal pain.
Upon returning to the nursing home, he complained to his
nurse of a headache. When the nurse returned with pain
medicine five minutes later, the patient was found to be
tonic-clonic seizures, unresponsive. EMS was called. When
they arrived, he was found to have aspirated a good amount of
food contents. Was intubated for airway protection and
transferred to [**Hospital1 **] Hospital.
Of note, the patient seized for approximately 10 minutes, and
the seizures were broken by Valium 5 mg, Versed 2 mg, and
Ativan 2 mg. At the time of the seizure, the patient's blood
sugar was noted to be 46. He was given 1 amp of D50 and 1 mg
of glucagon, and the fingerstick glucose rose to 154. En
route to the hospital, he was given lidocaine for question of
increased intracranial pressure.
At [**Hospital1 18**] ED, a CT of the head was performed, which showed
evidence of an old CVA, but no acute hemorrhage. A LP was
performed and was negative. The patient was given 2 grams of
Rocephin prior to the LP for meningitis prophylaxis. He was
also given aspirin and Versed. Of note on the patient's
admission EKG, he did have lateral ST depressions, which were
new compared with his prior EKGs from [**2128**] at [**Hospital6 2121**] as well as [**2128**].
At the time, the patient was unresponsive to deep painful
stimuli, but was minimally responsive to deep sternal rub.
In the Emergency Room, he continued to have food suctioned
from his ET tube, but he was able to maintain his oxygenation
and ventilation. On the ventilator, he was transferred to
the MICU.
PAST MEDICAL HISTORY:
1. Diabetes mellitus x15 years.
2. Coronary artery disease status post cardiac
catheterization with three-vessel disease not intervened upon
because there were no critical lesions at the time. Date of
cardiac catheterization unknown.
3. History of peripheral vascular disease status post left
below the knee amputation.
4. Status post CVA diffuse ischemic of unknown date.
5. GERD on Protonix.
6. Hypertension.
7. Depression.
8. Glaucoma.
9. Right eye enucleation for phthisis bulbi, legally blind in
his left eye.
10. COPD with some component of restrictive disease as well
by pulmonary function tests performed in [**2124**] demonstrating
FVC and FEV1 of 30% of predicted, FEV1 to FVC ratio of 120%
of predicted.
11. Acute atypical psychosis.
12. Osteomyelitis status post debridement procedure and
amputation of several toes of the right leg in [**2123**].
13. Chronic pancreatitis with history of chronic alcohol
abuse.
14. L3-L4, L4-L5 spinal stenosis status post laminectomy.
MEDICATIONS:
1. Melatonin 3 mg q.h.s.
2. Protonix 40 mg q.d.
3. Imdur 30 mg q.d.
4. Effexor 75 mg q.d.
5. MOM prn.
6. Dulcolax prn.
7. Fleet's enema prn.
8. Aspirin 325 q.d.
9. Albuterol and Atrovent nebulizers q.6.
10. Sublingual nitroglycerin prn.
11. NPH 4 units q.a.m.
12. Artificial Tears.
13. Insulin-sliding scale, NPH.
14. Atropine drops o.d.
15. Pred-Forte drops 1% o.d.
16. Lamictal 25 mg q.d.
17. Creon 10 mg t.i.d.
SOCIAL HISTORY: Former heavy smoker. Former alcohol abuse.
Lives at assisted-living facility. Has a healthcare proxy
designated by the court, the State of [**State 350**].
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAM ON ADMISSION: Temperature 98.8, blood pressure
120/72, heart rate 70, respirations 14, and 100% on AC 550/14
with a FIO2 of 1.0 and a PEEP of 5. General: Intubated,
sedated, and unresponsive to painful stimuli. HEENT:
Right-sided enucleation. Left eye: Pupil fixed and dilated.
Moist mucous membranes. Edentulous. Cardiovascular:
Regular rate and rhythm, no murmurs, rubs, clicks, or
gallops. Chest was clear to auscultation anteriorly.
Abdomen: Positive bowel sounds, no organomegaly, nontender,
and nondistended. Extremities: Status post left below the
knee amputation. Poor peripheral pulses. Distal extremities
warm. Capillary refill less than two seconds.
DATA: White blood cell count 14.3, hematocrit 30, platelets
226. Chem-7: 141, 3.9, 106, 27, 18, 1.6, 106. INR 1.0.
Lactate 0.5. CK 54, troponin 0.03. Serum tox is positive
for benzos, negative for aspirin, EtOH, Tylenol,
barbiturates. CSF: No white cells, no red cells, protein
25, and glucose 83. Gram stain negative. Culture negative.
CT of the head: No bleed, multiple old infarcts, sinus
inflammation.
Chest x-ray: Clear. ET tube in correct position.
EKG shows normal sinus rhythm at 70 beats per minute with
T-wave inversions in V4 through V6 with ST depressions of 1
mm in V5 and V6. T-wave flattening in I and L, new compared
with prior.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUES:
1. Seizures: It was unclear exactly why the patient seized.
It is likely that he has underlying areas of ischemia
secondary to massive CVA. He seems to have suffered anoxic
brain injury as he had several episodes of myoclonic jerks,
which could be consistent with [**Doctor First Name **]-[**Location (un) 1683**] syndrome as well
as some component of hypoglycemia. An EEG was performed,
which shows diffuse slow wave pattern, which ruled out status
epilepticus and suggest some sort of encephalopathy perhaps
due to sepsis.
The patient's psychotropic medications Lamictal and Effexor
were discontinued. His blood sugar was monitored q.i.d. and
kept euglycemic. TSH, calcium, magnesium, and phosphorus as
well as a RPR were all unrevealing. The patient did not
receive any Versed, and was still unresponsive for 48 hours
on the ventilator. We did consider getting a MRI, however,
due to the patient's penile prosthesis, this was not
possible.
Neurology felt that most likely this was anoxic brain injury,
and the chance of recovery was very poor as the patient was
unresponsive to deep painful stimuli. Cold calorics were
unreactive. Dolls eyes were abnormal. The patient did have
not spontaneous respirations when he was extubated.
2. Aspiration pneumonia: Originally the diagnosis of
aspiration pneumonia was entertained given the food contents
were suctioned from the ET tube. Repeat chest films were
negative, however, the patient was placed on levofloxacin and
Flagyl for 48 hour period until the chest x-ray was
definitively clear.
3. Respiratory failure: Patient was intubated for airway
protection. ABG showed excellent oxygenation and
ventilation. However, the patient had no spontaneous
respirations when the ventilator was discontinued.
4. Diabetes mellitus: The NPH was held. The patient was
kept euglycemic on insulin-sliding scale.
5. Coronary artery disease: The patient did have mild
elevation of the troponins, but CKs were negative although
rising in the setting of lateral T-wave changes, and lateral
ST depressions. It is likely that the patient did experience
some sort of demand ischemia with whatever inciting events
had occurred. He was given aspirin and beta blocker,
however, Heparin was not initiated due to his allergy of
unknown type.
6. Renal failure: He appeared to be at his baseline
creatinine of 1.8.
7. GERD: He was continued on his proton-pump inhibitor.
8. Ophthalmology: He was continued on his eyedrops per
outpatient regimen.
9. Chronic pancreatitis: He was repleted with Creon.
10. Zyprexa. All psychotropic medications were discontinued.
11. FEN: The patient was kept NPO.
12. Access: An A-line was placed for arterial monitoring and
pneumoboots were used for DVT prophylaxis.
13. Code status: Discussion with the [**Hospital 228**] healthcare
proxy, it was felt that the patient would want to be do not
resuscitate/do not intubate comfort measures only given his
prior poor functional status and new diagnosis with extremely
poor prognosis. Therefore, after discussion with five of the
eight children and discussion with the healthcare proxy with
documentation in the chart, that she indeed is the healthcare
proxy, the patient was extubated on [**2132-2-2**] and had no
spontaneous respirations, went into an asystolic period, and
was pronounced dead at 1:40 p.m. on [**2132-2-2**].
At that time the family declined autopsy. The attending was
notified and admitting was notified per standard protocol.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2132-2-2**] 17:40
T: [**2132-2-3**] 11:02
JOB#: [**Job Number 111713**]
(cclist)
ICD9 Codes: 5070, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4075
} | Medical Text: Admission Date: [**2162-12-27**] Discharge Date: [**2162-12-31**]
Date of Birth: [**2103-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
passing out
Major Surgical or Invasive Procedure:
s/p cardiac catheterization with stent
History of Present Illness:
59 yo M woth no PMHX, no meds or primary care physician, [**Name10 (NameIs) 151**]
syncopal episode while at work. He was working at [**Male First Name (un) **]
Sporting Goods when he felt dizzy/lightheaded, diaphoretic, pale
and passed out hitting his head and causing a left forehead
laceration. He was brought to an outside hospital where he was
found to have inferior and posterior STEMI. Patient states he
felt well the night prior. Patient denies any preceding chest
pain, shortness of breath, orthopnea, PND. Able to walk, shovel
snow without getting very SOB. He was brought to [**Hospital1 **], found to have ST elevation MI, given aspirin and had
his head laceration repaired. Upon transfer to [**Hospital1 18**], started on
hep gtt and taken to cath lab where RCA stent was placed. Head
CT and c-spine normal.
Past Medical History:
none
Social History:
Lives with wife, no children. Still smokes, has decreased from
2ppd to < 1 ppd. 1 drink EtOH/day. No ivdu. Works at [**Male First Name (un) **]
Sporting Goods.
Family History:
Father died at 82 of CHF, unknown CAD history
Mother died of [**Name (NI) 2481**]
Physical Exam:
97.3 HR 83 BP 119/72 RR 13 100%/2L n.c.
Gen: AOx3, pleasant, lying flat, NAD
HEENT: MMM
Neck: no JVD
CV: distant S1, S2, RRR, no murmurs
Pulm: CTA-Anteriorly
Abd: (+) BS, soft, obese, nontender
Right Groin: no hemtoma or bruit
Ext: WWP, no edema, 2+DP/PT b/l
Pertinent Results:
[**2162-12-27**] 03:32PM WBC-16.9* RBC-4.17* Hgb-13.4* Hct-37.4* MCV-90
MCH-32.0 MCHC-35.8* RDW-12.7 Plt Ct-237
PT-13.2 PTT-41.5* INR(PT)-1.2
Glucose-105 UreaN-16 Creat-0.9 Na-139 K-4.4 Cl-108 HCO3-23
AnGap-12
.
[**2162-12-27**] 03:32PM CK(CPK)-2100* CK-MB-229* MB Indx-10.9*
[**2162-12-27**] 11:05PM CK(CPK)-3173* CK-MB-298* MB Indx-9.4*
[**2162-12-28**] 04:30AM CK(CPK)-3066* CK-MB-205* MB Indx-6.7*
cTropnT-9.03*
[**2162-12-28**] 02:23PM CK(CPK)-2432* CK-MB-106* MB Indx-4.4
cTropnT-5.47*
[**2162-12-29**] 03:49AM CK(CPK)-1234* CK-MB-33* MB Indx-2.7
cTropnT-4.63*
[**2162-12-30**] 04:27AM CK(CPK)-533* CK-MB-8 cTropnT-4.36*
.
[**2162-12-28**] 04:30AM BLOOD ALT-54* AST-223* CK(CPK)-3066* AlkPhos-98
TotBili-0.6
.
[**2162-12-27**] Cardiac Catheterization:
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderately elevated left and right heart filling pressures.
3. Preserved cardiac output.
4. Successful stenting of the mid RCA total occlusion.
COMMENTS:
1. Selective coronary angiography in this right dominant
circulation
demonstrated three vessel coronary artery disease. The LMCA was
without
any angiographically apparent flow limiting disease. The LAD had
a 30%
proximal stenosis and then a 50-60% eccentric lesion in the mid
vessel.
The D1 and D2 were small caliber vessels arising proximally on
the LAD.
The D3 was a moderate size vessel without flow limiting disease.
The LCx
had a 50-60% stenosis in the proximal segment before the takeoff
of the
OM1. The OM1 and OM2 were moderate size vessels. OM2 had no flow
limiting disease. The RCA had an acute total occlusion in the
mid
segement. The distal R-PDA and R-PL filled faintly by left to
right
collaterals. Both R-PDA and R-PL were large vessels.
2. Resting hemodynamics from right catheterization demonstrated
mildly
elevate right and left heart filling pressures (RVEDP 15mmHg,
PCWP
17mmHg). The pulmonary arterial pressure was normal. The
systemic
arterial pressure was moderately elevated. The cardiac output by
the
Fick method was 5.7L/min with a cardiac index of 2.6.
3. The acute mid RCA occlussion was dottered using the 2.0 X
15mm
Voyager balloon, predilated using the same balloon, thrombus
aspirated
using the pronto catheter, stented using a 3.5 X 23mm Cypher
stent with
lesion reduction from 100% to 0%. The proximal end of the RCA
was was
directly stented using 3.5 X 23mm Cypher stent and post dilated
using
4.0 X 15mm NC Ranger balloon with an excellent angiographic
result. The
final angiogram showed no residual stenoses in the stented
segments,
TIMI III flow with no dissection or embolisation. (see PTCA
comments)
.
[**2162-12-28**] Echocardiogram:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (ejection fraction 40-50 percent) secondary to severe
hypokinesis of the inferior and posterior walls; the other walls
are normal-to-hyperdynamic. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size is normal. Right ventricular systolic
function appears depressed. The aortic root is mildly dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is no
pericardial effusion.
Brief Hospital Course:
59 year old male with no PMH presents after syncopal event,
found to have Inferior-posterior STEMI at OSH. He was
tranferred to [**Hospital1 18**] for emergent cardiac catheterization. He
had 2 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] to 100% mid-RCA thrombus and prox RCA. He
tolerated the procedure well without immediate complications.
Post-procedure, his blood pressure remained low for 12-24 hours
(sbp 80's) with Heart rate 70's, patient was without symptoms
(no dizziness or lightheadedness) and this was thought to be due
to increased vagal tone s/p inferior MI. The day after cath,
patient had asymptomatic episodes on Telemetry of accelerated
idioventricular rhythm for up to 20 beats. He remained in the
CCU for monitoring and then had 5-20 beat runs of what appeared
to be Ventricular tachycardia vs AIVR 24-36 hours post-cath.
Vitals remained stable and patient continued without symptoms.
He was given Lopressor 5 mg iv x 2 and increased his po dose of
Metoprolol. Heart rate and blood pressure tolerated the
increased dose and patient did not have further episodes. He
was transferred to medical floor 72 hours post-cath for
additional day of monitoring.
.
1. CV:
Ischemia: Continue ASA, Statin, Plavix. Asymptomatic
hypotension 12-24 hours post-cath, bp 70's-80's, HR 70's (likely
vagal stimulation). Integrelin continued for 18 hours
post-cath. Heparin stopped on [**12-28**].
Pump: Echo done [**12-28**] to assess function, EF 40-50%.
Patient appeared euvolemic during admission. Patient was
started on Lisinopril 5 mg po qday for afterload reduction.
Rhythm: Patient in sinus rhythm, but w/ AIVR followed
by 5-20 beat runs of likely VTach (Asx, no change in vitals)
post-cath. Pt continued with decreased ectopy and only
occasional pVCs when Metoprolol dose increased. He was
monitored on Telemetry. Consulted Electrophysiology as frequent
ectopy (5-20 beat runs). This was felt to most likely be
Ventricular tachycardia in post-MI period. Given 5mg iv
Lopressor x 2 and increased po Lopressor to 50 TID on [**12-29**] and
100 po bid on [**12-30**] and switched to Toprol prior to discharge.
No NSVT or VTach since [**12-28**].
.
2. FEN: Cardiac Heart Healthy, monitor electrolytes to keep K >
4 and Mg > 2.
.
3. Hypotension: in post-cath setting, likely vagal reaction.
Given 500 cc bolus x 2, bp with minimal response several hours
after catheterization. Blood pressure slowly increased and
patient's heart rate and blood pressure tolerated metoprolol.
.
4. Leukocytosis: likely post-MI reaction. Afebrile, no other
signs of infection. UA negative. White blood cell count
trended down post-MI.
.
5. Dispo: Patient to be discharged to home. He was set up with
a new primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6160**] and a new outpatient
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13175**]. He should have LFTs monitored
as an outpatient while on statin.
.
FULL CODE
Medications on Admission:
None
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day:
Take it at night.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Inferior/Posterior ST elevation Myocardial infarction
Discharge Condition:
good
Discharge Instructions:
Please call your physician or return to the hospital if you
experience chest pain, shortness of breath, increased leg
swelling, passing out or other concerning symptoms.
Followup Instructions:
Please keep your scheduled follow-up appointment with Dr. [**Known firstname **]
[**Last Name (NamePattern1) 6160**] on [**1-3**].
Please keep your scheduled follow-up appointment with your
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13175**] in 2 weeks.
Liver function test in a month.
Completed by:[**2162-12-31**]
ICD9 Codes: 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4076
} | Medical Text: Admission Date: [**2128-11-18**] Discharge Date: [**2128-12-6**]
Date of Birth: [**2128-11-18**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 41776**] was the 1.22-kilogram product of a
30-3/7-weeks twin gestation born to a 35-year-old G5, P4 now
5 mother. Prenatal screens: O-negative, antibody negative,
RPR nonreactive, GBS unknown, rubella immune. This pregnancy
complicated by spontaneous di-di twins. Prenatal screen was
remarkable for elevated aFP. Amniocentesis was declined. This
pregnancy was otherwise unremarkable until 26-weeks gestation
when she presented from [**Hospital6 2561**] with premature
rupture of membranes. She received antibiotics and
betamethasone at that time. Fetal scans were normal.
She continued her pregnancy successfully up until date of
delivery when she presented with vaginal bleeding and
suspected abruption. She was delivered by cesarean section.
Infant delivered by C-section. Cried immediately after birth.
Did not need any resuscitation apart from blow-by O2 and bulb
suctioning. Apgars were 8 and 9, noted to have mild
retractions.
PHYSICAL EXAM ON ADMISSION: Weight 1220 grams (50th
percentile), head circumference 27.5 cm (50th percentile),
length 38.5 (25th-50th percentile). General appearance:
Active, crying, with moderate subcostal retractions. Anterior
fontanel: Level. Sutures: Normal. Intact palate. Neck:
Supple. Pink in room air, moderate subcostal retractions,
bilateral moderate aeration. Cardiovascular: Well perfused.
S1, S2 normal. No murmur. Femoral pulses present. Abdomen:
Soft, nondistended. GU: Normal male, preterm genitalia.
Testes: Bilaterally descended. Spine: Within normal limits.
Neuro: Active, moving all 4 limbs, appropriate tone from
prematurity.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: [**Known lastname **], respiratory
wise, was admitted to the newborn intensive care unit and
placed on CPAP for management of mild respiratory distress
syndrome. He remained on CPAP for a total of 24 hours at
which time he transitioned to room air and has remained in
room air since that time. He was started on caffeine citrate
on [**11-23**] and was discontinued on [**12-4**]. Infant
continues to have occasional apnea and bradycardic spells not
requiring intervention.
Cardiovascular: Has been cardiovascularly stable throughout
hospital course without any intervention. His heart rates run
150s-180s with blood pressures 67/38 with a mean of 48.
Fluid and electrolytes: Birth weight was 1,220 grams. Infant
was initially started on 80 cc per kilogram per day of D10W.
Enteral feedings were initiated on day of life #1. Full
enteral feedings were achieved by day of life #7. Infant is
currently receiving 150 cc per kilograms per day of Special
Care 30 calorie with Beneprotein. Discharge weight is 1790 gm,
head circumference is 29 cm and length is 42 cm.
GI: Peak bilirubin was on day of life #2 of 7.1/0.4. He was
treated with phototherapy and the issue has since resolved.
Hematology: Hematocrit on admission was 42.7. Infant has not
required any blood transfusions. He is currently receiving
ferrous sulfate supplementation of 25 mg per mL, dose is 1.5
mL p.o. daily.
Infectious disease: A CBC and blood culture obtained on
admission. CBC was benign with a white count of 6.4;
platelets are 250, 14 polys, and 0 bands. Infant received 48
hours of ampicillin and gentamicin at which time they were
discontinued with a negative blood culture. No other sepsis
concerns during this hospital course.
Neuro: Infant has been appropriate for gestational age. Head
ultrasound performed on day of life #7 was within normal
limits.
Sensory: Hearing screen was not performed, but should be done
prior to discharge.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: [**Hospital6 2561**].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3501**]. Telephone
number is [**Telephone/Fax (1) 49840**].
CARE RECOMMENDATIONS: Continue 150 cc per kilogram per day
of Special Care 28 calories with Beneprotein weaning calories
as appropriate to maintain a weight gain of 30 grams per
kilogram per day.
MEDICATIONS: Continue Fer-In-[**Male First Name (un) **] supplementation of 0.15 mL
(25 mg per mL).
CAR SEAT POSITION: Was not performed.
STATE NEWBORN SCREEN: Most recently sent on [**2128-12-2**].
IMMUNIZATIONS RECEIVED: Infant has not received any
immunizations to date.
DISCHARGE DIAGNOSES: Premature twin #1, mild respiratory
distress syndrome, rule out sepsis with antibiotics,
hyperbilirubinemia resolved, apnea and bradycardia of
prematurity, anemia of prematurity.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2128-12-5**] 21:27:36
T: [**2128-12-6**] 06:39:46
Job#: [**Job Number 68556**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4077
} | Medical Text: Admission Date: [**2118-5-5**] Discharge Date: [**2118-5-21**]
Date of Birth: [**2061-1-21**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Worsening hepatorenal failure from outside
hospital.
HISTORY OF PRESENT ILLNESS: The patient was initially
admitted to the hepatology service, and then transferred onto
the transplant service on [**2118-5-5**].
The patient is a 57-year-old male admitted with worsening
hepatorenal failure from outside hospital where he was
admitted on [**5-5**] for increasing resistance to diuretics,
ascites, and renal failure. He managed briefly at the outside
hospital and then transferred to [**Hospital1 18**] on [**5-5**]. He was
previously admitted to [**Hospital1 18**] on [**2118-2-26**] for same
problems, MELD score of 30.
Upon admission paracentesis was done for worsening abdominal
distention. Fluid culture was negative for bacterial or
fungal growth. Urine culture on admission was done and this
was less than 10,000 organisms. CMV IGG was done. This was
negative. Hepatology initially managed this patient. He is
using lactulose.
ADMISSION PHYSICAL EXAMINATION: Temperature 96.5, BP 111/61,
heart rate 82, respiratory rate 18, 100% on room air.
GENERAL: Frankly icteric male appearing his stated age, lying
in bed comfortably. HEENT: Neck supple. CARDIOVASCULAR: S1
and S2 with no MRG. LUNGS: Clear. ABDOMEN: Soft, nontender,
distended. Positive distention. EXTREMITIES: 2+ pedal edema.
LABORATORY DATA: Labs at the outside hospital show AST 209,
ALT 106, T.bili 10.9, direct bili 5.6, sodium 123, potassium
4.9, chloride 92, CO2 19, BUN 63, creatinine 3.4, and glucose
of 126, hemoglobin 11.7, hematocrit 30.8, and platelet count
less than 120. An ultrasound done on [**2118-3-3**]
demonstrated cirrhotic liver with large ascites, sluggish
hepatopedal flow. Transplant service was consulted.
MEDICATIONS:
1. Wellbutrin 150 mg once daily.
2. Nadolol 20 mg once daily.
3. Ambien 5 mg q.at bedtime
He is off diuretics.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Hepatic cirrhosis, alcohol associated
condition; ceased drinking in [**2117-4-28**]. Shortly
thereafter developed pedal edema and jaundiced throughout the
latter half of [**2116**]. Ascites, encephalopathy, acute renal
failure, GERD, hypertension.
SOCIAL HISTORY: The patient has numerous supportive brothers
and sisters throughout the country, a total of 9. He is
divorced, has two children who was not overly involved in
care.
HABITS: Alcohol abuse in the past, stopped in [**2117-4-28**].
He denies tobacco. No history of IV drug abuse.
SOCIAL HISTORY: Former bus driver. Currently on disability.
Transplant service was consulted and followed along.
On [**2118-5-7**], an offer for liver transplant occurred. He
was taken to the OR by Dr. [**First Name (STitle) **] [**Name (STitle) **] for orthotopic liver
transplant from standard brain dead donor, piggyback
technique, portal vein to portal vein, with replaced left
hepatic artery to hepatic artery branch patch anastomosis,
bile duct to bile duct. Liver biopsy was done at that time.
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] assisted. Estimated blood loss was 1
liter. Please see operative report for further details. The
patient remained hemodynamically stable throughout the case.
The patient was in stable condition, intubated and
transferred to the surgical intensive care unit for
postoperative management. Postoperatively his LFTs decreased.
He was initially transfused with 2 units of packed red blood
cells and 1 unit of platelets for hematocrit of 24.5, down
from 32.4 and platelet count of 46. His vital signs were
stable. His creatinine trended down slowly over the course of
the hospitalization to 1.8.
Immediately postoperative, hepatic duplex was done. This
demonstrated all vessels in the liver being patent. A
recipient liver donor biopsy demonstrated established
cirrhosis, stage 4 fibrosis. Please see pathology report for
further details.
Nephrology consult was also obtained. Nephrology followed the
patient in the immediate postoperative period, deferring
hemodialysis with improvement of creatinine. He was extubated
on [**5-9**]. [**2117**]. Vital signs were stable.
He received the standard induction immunosuppression of
CellCept 1 gram IV and 500 mg of Solu-Medrol. over the
hospital course he continued on CellCept 1 gram PO b.i.d.
with a Solu-Medrol taper per protocol. His protocol steroid
taper was altered on postoperative day 10 for alteration of
mental status which was initially noted in the surgical
intensive care unit. The patient was confused.
Neurology consult was obtained. He was inattentive. He was
able to follow simple commands but these were sparse.
Sedation was minimized. It was felt the patient had a
metabolic derangement. He underwent an EEG to rule out
seizure activity. No seizure activity was noted. A head CT
was done. This was also negative. No evidence of intracranial
hemorrhage or mass effect was noted. Head MRI was done as
well with and without contrast. This demonstrated mild age
inappropriate prominence of the sulci and ventricles. No
acute infarct was noted. No mass effect or hydrocephalus was
noted. No abnormal enhancement was noted. Altered mental
status was attributed to steroids and his prednisone was
decreased on postoperative day 10 to 15 mg. This was further
decreased to 10 mg on postoperative day 12 with improvement
in the patient's mental status. His speech was more fluent.
He was more attentive and appropriate. Speech therapy consult
was obtained for concerns for altered mental status.
In summary, it was felt that the patient was experiencing a
toxic metabolic insult. He did not have an expressive or
receptive dysphagia. It was expected that the patient's
communication abilities would return to baseline once medical
issues were resolved. Given concerns for multifactorial
confusion secondary to increased creatinine and decreased
sodium, he did undergo a hemodialysis briefly on [**2118-5-10**]. His sodium remained in the 127 range. He underwent
dialysis again on [**2118-5-11**]. His sodium gradually
improved up to 132 with improvement in his creatinine to 1.9
without dialysis.
Due to poor PO intake, a nutrition consult was obtained. TPN
was started. [**Last Name (un) **] consult was obtained for management of
hyperglycemia with improvement in mental status. The
patient's oral intake improved and TPN was stopped. Physical
therapy worked with him initially recommending rehab but with
improvement in mental status. It was felt that the patient
would be safe to be discharged to home or to family member's
home. He was ambulatory in the hallway with supervision.
The patient experienced significant weight gain and pedal
edema. This was treated with IV Lasix with improvement of
edema. He was switched to Lasix 20 mg PO once daily. His
weight dropped down to 100.3 from preoperative weight of
114.1. He had two JP drains. These were removed and sutured
and he experienced large volume output from the medial JP up
to 2 liters per day. The JP drain was removed and the site
sutured without further leaking his incision. A duplex of the
abdomen was done on [**5-10**]. Patent hepatic and portal
vessels were noted. Bilateral lower extremity non-invasive
studies were done to evaluate edema. This was done on [**5-17**]. There was no evidence of DVT.
On [**5-18**], a post-pyloric bleeding tube was placed for
concerns that the patient would not be able to meet his
caloric intake need. Unfortunately the patient pulled out his
post-pyloric feeding tube during the night. This was not
replaced given improved mental status. The patient was taking
in at least 1800 Kcal the following day. Improved mental
status was attributed to less steroids given.
In summary, the patient has been in stable condition,
ambulatory, tolerating a regular diet, his incision clips
were opened at the top of the incision in his left lateral
side for leaking of serosanguineous drainage. Normal saline
damp to dry dressings were placed on the open areas b.i.d.
His liver function tests improved with an AST of 22, ALT of
39, alkaline phosphatase 75, and total bilirubin of 0.8,
creatinine was down at 1.9. His hematocrit was stable in the
range of 25.2 to 27.3. Platelet count was 114. He continued
on immunosuppression with CellCept, prednisone and Prograf
which was adjusted. This was titrated to 1 mg PO b.i.d for a
level of 17.9.
Plan was to send the patient home and not to rehab given
improved mental status. It is anticipated that he will be
discharged home to his brother's home with follow up in the
outpatient clinic.
DISCHARGE MEDICATIONS:
1. Prograf 1 mg PO b.i.d.
2. Prednisone 10 mg PO once daily, started on [**5-18**].
3. CellCept 1 gram PO b.i.d.
4. Protonix 40 mg PO once daily.
5. Bactrim single strength q Monday, Wednesday and Friday,
renally dosed.
6. Valcyte 450 mg PO once daily.
7. Thiamine 100 mg PO once daily.
8. Folic acid 1 mg PO once daily.
9. Fluconazole 400 mg PO once daily.
10. Lasix 20 mg PO once daily.
11. NPH insulin 16 units s.c. q.a.m. and NPH 10 units s.c.
q.h.s. with sliding scale regular insulin QID.
DISCHARGE DIAGNOSES:
1. Alcoholic cirrhosis.
2. Hepatorenal syndrome.
3. Gastroesophageal reflux disease.
4. Hypertension.
5. Chronic renal insufficiency.
6. Status post orthotopic liver transplant on [**2118-5-7**].
7. Glucose intolerance secondary to steroids.
8. Altered mental status secondary to steroids.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 62381**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2118-5-20**] 10:54:20
T: [**2118-5-21**] 00:21:10
Job#: [**Job Number 62382**]
ICD9 Codes: 5845, 4280, 2761, 5859, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4078
} | Medical Text: Admission Date: [**2101-7-27**] Discharge Date: [**2101-8-9**]
Date of Birth: [**2040-1-14**] Sex: M
Service: Surgery
HISTORY OF PRESENT ILLNESS: This is a 61-year-old male with
mucinous adenocarcinoma arising from appendix with extensive
carcinomatosis and tumor involving the small bowel near the
SMA diagnosed by exploratory laparotomy in [**2100-5-6**]. He
underwent a palliative bypass procedure at that time. He was
readmitted on [**7-27**] with a 2-week history of increasing
abdominal pain, fever, vomiting, and a temperature of 104.8
degrees with peritoneal signs on abdominal examination. CT
scan revealed worsening of small bowel distention, small
bowel wall thickening, increased ascites, and extra luminous
air, and a small collection in the right lower quadrant.
This collection did not appear amenable to drainage.
HOSPITAL COURSE: Thus, on [**2101-7-28**], in the early a.m.
the patient underwent an exploratory laparotomy and a small
bowel resection. Preoperative diagnosis was perforated
viscous. Postoperative diagnosis was small bowel
perforation. The surgeon of record was Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1305**].
Findings intraoperatively included a closed-loop obstruction,
bypass small bowel with perforation in the right upper
quadrant. The patient was admitted to the Surgical Intensive
Care Unit for postoperative care. He was intubated as of
postoperative day one. Due to the perforated viscous, the
patient was kept on Kefzol and Flagyl antibiotics
postoperatively. The patient was extubated on [**7-29**]. He
did remain n.p.o. with nasogastric tube suction at this time
and remained on Kefzol and Flagyl. He required transfusion
of 1 unit of packed red blood cells on [**7-30**] for a
hematocrit of 27.8.
The patient was transferred to the floor on [**7-31**]. His
nasogastric tube was discontinued. The patient was to be
transferred to the floor, but he still had some hypotension
issues and was actually kept until [**8-1**]. Enalapril and
Lopressor were able to keep his blood pressure under control,
and he was transferred to the floor on [**8-1**].
On [**8-2**], the patient continued to do well, and his
Kefzol and Flagyl were discontinued. The Foley catheter was
discontinued on [**8-3**]. The patient was tolerating clears
as of [**8-3**]. On [**8-4**], on the patient's abdominal
examination, there was noted to be an increase in
serosanguineous drainage from the site of the incision, and
the patient had a temperature of 101.2 degrees. A CT scan on
[**8-4**] revealed a right-sided intra-abdominal fluid
collection. This collection was drained by Interventional
Radiology on [**8-5**] with a #12 French pigtail placed in
the right lower quadrant; 70 cc of purulent material were
drained at this time. At the time of discharge, the culture
from this fluid had grown out no anaerobes, no enterococcus,
two colonies of gram-negative rods in moderate quantity. A
third gram-negative rod species, sparse, gram-positive
bacteria, also streptococcus and gram-positive rods in broth
only.
The patient did very well after this drain was put in. The
patient was also put on levofloxacin and Flagyl as of
[**8-5**]. The patient was advanced to a regular diet as of
[**2101-8-7**].
DISCHARGE DISPOSITION: As of [**2101-8-9**], the patient
was stable for discharge to home with [**Hospital6 1587**] care.
MEDICATIONS ON DISCHARGE: He was to be discharged on
Avandia 4 mg p.o. q.d., levofloxacin 500 mg p.o. q.d.,
Flagyl 500 mg p.o. t.i.d.
DISCHARGE FOLLOWUP: He was to follow up with Dr. [**Last Name (STitle) 1305**]. The
patient will also receive [**Hospital6 407**] for
drain care at home, and also b.i.d. dry sterile dressing
changes to his wound.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**]
Dictated By:[**Last Name (NamePattern1) 4039**]
MEDQUIST36
D: [**2101-8-9**] 13:21
T: [**2101-8-11**] 09:05
JOB#: [**Job Number 28903**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4079
} | Medical Text: Admission Date: [**2146-2-9**] Discharge Date: [**2146-2-16**]
Date of Birth: [**2098-10-13**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Compazine / Reglan / Betadine Surgi-Prep / Tape /
Iodine; Iodine Containing / Vancomycin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Replacement of left groin double-lumen central venous line under
anesthesia.
2D transthoracic Echocardiogram
History of Present Illness:
Ms. [**Known lastname 1557**] is a 47 year-old with a history of [**Last Name (un) 111738**]??????s syndrome
s/p colectomy and small bowel resection (on TPN) presenting with
hypotension.
.
Most recently admitted ([**Date range (1) 12405**]) with a line infection (coag
negative staph). She was treated with Linezolid (plan for 8
days) and IR performed an immediate replacement of her femoral
line at the same site over wire under general anesthesia on HD
#1. Her SBPs ranged 80-90s.
.
Reports pain in hips, chills, nausea and rigors on Monday
evening. This recurred on Tuesday morning with vomiting. Given
these symptoms, she presented to an OSH for evalution.
.
Initially presented to an OSH where she was afebrile with BP
75/49 and HR 133. WBC was 11.4 with 11% bands. Linezolid was
given.
In the ED, afebrile with BP 69/45 and HR 102. Remained in the
60-80s SBP during ED stay. Got cefepime 2g IV, fentanyl and
tylenol and 3L of NS.
Past Medical History:
1. [**Location (un) **] syndrome
- diagnosed at age 23 s/p colectomy ([**2121**])
- repeated small bowel resections [**12-27**] persistent polyp growth
- short [**Month/Day (2) **] syndrome and on chronic TPN since [**2123**]
- (states she has "3 feet" of small bowel left and [**11-27**] of it has
polyps)
2. History of line infections, including:
- [**2-25**]: [**Female First Name (un) **] parapsilosis
- [**9-29**]: coag negative staph; [**Female First Name (un) **] parapsilosis
- [**10-2**]: klebsiella
3. Right femoral vein thrombosis
4. History of GI bleed (remote)
5. Fibromyalgia causing generalized fatigue
6. Spinal stenosis with RLE weakness
7. Osteoporosis
- bilateral hip fracture s/p ORIF repair
8. Scoliosis s/p repair
9. s/p TAH BSO
10. s/p dermoid cyst removal, originally in small bowel, then
extended to ovaries
Social History:
The patient lives w/ her mother who assists her with her medical
needs. No ETOh or Tob.
Family History:
Father with [**Name2 (NI) **] syndrome as do 6 of 8 siblings. Mother and
relatives with HTN and resulting CVA. Sister with breast cancer.
Her father's parents died of cancer.
Physical Exam:
GEN: Thin, lying in bed in no distress.
HEENT: No icterus or pallor. JVP difficult to assess.
CV: Regular. No murmurs.
PULM: Clear.
ABD: Scaphoid. Ostomy bad in place. [**6-3**] TTP.
EXT: Warm. No edema.
NEURO: Pupils 4mm->2mm and equal. CNII-XII intact. Sensation
intact in all four extremeties to gross touch. BLUE 4+/5 in
proximal and distal muscles; LLE 4+/5; RLE 4-/5
Pertinent Results:
Admission Labs:
[**2146-2-9**] 03:40PM BLOOD WBC-18.7*# RBC-3.79* Hgb-11.9* Hct-33.9*
MCV-89 MCH-31.4 MCHC-35.2* RDW-14.2 Plt Ct-228
[**2146-2-9**] 03:40PM BLOOD Neuts-95.2* Lymphs-1.7* Monos-1.7*
Eos-1.3 Baso-0.1
[**2146-2-10**] 03:26AM BLOOD PT-14.4* PTT-30.7 INR(PT)-1.3*
[**2146-2-9**] 03:40PM BLOOD Glucose-223* UreaN-41* Creat-2.0*#
Na-132* K-3.8 Cl-103 HCO3-16* AnGap-17
[**2146-2-9**] 03:40PM BLOOD ALT-101* AST-76* CK(CPK)-15* AlkPhos-376*
TotBili-1.2
[**2146-2-9**] 03:40PM BLOOD Albumin-3.6 Calcium-8.5 Phos-2.8 Mg-1.5*
[**2146-2-9**] 05:33PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2146-2-9**] 05:33PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2146-2-9**] 05:33PM URINE RBC-0-2 WBC-2 Bacteri-OCC Yeast-RARE
Epi-0-2
.
Microbiology:
[**2146-2-9**] 3:40 pm BLOOD CULTURE SOURCE: HICKMAN.
**FINAL REPORT [**2146-2-12**]**
Blood Culture, Routine (Final [**2146-2-12**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final [**2146-2-10**]):
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17604**] ON [**2146-2-10**] @ 8:40
P.M..
Anaerobic Bottle Gram Stain (Final [**2146-2-10**]): GRAM
NEGATIVE ROD(S).
Studies:
[**2146-2-9**] CXR - CONCLUSION: Multiple vascular stents, unchanged
since the prior examination. No acute cardiopulmonary process.
[**2146-2-10**] CT abdomen, pelvis - IMPRESSION:
1. Peripancreatic fluid adjacent to the pancreatic tail and in
the
right anterior pararenal space, consistent with tail
pancreatitis. Recommend correlation with amylase.
2. Elevation of the right hemidiaphragm is similar to [**2142-10-22**]
and suggests chronic right phrenic nerve paralysis.
3. Resolving discitis/osteomyelitis since [**2145-9-23**].
4. No evidence of abdominal abscess or small-bowel obstruction.
5. Lower lobe atelectasis.
[**2146-2-11**] TTE:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. No vegetation/mass is seen on the pulmonic valve. There
is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2145-11-8**],
no change.
IMPRESSION: No valvular vegetations or significant valve disease
seen.
Brief Hospital Course:
47F with Gardners Syndrome, short [**Year (4 digits) **], and tunneled line,
presented with bacteremia and likely line infection.
1. Klebsiella sepsis with hypotension: 7/8 bottles from OSH
positive for Klebsiella and 1/2 blood cultures positive here.
Previously has had Klebsiella bacteremia felt to be line
related. Patient intially required levophed for blood pressure
support which was weaned off after the tunnelled line was
changed out in the OR under anesthesia on [**2-11**]. Of note, the
patient normally has systolic blood pressures in the 80s.
Initial lactate of 3.5, down to 0.8 with 4+ liters of IVF. No
evidence for intra-abdominal abscess or other source of
infection on CT scan. TTE on [**2-11**] neg for vegetations, so less
likely endocarditis. Patient was initially started on meropenem
and daptomycin (had been on linezolid for coag neg Staph
bacteremia) pending blood culture results and daptomycin was
dropped when cultures were positive for Klebsiella. She
finished her course of treatment for the Staph bacteremia.
Meropenem was changed to ceftriaxone on [**2-12**] per ID recs. ID
recommends a 2 week course of ceftriaxone with Day 1 = [**2-11**].
The patient has had a prior history of a questionable lesion on
her SVC ([**11-1**] ECHO). Cardiology declined TEE at the time of
the line change out feeling that lesion likely not abscess. ID
recommended a chest CT, however, radiology did not feel that the
scan would be informative and the patient has a history of IV
contrast allergy. She was discharged home on IV antibiotics to
complete a 2 week course and will follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 111**] from [**Hospital **] clinic for further management.
2. Acute renal failure. Resolved. Likely related to prerenal
volume depletion. FENA 1% and Cr trended down to 0.4.
3. Transaminitis: On admission that resolved spontaneously.
Likely from hypoperfusion.
4. Hyperglycemia: Blood sugars in 300-400's while in MICU likely
related to infection. Was continued on HISS while septic, but
sugars normalized without need for sliding scale coverage while
on general medical floor prior to discharge.
5. Anemia. Hematocrit was below recent baseline, but stable
throughout admission
6. Right femoral vein thrombosis: Chronic with no acute issues.
She was continued on Plavix
7. Hypokalemia ?????? Patient required aggressive IV potassium
repletion for hypokalemia. This was stable prior to discharge
8. Metabolic acidosis: On admission had combination of elevated
lactate and ARF though also non-gap component as well (possibly
from ostomy output though does not report increase in this; now
partly from IVF). Received NaHCO3 on [**2-10**] and HCO3 improved to
her normal range.
9. Fibromyalgia causing generalized fatigue: Continued on
Fentanyl patch for sustained relief with Fentanyl IV prn for
breakthrough
10. Lower Abdominal pain: This has been chronic for several
months but had worsened prior to admission. No evidence for
intraabdominal abscess on CT scan. Pain improved overall since
admission.
FEN: IVF boluses; regular diet for pleasure; TPN started [**2-12**]
per nutrition consult. Patient is chronically TPN dependent
PPX: HSC; no need for PPI
CODE: DNR/DNI, but will intubate for some procedures
Medications on Admission:
1. Plavix 75 mg daily
2. Fentanyl 150mcg
3. Zofran 4mg Q6H PRN
4. Ativan 0.5mg TID
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID PRN ().
4. Ceftriaxone 1 gram Recon Soln Sig: One (1) Intravenous once
a day for 14 days: Total of 14 days of antibiotics starting on
[**2-11**]. Last dose on [**2146-2-24**].
Disp:*qs (8days) * Refills:*0*
5. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous prn:
Hickman line flush.
Disp:*qs * Refills:*0*
6. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) mL Injection
once a day.
Disp:*qs * Refills:*0*
7. Heparin Lock Flush 100 unit/mL Solution Sig: Two (2) mL
Intravenous once a day.
Disp:*qs * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Diversified VNA [**Location (un) 1157**]
Discharge Diagnosis:
Primary:
Klebsiella bacteremia
Sepsis
.
Secondary:
Gardners syndrome
Discharge Condition:
Good. Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted to the hospital with a low blood pressure and
found to have bacteria in your blood. You were treated with a
medication to increase your blood pressure, IV fluids and IV
antibiotics and your blood pressure improved. Your catheter was
changed because of the risk of infection.
You will need to complete a 2 week course of IV antibiotics. A
company will come to your house and administer ceftriaxone daily
until [**2146-2-24**].
Please return to the emergency department if you experience
fevers, chills, loss of consciousness, confusion, chest pain or
any other symptoms that are concerning to you.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**11-26**] weeks.
Please follow up in the Infectious disease clinic at the
appointment time listed below:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2146-2-25**] 11:00
Completed by:[**2146-3-21**]
ICD9 Codes: 5849, 2859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4080
} | Medical Text: Admission Date: [**2122-2-12**] Discharge Date: [**2122-2-17**]
Date of Birth: [**2042-12-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2122-2-12**] Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**] Porcine), PFO
closure
History of Present Illness:
79-year-old female who presented to [**Hospital 11333**] Hospital in [**Month (only) 956**]
with dyspnea and was found to be in congestive heart failure and
atrial fibrillation. She was worked up and an echocardiogram
showed that she had severe aortic valve stenosis with an aortic
valve area of 0.8 cm2. Her left ventricular ejection fraction
was 55%. There was also a question of patent foramen ovale
closure since she was found to have a small left-to-right shunt
with an atrial septal aneurysm noted on the echocardiogram. She
underwent cardiac catheterization and this showed no significant
coronary artery disease.
Past Medical History:
Aortic Stenosis
Congestive heart failure
Atrial fibrillation
Depression
Degenerative joint disease
Hypothyroidism after ablation
s/p right knee replacement
Social History:
Race: white/caucasian
Last Dental Exam:
Lives with: alone
Occupation: retired
Tobacco: none
ETOH: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T= 98.3 BP= 113/64 HR= 72 in NSR R 16 O2 sat= 98%RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no discernable JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line RRR, III/[**Doctor First Name 81**] systolic ejection murmur heard throughout
precordium with radation to carotids. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Cath site: well healed
with no bruit.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ dopplerable DP/PT
[**Name (NI) 2325**]: Carotid 2+ Femoral 2+ dopplerable DP/PT
Pertinent Results:
[**2-12**] Echo: No thrombus is seen in the left atrial appendage. A
patent foramen ovale is present. A left-to-right shunt across
the interatrial septum is seen at rest. Left ventricular wall
thicknesses are normal. The remaining left ventricular segments
contract normally. Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the aortic root.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Post Bypass: The patient is now s/p 23 [**First Name8 (NamePattern2) **]
[**Male First Name (un) 1525**] Bioprosthetic aortic valve placement The patient is now
on a neosynephrine drip @0.4mcg/kg/min,and AV sequentially
paced. The aortic valve is well seated,with no regurgitation and
a mean gradient of 4mmhg at a cardiac index of 1.9. There is
mitral regurgitation which is similar to prebypass and is 1+.
There is Moderate Tricuspid regurgitation. LV function is
preserved and EF is similar to prebypass @ 45-50%.
[**2122-2-12**] 10:57AM BLOOD WBC-7.4# RBC-2.85*# Hgb-9.2*# Hct-26.2*#
MCV-92 MCH-32.3* MCHC-35.0 RDW-14.9 Plt Ct-141*
[**2122-2-17**] 05:46AM BLOOD WBC-4.8 RBC-3.04* Hgb-9.8* Hct-27.9*
MCV-92 MCH-32.2* MCHC-35.1* RDW-14.9 Plt Ct-142*
[**2122-2-12**] 10:57AM BLOOD PT-16.2* PTT-31.4 INR(PT)-1.4*
[**2122-2-17**] 05:46AM BLOOD PT-14.6* INR(PT)-1.3*
[**2122-2-12**] 12:08PM BLOOD UreaN-13 Creat-0.7 Na-142 K-4.3 Cl-112*
HCO3-23 AnGap-11
[**2122-2-17**] 05:46AM BLOOD Glucose-97 UreaN-19 Creat-0.5 Na-139
K-3.9 Cl-102 HCO3-32 AnGap-9
[**2122-2-17**] 05:46AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.2
Brief Hospital Course:
Ms. [**Known lastname 89904**] was a same day admit and was brought to the
operating room on [**2-12**] where she underwent an aortic valve
replacement and PFO closure. Please see operative report for
surgical details. Following surgery she was transferred to the
CVICU for invasive monitoring in stable condition. Within 24
hours she was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one she was started on beta
blockers and diuretics and she was gently diuresed towards her
pre-op weight. She went into atrial fibrillation and was given
Amiodarone and beta-blockers. Chest tubes were removed and she
was transferred to the step-down floor on post-op day two.
Coumadin was initiated for her atrial fibrillation and titrated
for goal INR. Epicardial pacing wires were removed per protocol.
She worked with physical therapy during her post-op course for
strength and mobility. On post-op day five she appeared to be
doing well and was discharged to rehab with the appropriate
medications and follow-up appointments.
Date INR Coumadin dose
3/7 1.3 4
[**2-15**] 1.2 4
[**2-14**] 1.1 3
[**2-13**] -- 2.5
Medications on Admission:
At home are Coumadin 5 mg daily, Cartia XT 180 mg daily, and
Lopressor 100 mg b.i.d.
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please give 400mg twice daily for 5 days. Then 200mg
twice daily x 7 days. Finally 200mg daily until stopped by
cardiologist.
5. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
6. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust Coumadin dose and check INR accordingly for atrial
fibrillation. Goal INR 2-2.5.
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 16492**] [**Doctor Last Name **]
Discharge Diagnosis:
Aortic Stenosis/Patent foramen ovale s/p Aortic Valve
replacement and PFO closure
Past medical history:
Atrial fibrillation
Depression
Degenerative joint disease
Hypothyroidism after ablation
s/p right knee replacement
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram or Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2122-3-11**] at 2PM
Cardiologist: Dr.[**Name (NI) 14643**] office will contact you regarding
appointment. Should be seen in approximately 4 weeks.
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) 6382**] [**Last Name (NamePattern1) 29065**] in [**3-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: Atrial Fibrillation
Goal INR 2-2.5
First draw [**2122-2-18**]
Completed by:[**2122-2-17**]
ICD9 Codes: 4241, 4280, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4081
} | Medical Text: Admission Date: [**2115-3-17**] Discharge Date: [**2115-3-28**]
Date of Birth: [**2078-9-14**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 36-year-old male
status post ileostomy closure on [**2115-3-4**] with increased
abdominal pain for one day and with decreased flatus.
Patient was recently discharged from the hospital on
[**2115-3-8**]. The symptoms started gradually and have increased
with intensity over the past 24 hours. Patient denies any
nausea or vomiting.
PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. History of DVT.
3. Cryptorchidism.
PAST SURGICAL HISTORY:
1. Colectomy and ileoanal pouch.
2. Ileostomy takedown.
MEDICATIONS ON ADMISSION:
1. Coumadin 5 mg p.o. q.d.
2. Loperamide.
3. Reglan.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAM: On physical exam, the patient was afebrile.
Vital signs stable. In no apparent distress. Heart was
regular rate and rhythm. Chest was clear to auscultation
bilaterally. Abdomen was diffusely tender with decreased
bowel sounds. Positive rigidity and no guarding.
Extremities were devoid of edema and patient was guaiac
negative on rectal exam.
LABORATORIES: All admission laboratories were within normal
limits.
KUB shot at this time showed a partial obstruction.
A CT of the abdomen showed small bowel obstruction with
dilated duodenum. There appeared to be decompressed loops of
proximal jejunum, dilated loops again in mid jejunum. Large
amount of free fluid in the abdomen portion of the right
upper quadrant heterogeneous appearance. No extravasation of
contrast or free air seen. Both studies were performed on
[**2115-3-17**].
SUMMARY OF HOSPITAL COURSE: Patient is a 36-year-old male
status post ileostomy closure, who presents with abdominal
pain and apparent small bowel obstruction with intraabdominal
free fluid. Patient was taken emergently to the OR for
exploratory laparotomy. Patient was found to have a small
bowel obstruction and an intraabdominal hematoma. Hematoma
was evacuated, and extensive lysis of adhesions was
performed. For more detailed account, please see operative
report.
Patient was transferred to the Trauma SICU on [**2115-3-18**],
postoperative day #1 for monitoring of bladder pressures,
CVP, and fluid resuscitation. Patient was placed
postoperatively on levofloxacin and Flagyl antibiotics.
Patient was transferred to the floor on postoperative day
#[**1-22**], where he did well. He was started on TPN for IV
nutrition, while we awaited bowel activity. In addition,
nasogastric tube was placed to low wall suction. The
remainder of postoperative course was unremarkable.
On [**2115-3-21**], the patient was examined rectally and
anastomosis was found to be patent. Patient had flatus on
postoperative day #9 at which time the patient was advanced
to full liquids, which he tolerated well.
On postoperative day #10, the patient was advanced to a
regular diet, which he had also tolerated well. On
postoperative day #11, the patient was weaned off of his TPN,
tolerating a regular diet, nasogastric tube was out, and
patient was tolerating a regular diet. Pain was controlled
with p.o. pain medications. Patient was having positive
flatus and positive bowel movements. Patient was deemed well
enough to go home at this time. Patient was discharged to
home. The patient was recoumadinized on discharge with an
INR of 1.8 to be managed by his primary care physician.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Ulcerative colitis.
2. Intraabdominal hematoma.
3. History of deep venous thrombosis.
DISCHARGE MEDICATIONS:
1. Coumadin 5 mg p.o. q.h.s.
2. Percocet 1-2 tablets p.o. q.4-6h. prn for pain.
3. Colace 100 mg p.o. b.i.d.
FOLLOW-UP INSTRUCTIONS: The patient is to followup with Dr.
[**Last Name (STitle) **] in [**1-22**] weeks. Please call for an appointment.
[**Known firstname **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11126**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2115-3-29**] 23:49
T: [**2115-4-3**] 06:36
JOB#: [**Job Number 26690**]
ICD9 Codes: 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4082
} | Medical Text: Admission Date: [**2119-11-6**] Discharge Date: [**2119-11-11**]
Date of Birth: [**2049-8-23**] Sex: F
Service: Medicine
HISTORY AND CLINICAL COURSE: The patient is a 70 year old
woman with a history of diabetes mellitus, end-stage renal
disease, on hemodialysis, coronary artery disease, status
post prior myocardial infarction, peripheral vascular
disease, status post left iliac stent and right femoral
bypass and above the knee amputation, who presented with an
inferior myocardial infarction in the setting of
gastrointestinal bleeding and an INR of 3.7 on [**2119-11-6**].
The patient was intubated for flash pulmonary edema secondary
to fluid overload after receiving blood products for a
dropping hematocrit and elevated INR. She went for a cardiac
catheterization the following day and had ostium and right
coronary artery successfully stented. However, both cardiac
catheterization and echocardiogram revealed severe aortic
stenosis. The patient remained pressor dependent with
aggressive medical management and periodic hemodialysis.
The patient went for vasculoplasty on [**2119-11-9**] in the
hopes of decreasing her outflow and help her cardiac output.
However, the patient continued to deteriorate clinically and
required more pressors for blood pressure support. On
[**2119-11-10**], the patient began more hypotensive and
acidotic and required a bicarbonate drip.
On [**2119-11-11**], the patient went into a ventricular
tachycardia arrest. She received cardiopulmonary
resuscitation and epinephrine initially. However, given the
patient's poor prognosis and critical condition, the family
decided not to pursue more aggressive treatment and the
patient passed away around 10:10 a.m. on [**2119-11-11**].
FINAL DIAGNOSIS:
Cardiac arrest.
Cardiogenic shock.
Septic shock.
Profound metabolic acidosis.
Diabetes mellitus.
End-stage renal disease.
Severe peripheral vascular disease.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-749
Dictated By:[**Last Name (NamePattern1) 225**]
MEDQUIST36
D: [**2119-11-12**] 16:18
T: [**2119-11-15**] 13:00
JOB#: [**Job Number 30794**]
ICD9 Codes: 2851, 5789, 4271, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4083
} | Medical Text: Admission Date: [**2149-9-29**] Discharge Date: [**2149-10-20**]
Date of Birth: [**2069-1-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
left sided SDH s/p fall (thought to be mechanical fall)
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
80 year old male s/p fall down cement stairs today. The
patient takes 81 mg of aspirin daily but is not on any
anticoagulation. He was in his usual state of health this
morning and went for his walk. When he came back his wife found
him down at the bottom of the stairs. The patient was brought
to
[**Hospital1 18**] where he was combative and oriented x 1. The ER intubated
him and then he had a head CT which showed a SDH on the left
side.
Past Medical History:
HTN, non insulin dependent DM, hypercholesterolemia
Social History:
lives with wife, has daughter who lives nearby
Family History:
non-contributory
Physical Exam:
T:97 BP:124/65 HR:63 RR:18 O2Sats: 100% intubated
Gen: Intubated and sedated - sedation turned off for exam
HEENT: (+) posterior scalp abrasion on the right side
Pupils: PERRL EOMs-intact
No otorrhea. No rhinorrhea. (+) dried blood in nares.
Neck: In cervical collar.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Patient has no eye opening and is not following
commands. He is moving all 4 extremities spontaneously.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1 mm
bilaterally. His right pupil is slightly eccentric.
III-XII: unable to be tested
Motor: moving all extremities spontaneously and purposefully
Sensation: Appears to be intact to light touch bilaterally.
Toes downgoing bilaterally
Pertinent Results:
admission CBC [**2149-9-29**] WBC-16.4* HGB-13.0* HCT-35.7* MCV-88
RDW-13.3 PLT 247
admission chemistry [**2149-9-29**] GLUCOSE-277* UREA N-22* CREAT-0.9
SODIUM-138 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-27 CALCIUM-8.5
PHOSPHATE-4.9* MAGNESIUM-1.7 FIBRINOGEN 320 ETHANOL NEGATIVE ASA
NEATIVE ACETAMINOPHEN NEGATIVE BENZOS NEGATIVE BARB NEGATIVE TCA
NEGATIVE
CBC [**10-18**]: wbc 12.5 hct 26.8 plt 338
Discharge chemistry: glucose 279, bun 15 cr 0.8, na 139, k 3.9,
cl 105, bicarb 28
LP: bottle #4: WBC 500, RBC 59,500 POLYS 96, LYMPHS 2, MONOS 1,
MACRO 1
bottle #1: WBC 530, RBC 29,500 POLYS 94, LYMPHS 4, 2 MONOS
T PROTEIN 92, GLUCOSE 58
HERPES SIMPLEX CSF PCR: NEGATIVE
Blood cultures: negative [**9-30**], [**10-8**], pending from [**10-13**] as of
[**10-18**]
Urine cultures on [**10-7**] and [**10-13**] negative
Head CT scan [**10-17**]
1. No new areas of acute hemorrhage.
2. Mild interval increase in thickness of bilateral subdural
hematomas versus hygromas. There are no acute components
however.
3. Continued evolution of subarachnoid hemorrhage and left
temporal
hemorrhagic contusion.
4. Unchanged appearance of the ventricles.
Head CT scan [**10-4**]: Stable intracranial hemorrhage as described.
Right temporal bone fracture to be evaluated in further detail
on the subsequent CT of the orbits.
CT orbits [**10-4**]:
1. Predominantly transverse fracture of the right temporal bone
without
displacement of fragments, extending into the middle ear cavity,
but not
disrupting the ossicles, without extension into the inner ear
structures,
facial nerve course, or the carotid canal. There is, however,
opacification
of several right-sided mastoid air cells, and extension of the
fracture into the temporomandibular joint.
2. Although there is opacification of several left-sided mastoid
air cells, there is no middle ear opacification or evidence of
fracture line.
3. Soft tissue within both external auditory canal, which may
represent
cerumen, however, direct visualization is recommended.
[**2149-9-29**] Head CT:
1. Left inferior temporal lobe hemorrhagic contusion. Left SDH
and SAH as
described.
2. Right temporal bone fracture. Recommend correlation with
dedicated temporal bone CT.
CT C spine [**2149-9-29**]:
1. No evidence of cervical spine fracture or malalignment.
Degenerative
changes noted.
2. Opacification of right mastoid air cells with soft tissue
air. Right
temporal bone fracture not clearly seen on this study though
known to be
present based on concurrently performed head CT. Dedicated
temporal bone CT is recommended for further evaluation.
MRI L spine [**10-8**]:
1. There is no epidural hematoma or other epidural abnormality.
2. Mild degenerative disc changes at multiple lumbar levels,
with mild spinal canal stenosis at L2/3.
3. Mild edema in the posterior lumbar paraspinal muscles, of
undetermined
etiology or significance.
Chest AP [**10-14**]:
AP chest compared to [**10-3**] through [**10-13**]:
New nasogastric tube ends in the stomach. Lungs are clear.
Heart size
normal. No pleural abnormality. Healed right posterior rib
fracture is
noted.
EEG [**10-15**]:
Abnormal EEG due to the slow and disorganized background and
bursts of generalized slowing. These findings indicate a
widespread encephalopathy affecting both cortical and
subcortical structures. No prominent focal features were evident
although encephalopathies may obscure focal findings. There were
no clearly epileptiform features.
Brief Hospital Course:
SDH: Initially admitted to the neurosurgical service but no
neurosurgical intervention required. He was admitted to the
SICU. He was loaded on Keppra and was extubated on the third
hospital day. Keppra was continued until the time of discharge.
The patient's SDH/SAH were followed by serial CTs, cleared by
neurosurgery to restart subcutaneous heparin for DVT
prophylaxis. Patient will be discharged with neurosurgery
follow up and repeat head CT at that time.
DELERIUM: Initially reported to be delerious but then upon
extubation and transfer to the floor his mental status cleared.
After days of being AOx3 and interactive he acutely became
somnolent and AOx1 only. He would become agitated and his
conversations would not be intelligent. His mental status waxed
and waned and no cause of his delerium was found. LP performed,
initially thought to be meningitis and started on IV ceftaz and
vanc as well as ampicillin and listeria, after 6 days of
antibiotics ID re-evaluated and considered it much less likely
that his LP represented meningitis but more likely just a
traumatic tap. CSF cultures were negative. Rest of infectious
workup was negative. EEG just showed generalized slowing.
Patient would become much more agitated with restraints on.
Started on celexa 10mg to be titrated up as outpatient as
patient repeatedly expressed wishes to die but denied active
suicidality. Attempts to adjust sleep wake cycle were
undertaken. Patient showed some improvement, AOx2, less
somnolent, improved strength and more interactive however
remained with non-intelligent conversation. Low level elevation
of WBC count days previous to discharge however throughout
admission WBC count has been elevated, up to 20, with normal
differentials and no source of infection ever found. Goals are
to decrease patient's lines/tubes and improve sleep wake cycle.
Frequent reminders of location and date and window bed.
URINARY RETNETION / FOLEY CATHETER: Multiple times during this
admission the patient had episodes in which he pulled out his
foley catheter but then had urinary retention. Urology
consulted.
PLEASE NOTE THAT THE PATIENT HAS A TENDENCY TO BECOME AGITATED
AND HAS PULLED HIS FOLEY CATHETER MULTIPLE TIMES UPON THIS
ADMISSION CAUSING CONSIDERABLE TRAUMA TO HIS PROSTATE, HE MUST
KEEP THE FOLEY CATHETER IN UNTIL [**10-26**] IN ORDER TO ALLOW FOR
ADEQUATE HEALING OF THE PROSTATE. HE SHOULD HAVE A DIAPER ON AT
ALL TIMES AND THE FOLEY CATHETER SHOULD BE TAPED SECURELY (OR
USE TEGADERM) TO HIS LEG. USE MITTS AND PLACE PATIENT'S HANDS
ABOVE HIS COVERS AT ALL TIMES WHEN THE FOLEY IS IN.
IF URINE CONTINUES TO BE NON-BLOODY PLEASE REMOVE FOLEY ON [**10-26**]
AND CHECK BLADDER SCAN 2-3 TIMES PER DAY, IF GREATER THAN 200 CC
IN BLADDER PLEASE STRAIGHT CATH WITH 20 FRENCH COUDE CATHETER.
UPON THIS ADMISSION HE HAS HAD SUCCESSFUL STRAIGHT
CATHETERIZATIONS WITH A 20 FRENCH COUDE AND HEMORRHAGIC
CATHETERIZATIONS WITH NORMAL FOLEY CATHETERS AS THEY ARE NOT
CURVED AND DO NOT AVOID THE PROSTATE- CAUSING DIRECT BLEEDING
FROM THE TRAUMATIZED PROSTATE.
HTN: blood pressure relatively well controlled on discharge
regimen.
DM: Patient admitted on metformin 1000mg po bid and glipizide
10mg po bid. Discharging on glipizide 5mg po bid as patient is
taking decreased POs.
DIETARY: Patient initially taking decreased POs and would not
have much of an appetite. As delerium evolved he began to
refuse POs all together and given his somnolence and refusal of
medications an NGT was placed not only for tube feeds but also
for medication delivery. His NGT was discontinued on [**10-18**] after
3 days of feeding to attempt trial of oral intake. With
improvements in mental status, patient's oral intake increased
slightly but will need to be followed closely. Patient may need
PEG tube for nutrition, but team feels that patient needs
adequate trial before this measure is taken. Conversation has
begun with the family regarding PEG tube placement as an option
should he continue to be delerious and refusing POs.
Medications on Admission:
Aspirin 81 mg daily
Metformin
Atenolol
Glyburide
Discharge Medications:
1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
7. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous DAILY (Daily) as needed.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Ciprofloxacin 0.3 % Drops Sig: Four (4) Drop Ophthalmic TID
(3 times a day).
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
11. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q8H (every 8 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
Subdural Hematoma
Secondary:
Hypertension
Diabetes mellitus type 2 controlled
Urinary retention (likely due to prostatic hypertrophy)
Discharge Condition:
Good; afebrile with improved neuro status.
Discharge Instructions:
You were admitted with some bleeding on the surface of your
brain called a subdural hematoma. We have monitored you closely
and your condition has improved. You were started on a
medication to prevent seizures called KEPPRA.
If you develop worsening headache not relieved with medication,
develop weakness, or new seizures return to the ER. If you have
chest pain, shortness of breath, bleeding, or any other
concerning symptoms please call your doctor or return to the
emergency room.
You were admitted with some bleeding on the surface of your
brain called a subdural hematoma. We have monitored you closely
and your condition has improved. You were started on a
medication to prevent seizures called KEPPRA.
If you develop worsening headache not relieved with medication,
develop weakness, or new seizures return to the ER. If you have
chest pain, shortness of breath, bleeding, or any other
concerning symptoms please call your doctor or return to the
emergency room.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **]. Tuesday [**11-18**] at 1:00 p.m.
[**Hospital **] Medical Building, [**Hospital Ward Name **], [**Location (un) 470**], 3B.
[**Telephone/Fax (1) 2731**].
You should arrive for a Head CT at 11:30p.m. (same date [**11-18**]) CT
[**Hospital Ward Name **], clinical center, [**Location (un) 470**], nothing to eat or drink
3 hours prior.
Please follow up with urology within 1-2 months of discharge
from the hospital. Call [**Telephone/Fax (1) 164**] to make an appointment at
the [**Hospital1 18**].
Please follow up with your primary care physician [**Name Initial (PRE) 176**] [**4-18**]
weeks of your discharge from the hospital.
Follow up with Dr. [**Last Name (STitle) **]. Tuesday [**11-18**] at 1:00 p.m.
[**Hospital **] Medical Building, [**Hospital Ward Name **], [**Location (un) 470**], 3B.
[**Telephone/Fax (1) 2731**].
You should arrive for a Head CT at 11:30p.m. (same date [**11-18**]) CT
[**Hospital Ward Name **], clinical center, [**Location (un) 470**], nothing to eat or drink
3 hours prior.
Please follow up with urology within 1-2 months of discharge
from the hospital. Call [**Telephone/Fax (1) 164**] to make an appointment at
the [**Hospital1 18**].
Please follow up with your primary care physician [**Name Initial (PRE) 176**] [**4-18**]
weeks of your discharge from the hospital.
ICD9 Codes: 5990, 4019, 2767, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4084
} | Medical Text: Admission Date: [**2196-1-6**] Discharge Date: [**2196-1-11**]
Date of Birth: [**2133-5-11**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Macrolide Antibiotics / Sulfa (Sulfonamide Antibiotics)
/ Gemfibrozil / Loracarbef
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
intubation + ventilation
History of Present Illness:
62F h/o COPD, asthma, ?CHF (on lasix a home), on home O2 2L NC
with 1 day hx worsening SOB, fatigue, lethargy. EMS report: "per
husband was really sleepy all day, only responded to name by
lifting head and going back to sleep" and today found home by
EMS with O2 saturation 70% 2L (home O2 requirement), brought to
OSH where she was unresponsive initial gas was 7.22/94/80/40,
intubated with good response to hypoxia PaO2> 100, s/p
solumedrol, albuterol via CPAP, levaquin, did not recieve fluids
in OSH, transferred for further evaluation. No recent travel,
Has dog at home, denies other animal exposures, denies contact
with [**Name2 (NI) **] people. Unknown if had flu vaccine
.
Per husband had 4 hospitalizations over past year for pulmonary
issues as well as a recurrent RLE cellulitis. Most recently was
admitted to [**Location (un) **] ~ 4 weeks ago. Was treated with Abx,
unknown which.
.
On arrival to our ED vitals were 98.4, 86, 96/78, 14, 100% on
100% FiO2, her exam was notable for bil coarse weezes and
diffuse erythema over panus + RLE erythema and edema. CXR
question of aspiration per RML infiltrate, her labs were notable
for WBC = 11,700, Neu = 95%, Hct = 51, K = 5.3, ABG:
7.23/102/384, HCO3 = 39. Trop X1 neg.
On ED admission proved to be difficult to ventilate, and was
sedated with propofol and versed with SBP drop from 90 to 70
shortly thereafter, got 2 L fluids, and required Levofed with
improvement in her BP's. Blood cultures were drawn X 2. Also
given Vancomycin s/p levaquin in OSH. Prior to transfer to ICU
was on Levofed 0.03 mg/kg/min on perippheral IV, vent settings
were CMV FiO2 40% PEEP 10 RR 16 TV 460. Transfer vitals were 82
106/54 16 97%. .
.
Past Medical History:
.
COPD/Emphysema
Recurrent RLE cellulitis
HLD
HTN
? DM
s/p cholecystectomy
s/p hysterectomy
.
Allergies: Iodine, Macrolids, Azithromycine, Sulfa, Gemfibrozil,
Loracarbef (unkown severity)
Social History:
Smoking > 30 pack years, no alcohol
Married + 5. 2 kids live with the parents aged 32 and 36.
Husband is HCP. Reduced ADL over past 2-3 months, can't walk
more than 5 feet, can't bathe herself.
Family History:
Family History: unknown
Physical Exam:
On ICU admission:
.
VS: Temp:99.1 BP: 152/ 72 HR:79 RR:17 O2sat 98%
GEN: Obese, intubated, sedated
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, heard to
asses jvd d/t habitus, no carotid bruits, no thyromegaly
RESP: ronchorus bilaterally
CV: distant HS, heard to assess
ABD: obese, NTnd, +b/s, soft, nt, hard to assess masses or
hepatosplenomegaly, diffuse erythematous intertrigenous eruption
under panus and in bilateral inguinal areas with satellite
lesions. Without local discharge
EXT: RLE pretibial edema, erythema and chronic skin peau
d'orange-type chronic skin changes. Otherwise well and warm
perfused extremities.
splinters
NEURO: PERRL,DTR [**Name (NI) 90427**] and [**Name2 (NI) 90428**], flexor plantar
responses.
.
Pertinent Results:
Labs:
.
WBC = 11,700, Neu = 95%, Hct = 51, PLT = 237
139 92 36
-------------176
5.3 39 1.0
Ca/Mg/P = 9.2/2.3/5.3
ABG: 7.23/102/384
.
INR = 1.0, PTT = 36
ALT = 28, AST = 35, ALP = 126, T.Bili = 1.3
.
EKG: sinus tachycardia 100, border line left axis, PRWP, small
QRS voltage,
.
Imaging:
CXR: semi-upright AP film, NG tube in place, ET tube at Carina,
exenuated lung hiluses with vascular congestion, cephalization
as well as some peribronchial thickening, there is loss of bil
heart borders as well as diaphragmatic contours concerning for
effusions and possible infiltrate.
Brief Hospital Course:
62 year old woman with COPD, asthma, ?CHF (on Lasix at home), on
home O2 2L NC admitted intubated and ventilated from OSH with
acute on chronic respiratory failure from the day of her
admission likely [**12-23**] to COPD exacerbation. The patient was
intubated and ventilated at OSH prior to transfer to our
institution. ABG on admission was consistent with acute on
chronic respiratory acidosis. She is on 2L nasal canula at home.
Acute respiratory failure was attributable to pneumonia, COPD
exacerbation and fluid overload from CHF exacerbation. CXR
showed possible bilateral effusions and basilar infiltrates. TTE
showed normal to hyperdynamic EF with diastolic dysfunction.
STREPTOCOCCUS PNEUMONIAE grew in sputum. Patient was initially
treated with Levofloxacin + Ceftriaxone + Vancomycin and then
only oral Levaquin. She was covered for Influenza with Tamiflu
for 3 days until she ruled out per nasal swab. Patient was
extubated on day 2 of admission, following extubation she had
some hypoxia which improved with IV Lasix 40 mg (acute diastolic
heart failure). She was subsequently started on her home dose of
Lasix 40 mg [**Hospital1 **]. Patient was additionally treated with a course
of prednisone as well as Albuterol and Ipratropium nebs and
Advair 250/50 1 puff [**Hospital1 **]. She had abdominal/inguinal superficial
skin infection which appeared fungal and improved markedly with
topical treatment. She had hypotension on admission was from
sedation agents. AM cortisol was elevated, ruling out adrenal
insufficiency. Levophed was weaned quickly without any need for
pressors since AM of [**1-6**]. She had RLE edema: from chronic
lymphedema without recurrent cellulitis. No evidence of DVT on
U/S. She was discharged home on [**12-24**] L of oxygen without rales or
wheezing.
Medications on Admission:
Medications at home (confirmed with husband):
.
Lassix 40mg [**Hospital1 **]
Norvasc 5mg QD
Potassium 8meq [**Hospital1 **]
Aspirin 81mg QD
B12 Inj 1000mcg Q3weeks
Xanax 0.5mg PRN
Fioricet 2 tabs q4h PRN for Jaw pain
Oxygen 2 L
pharmacy [**Telephone/Fax (1) 90429**]
.
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 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).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day
for 4 days: then 3 tablets daily for 3 days then 2 tablets daily
for 2 days then 1 tablet for 1 day.
Disp:*30 Tablet(s)* Refills:*0*
9. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
smoking
streptococcal pneumonia
acute COPD exacerbation
acute diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please stop smoking because smoking give you lung cancer. You
had pneumonia and acute COPD exacerbation. You will take
antibiotic and prednisone taper for few days.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] G. [**Telephone/Fax (1) 28612**]
ICD9 Codes: 2762, 4280, 2724, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4085
} | Medical Text: Admission Date: [**2148-9-4**] Discharge Date: [**2148-10-2**]
Date of Birth: [**2088-6-29**] Sex: M
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
gentleman with a history of left hip replacement in [**2145**],
bladder cancer, and degenerative joint disease who presented
to [**Hospital3 **] Hospital on [**8-29**] with neck pain and back
pain times one week that radiated to his legs and a pustular
rash over his arms bilaterally and his left leg. He was
admitted for a fever of unknown origin and was subsequently
found to have methicillin-resistant Staphylococcus aureus
bacteremia, for which he was treated with oxacillin and
levofloxacin.
On [**9-4**], he was transferred to [**Hospital1 190**] for further evaluation. The patient was also
noted to have a septic right ankle and suspected left wrist
infection. Of note, the patient was complaining of one month
of low back pain and headache with total spine and neck pain.
His temperature maximum prior to admission was 103.1 degrees
Fahrenheit. The patient was noted to have arthralgias and
myalgias as well as tachycardia at the outside hospital.
The patient had a transthoracic echocardiogram done at the
outside hospital which was negative for vegetations. He had
low-grade hemolysis with slight anemia. A bone scan was done
also at the outside hospital which was negative for
osteomyelitis, discitis, or infection of the prior hip
surgery. The patient also had a magnetic resonance imaging
done of his head which was negative for acute infarction and
negative for abnormal parenchymal or left meningeal
enhancement.
PAST MEDICAL HISTORY: (The patient's past medical history
included)
1. Bladder cancer.
2. Degenerative joint disease.
3. Hyperlipidemia.
4. Left hip surgery replacement secondary to degenerative
joint disease in [**2145**].
5. Low back pain.
6. Status post herniorrhaphy in [**2148-1-27**].
MEDICATIONS ON ADMISSION: (His medications on admission
were)
1. Oxacillin 2 g intravenously q.4h.
2. Levofloxacin 500 mg intravenously once per day.
3. Rifampin 900 mg by mouth once per day.
4. Protonix 40 mg by mouth once per day.
5. Morphine 2 mg to 4 mg intravenously q.2h. as needed.
6. Heparin 5000 units subcutaneously q.12h.
7. Toradol 15 mg intravenously q.6h. as needed.
8. Ativan 0.5 mg by mouth q.6h. as needed.
9. Bowel regimen.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in [**Location 30150**]. He
works as a stock broker. No tobacco. Positive alcohol of
one to two drinks per day.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's physical
examination on admission revealed vital signs with a
temperature of 100.9 degrees Fahrenheit, his blood pressure
was 147/78, his heart rate was 102, his respiratory rate was
20, and his oxygen saturation was 97% on 4 liters nasal
cannula. In general, the patient was anxious and awake.
Alert and oriented times three. In no significant distress.
Head, eyes, ears, nose, and throat examination revealed the
mucous membranes were moist. Pupils were equal, round, and
reactive to light. Extraocular muscles were intact. The
neck was supple. No lymphadenopathy. The lungs were clear
to auscultation bilaterally. Cardiovascular examination
revealed positive first heart sound and positive second heart
sound. A systolic ejection murmur at the left upper sternal
border. No gallops. No additional heart sounds. The
abdomen was soft, nontender, and nondistended. Positive
bowel sounds. No masses. Extremity examination revealed no
clubbing or cyanosis. There was 1+ lower extremity edema to
the midshin bilaterally. Skin examination revealed an
erythematous left arm with papular lesions in a heterogenous
distribution. A papular nontender rash without sloughing
skin was present in the bilateral inner thighs without
extension to genitals.
PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent
laboratories and studies on admission revealed his white
blood cell count was 19.8, his hematocrit was 27, and his
platelets were 364. Chemistry-7 revealed his sodium was 140,
potassium was 4, chloride was 106, bicarbonate was 20, blood
urea nitrogen was 24, creatinine was 0.8, and his blood
glucose was 132. Calcium was 7.2, magnesium was 2.7, and his
phosphorous was 4.7. His liver function tests revealed his
albumin was low at 1.9. His alkaline phosphatase was
elevated at 382. His total bilirubin was elevated at 3.7.
His direct bilirubin was 2.1. His AST was elevated at 81.
His ALT was elevated at 117. His creatine kinase was
elevated at 425. His troponin was less than 0.01.
DR.[**Doctor Last Name **].[**Doctor First Name **] 12-ABJ
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2148-10-1**] 16:26
T: [**2148-10-1**] 16:34
JOB#: [**Job Number 50104**]
ICD9 Codes: 0389, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4086
} | Medical Text: Admission Date: [**2172-10-22**] Discharge Date: [**2172-11-4**]
Date of Birth: [**2108-2-26**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
64 M with history of cirrhosis presumed due to EtOH, PUD s/p
past Billroth [**Hospital 40608**] transfer from [**Hospital3 **] with melena and
BRBPR. Patient was admitted on [**2172-10-16**] with melena and BRBPR x
2 days. Also associated with crampy abdominal pain and nausea.
Initial hematocrit 26.5, INR 1.8, developed thrombocytopenia to
60s as well. Had EGD in ED which showed no varices, obvious
ulcers or tears. Source thought to be "dusky" patch in stomach.
Stomach filled with blood and unable to visualize duodenum. Per
HO report 6 units PRBCs given in addition to 2 units FFP (though
nursing reports 10 units PRBCs, FFP and platelets). Per notes,
repeat EGD performed [**10-20**]. Bright red blood in gastric
reminant without ulceration seen. Also appears to have had
bleeding scan performed with results unavailable currently.
Continued to have evidence of bleeding during hospital course;
HO reported cessation of bleeding and then restart, though not
clear from notes. Patient has complained of epigastric area
abdominal pain, but nothing out of ordinary from usual chronic
abdominal pain. Denies hematemesis. No chest pain or shortness
of breath. + occasional palps. Denies abdominal
swelling/ascites. Patient also with Afib with RVR (to 160) on
presentation requiring diltiazem gtt with eventual transition to
dilt PO and digoxin PO. [**Hospital1 **] notes some hypotension (as low
as 84/50 seen in notes) but not requiring pressors at any time.
Sodium 157 today; D5W with K started. Patient also noted to
have leukocytosis to 24K on [**10-19**], also with slight amylase
elevation, prompting CT (report not included with paperwork; per
HO was normal with ?no ascites; progress notes suggest "air
within thickened gastric remnant - air trapped in folds vs.
contained perforation"). Given zosyn due to leukocytosis and
?concern for bowel ischemia since admission.
.
Vitals prior to transfer: 98.1, HR 87, 114/90, 23, 100% on 2L
NC.
.
Past Medical History:
- Cirrhosis [**1-11**] EtOH. Noted to have grade I varices on [**2160**]
endoscopy report, none in [**2166**] (though did have gastric
varices).
- h/o Billroth II for PUD "many years ago" and about 5 abdominal
surgeries (between age 20 and ~[**2153**])
- Recurrent UGIB with PUD as above. Reports last GI bleeding
about 10 years ago, but OSH notes with melena and hematocrit
drop (49 down to 24), found to have gastritis without ulcer or
varices on EGD.
- History of EtOH abuse, none since ~[**2153**].
- Chronic pain of bilateral arms (thought due to OA) and
abdomen.
- Atrial fibrillation. On coumadin in the past.
- Depression, psychosis
- history of DVT and s/p IVC filter placement
- chronic pancreatitis, history of pseudocyst with resection.
- HTN
Social History:
PhD in English, once worked at [**Hospital3 1810**]. Currently on
disability. No tob, drug use. No EtOH in 10 years. Lives in [**Hospital1 1501**]
x yrs
Family History:
Denies family history of liver disease. Mother with increased
bleeding of unclear etiology.
Physical Exam:
VS: T: 97.9 BP: 140/72 HR: 74 Afib RR 16 100% on 2L nc
GEN: NAD, chronically ill appearing, pleasant
HEENT: NC/AT, EOMI, PERRL, no OP lesions, poor dentition
CV: irregularly irregular, no mrg
PULM: coarse breath sounds
ABD: +bs, soft, NTND
EXT: 2+ hand edema, 2+ LLS to knees
NEURO: CN 2-12 intact, UE/LE strength 5/5 bilat,
PSYCH: appropriate
Pertinent Results:
[**2172-10-23**] 03:13PM BLOOD WBC-11.1* RBC-3.85* Hgb-11.4* Hct-32.7*
MCV-85 MCH-29.7 MCHC-35.0 RDW-17.0* Plt Ct-114*
[**2172-10-25**] 04:52AM BLOOD WBC-11.1* RBC-3.73* Hgb-11.0* Hct-32.2*
MCV-87 MCH-29.6 MCHC-34.2 RDW-17.5* Plt Ct-153
[**2172-10-27**] 10:39PM BLOOD WBC-19.5* RBC-3.02* Hgb-9.0* Hct-27.3*
MCV-91 MCH-29.9 MCHC-33.0 RDW-17.4* Plt Ct-195
[**2172-10-29**] 12:59PM BLOOD WBC-10.0 RBC-2.99* Hgb-9.0* Hct-26.6*
MCV-89 MCH-30.0 MCHC-33.6 RDW-18.1* Plt Ct-271
[**2172-11-1**] 05:20AM BLOOD WBC-8.5 RBC-3.05* Hgb-9.2* Hct-27.3*
MCV-90 MCH-30.2 MCHC-33.6 RDW-17.6* Plt Ct-319
[**2172-11-4**] 05:16AM BLOOD WBC-6.1 RBC-3.04* Hgb-9.2* Hct-27.4*
MCV-90 MCH-30.2 MCHC-33.5 RDW-17.0* Plt Ct-355
[**2172-10-22**] 03:17AM BLOOD Neuts-79.5* Lymphs-11.0* Monos-7.8
Eos-1.4 Baso-0.2
[**2172-10-26**] 06:00PM BLOOD Neuts-77.2* Lymphs-13.9* Monos-6.4
Eos-2.2 Baso-0.3
[**2172-10-24**] 03:09AM BLOOD PT-14.1* PTT-29.0 INR(PT)-1.2*
[**2172-10-28**] 03:59AM BLOOD PT-14.8* PTT-28.9 INR(PT)-1.3*
[**2172-11-3**] 05:33AM BLOOD PT-14.5* PTT-47.3* INR(PT)-1.3*
[**2172-11-3**] 05:33AM BLOOD Plt Ct-363
[**2172-10-22**] 03:17AM BLOOD Ret Aut-2.4
[**2172-10-23**] 03:12AM BLOOD Glucose-156* UreaN-20 Creat-0.9 Na-142
K-3.9 Cl-109* HCO3-31 AnGap-6*
[**2172-10-25**] 04:52AM BLOOD Glucose-113* UreaN-11 Creat-1.0 Na-145
K-3.5 Cl-110* HCO3-30 AnGap-9
[**2172-10-29**] 03:27AM BLOOD Glucose-85 UreaN-12 Creat-1.1 Na-139
K-3.2* Cl-108 HCO3-24 AnGap-10
[**2172-11-2**] 05:39AM BLOOD Glucose-94 UreaN-12 Creat-0.9 Na-140
K-3.9 Cl-108 HCO3-25 AnGap-11
[**2172-11-4**] 05:16AM BLOOD Glucose-93 UreaN-13 Creat-1.0 Na-139
K-4.1 Cl-107 HCO3-27 AnGap-9
[**2172-10-22**] 03:17AM BLOOD ALT-56* AST-45* LD(LDH)-282* CK(CPK)-141
AlkPhos-39 TotBili-0.8
[**2172-10-25**] 04:52AM BLOOD ALT-30 AST-30 LD(LDH)-304* AlkPhos-49
TotBili-0.9
[**2172-10-31**] 05:52AM BLOOD ALT-18 AST-27 LD(LDH)-335* AlkPhos-49
TotBili-0.4
[**2172-10-24**] 03:09AM BLOOD Lipase-22
[**2172-10-23**] 03:12AM BLOOD CK-MB-4 cTropnT-0.02*
[**2172-10-27**] 11:22AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2172-10-27**] 10:39PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2172-10-28**] 03:59AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2172-10-23**] 03:12AM BLOOD TotProt-4.0* Albumin-2.7* Globuln-1.3*
Calcium-8.6 Phos-2.9 Mg-1.7
[**2172-10-30**] 02:29PM BLOOD Calcium-9.1 Phos-2.1* Mg-1.8
[**2172-11-4**] 05:16AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.4
[**2172-10-22**] 03:17AM BLOOD calTIBC-234* VitB12-1205* Folate-15.9
Ferritn-23* TRF-180*
[**2172-10-23**] 03:12AM BLOOD PEP-NO SPECIFI
[**2172-10-27**] 05:20AM BLOOD Digoxin-1.0
[**2172-10-31**] 05:52AM BLOOD Digoxin-0.9
[**2172-10-23**] 09:00PM BLOOD Lactate-1.3
[**2172-10-27**] 09:47AM BLOOD Lactate-2.8*
[**2172-10-27**] 11:34AM BLOOD Lactate-1.8
[**2172-10-23**] 09:00PM BLOOD freeCa-1.13
.
.
IMAGING STUDIES:
ECHO [**2172-10-22**]: The left atrium is elongated. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION: Normal global biventricular systolic
function. Limited study.
.
CXR [**2172-10-22**] AP SEMI-UPRIGHT CHEST: There is a right internal
jugular central venous catheter whose tip extends into the right
atrium. This could be pulled back approximately 3 cm for
placement in the cavoatrial junction if desired. The lungs are
hyperinflated. There is no evidence of pulmonary edema. The
thoracic aorta is tortuous. The heart is enlarged. The osseous
structures demonstrate bilateral abnormalities of the shoulders
and proximal humerus, nonspecific, possibly relating to
neuropathic joint or prior trauma. Please correlate with history
and consider dedicated plain films. In the upper abdomen, note
is made of multiple clips as well as a linear structure possibly
represents an IVC filter.
.
CXR [**2172-10-23**] Since yesterday, right internal jugular catheter
still ends in the very low right atrium, could be pulled back 5
cm to end in the cavoatrial junction. Tortuosity of the aorta
and hyperinflation are unchanged. Old left rib fractures and
bilateral humeral deformities are stable. Cardiomegaly is mild
and unchanged. Volume overload increased. Small left pleural
effusion increased. Clips are in the abdomen. An IVC filter is
probably in place. There is no free air.
.
ABD Xray [**2172-10-23**] FINDINGS: Two supine views of the abdomen
reviewed. An upright chest radiograph obtained one hour
previously was also reviewed.
There is a nonobstructive bowel gas pattern without dilated
bowel loops or
air-fluid levels. Scattered phleboliths are seen in the pelvis.
No other
soft tissue calcifications. There are surgical clips in the left
upper
quadrant. An IVC filter is in place. Patient is status post
right hip
fracture with surgical hardware present. On recent chest
radiograph, there
was no free air seen under the diaphragms.
IMPRESSION: No free air. Non-obstructive bowel gas pattern
without
pneumatosis or bowel wall thickening.
.
CT ABD/PEL [**2172-10-23**] CT OF THE ABDOMEN WITHOUT IV CONTRAST:
IMPRESSION: Limited study.
1. No evidence of small-bowel obstruction or ileus.
2. New, small amount of free air adjacent to small bowel loops
in the left
upper quadrant, in the abscence of a recent procedure this is
concerning for local perforation. No extraluminal oral contrast
is noted.
3. Anasarca.
4. New bilateral small pleural effusions with associated
atelectasis.
5. Multiple compression fractures of the lower thoracic and
lumbar spines ofunknown chronicity.
.
BIL UE US [**2172-10-24**]: BILATERAL UPPER EXTREMITY DOPPLER
ULTRASOUND: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 493**] images were
obtained that demonstrate an occlusive thrombus in the right
subclavian vein. Acoustic windows were limited on this patient
given his right internal jugular catheter and other, so the
study was therefore limited. Flow is demonstrated in the distal
right subclavian vein and axillary vein but one of two brachial
veins demonstrates occlusive thrombus. On the right, the
basilic and cephalic veins compressed and appear normal. The
left internal jugular and axillary veins demonstrated normal
compressibility and wall-to-wall flow, however, the left
subclavian vein could not be imaged. A non-compressible thrombus
was demonstrated in one left brachial vein. The left cephalic
was visualized and appeared normal.
IMPRESSION: Occlusive thrombus in the right subclavian vein and
in one
brachial vein on each side.
.
ECHO [**2172-10-27**]: 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
aortic valve leaflets are moderately thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The tricuspid valve leaflets are mildly thickened.
The estimated pulmonary artery systolic pressure is normal.
IMPRESSION: Suboptimal image quality. Focused views. Normal
right ventricular size and function. Overall normal left
ventricular function.
Compared with the prior study (images reviewed) of [**2172-10-22**],
right ventricular size and function are similar. The images are
suboptimal for comparison.
.
CXR [**2172-10-17**] Since [**2172-10-23**], a right PICC was installed
with its tip in the distal [**Year (4 digits) 17911**]. Right internal jugular catheter
still ends in the low right atrium, should be pulled back 5 cm
for optimal placement.
In IVC filter and clips in the abdomen are unchanged. Tortuosity
of the aorta and hyperinflation are stable. Old left rib
fractures and deformity of both shoulders are also unchanged.
.
CTA-CHEST [**2172-10-27**] FINDINGS: Scattered bilateral small
subsegmental pulmonary emboli (in right lower lobe 3:47, 60, 68
and left upper lobe in 3:44). No evidence of right heart strain.
Scattered small peripheral parenchymal opacities, some patchy,
some ground-glass (probably representing infection) and some
nodular with wedge shape (probably representing infarction
areas), most prominent in the right upper lobe. Peripheral
atelectasis, septal thickening, bronchial wall thickening and
peribronchial nodularity are seen in lung bases. Enlarged lymph
nodes are seen in right hilum, AP window, bilateral lower
paratracheal stations. Small bilateral pleural effusions with
adjacent compressive atelectasis are more prominent on the left
side. Prominent ascending aorta. At the level of the pulmonary
artery bifurcation, ascending aorta measures 37 mm
and descending aorta measures 22 mm. Limited visualization of
abdominal organs reveal presence of small hypodense lesion in
right kidney, likely cyst. Multiple anterior wedge compression
fractures in the spine of indeterminate chronicity. Old
bilateral rib fractures and old deformities of both shoulders.
IMPRESSION:
1. Scattered bilateral small subsegmental pulmonary emboli, in
right lower
and left upper lobes..
2. Multiple peripheral parenchymal opacities that could
represent infection. The wedge-shaped consolidations probably
represent infarction, in right upper lobe.
.
ECG [**2172-10-22**] Atrial fibrillation with mean ventricular rate 92.
Marked precordial T wave inversion. No previous tracing
available for comparison.
.
ECG:[**2172-10-22**] Atrial fibrillation. Extensive ST-T wave changes in
the precordium and inferior leads may be due to myocardial
ischemia. Compared to the previous tracing of [**2172-10-22**] the ST-T
wave changes are actually somewhat improved.
.
Brief Hospital Course:
In summary, Mr. [**Known lastname **] is a 64 year old male with alcoholic
cirrhosis cirrhosis and atrial fibrillation, and hx of DVTs,
admitted with an upper GI bleed of unclear etiology.
.
#Upper GI bleed. Patient has history of alcoholic cirrhosis so
was started on octreotide drip. However, EGD [**2172-10-22**] showed
one cord of grade I varices and friabilitiy of anastamosis site
from prior bilroth surgery which was initially thought to be the
likely source of bleeding. He was initially on PPI drip, but
this was transitioned to IV PPI [**Hospital1 **]. He was evaluated by
surgery for possible surgical resection of bleeding site,
however, they felt him to be a poor surgical candidate given
multiple surgeries in the past. Hematocrits remained stable
after the initial 3 units of pRBCs transfused on [**2178-10-22**]/08.
Etiology of the bleeding is not clear as repeat EGD on [**2172-10-29**]
did not show any varices or bleeding or friability at the
anasamosis site. Hepatology/GI recommended a colonoscopy both to
look for source of bleeding and given pts apparent
hypercoaguability given hx of DVTs and current bilaterally upper
extremety DVTS. Colonoscopy was unremarkable. Hepatology
recommended outpatient follow up with a capsule study and not
restarting any coagulation until follow up given risk of
re-bleeding. Pt was schedule to have follow up at the [**Hospital1 18**]
Liver Center.
.
#Air in mesentery. Concern for microperforations, per surgery,
perhaps related to scope trauma from OSH EGD. Initailly with
abdomominal pain, though this has improved. Has been evaluated
by surgery who wanted conservative management given multiple
prior surgeries. He was made NPO and monitored with serial
abdominal exams. He was started on fluconazole and zosyn per
surgery. Pt completed an empiric 7 day course of antibiotics.
His abdominal pain resolved, and he has remained afebrile and
his WBC count has trended down.
.
#Pulmonary embolism. Pt was transferred back to the MICU after
an episode of chest pain, hypoxia, and tachicardia to the
160s-170s with bigeminy. Pt had no acute ST-T changes on EKG,
and CEs remained flat 0.05, down from 0.07 on admission. On CTA
chest, patient noted to have bilateral subsegmental PEs. He had
several episodes of A. fib with RVR likely secondary to PEs,
possibly related to his bilateral upper extremity DVTs. Given
patient's recent significant GI bleed, decision was made not to
anticoagulate unless patient was stable for more than two weeks.
An [**Hospital1 17911**] filter was placed. Patient had an IVC filter in place
prior to admission. An echo was performed and shows normal
right ventricular function. Since placement of [**Name (NI) 17911**] pt has had no
furthe episodes of RVR, chestpain or hypoxia. His O2 sats have
remained normal on room air.
.
# B/l upper extremity clots. Patient has significant clot
burden, making line placement difficult. Unable to
anticoagulate at present due to GIB. Cachexia, weight loss, and
extensive clot burden concerning for malignancy.
Anticoagulation was not initiated given ongoing GI bleed. An
[**Name (NI) 17911**] filter was placed when patient was found to have PEs. Pt
underwent colonoscopy which was normal. Patient will need
outpatient age appropriate cancer screening.
.
# Abdominal pain. Patient has chronic abdominal pain secondary
to pancreatitis, but with concern for microperforation as above.
On methadone and percocet at home for pain, which was held due
to microperforation. Abdominal pain resolved.
.
# Afib. Patient in A. fib. Initially managed at OSH on
diltiazem drip. Patient had a few episodes of A. fib with RVR
associated substernal chest pain and ST depressions on EKG,
concerning for rate related demand ischemia. He was started on
lopressor to improve HR control to avoid tachycardia. Patient
is not anticoagulated due to GI bleed. Echo was performed
during admission.
.
# Cirrhosis. Patient has well compensated alcoholic cirrhosis.
He was followed by liver. He was noted to have one band of
grade I varices on EGD on [**2172-10-22**], but none were noted on the
repeat EGD, on [**2172-10-29**]. He will have follow up with Liver
Center as an outpatient.
.
Medications on Admission:
(upon transfer from OSH):
diltiazem 120 mg daily
Pantoprazole PO 40 mg daily
methadone 5 mg Q8H
lasix 20 daily
digoxin 0.125 daily
Zosyn 4.5 g Q12H ([**10-18**] planned through [**10-23**])
Oxycodone 10 mg Q6H prn
morphine IV 2 mg prn
zofran 4 mg IV prn.
D5W with 40K at 70/hr
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for SSCP.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13990**] Health Care Center
Discharge Diagnosis:
Gastrointestinal bleeding
Deep vein thrombosis
Discharge Condition:
Stable for rehab/skilled nursing facility
ICD9 Codes: 2760, 4271, 5715, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4087
} | Medical Text: Admission Date: [**2103-1-10**] Discharge Date: [**2103-1-17**]
Date of Birth: [**2027-9-7**] Sex: F
Service: [**Doctor Last Name 1181**]/MEDICINE
CHIEF COMPLAINT: Shortness of breath, weakness.
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
white woman discharged from [**Hospital1 188**] one day prior to presentation. Previous discharge
summary is reviewing in extensive detail her past medical
history and previous hospital courses. The patient presented
one day following discharge complaining of increased
shortness of breath and weakness. She denied chest pain,
abdominal pain, headache, fevers, sweating, orthopnea and
paroxysmal nocturnal dyspnea. However, she did complain of
nonproductive cough, nausea, and some diarrhea.
PAST MEDICAL HISTORY: As reviewed in the OMR previously:
1. Hypertension.
2. Breast cancer, underwent lumpectomy and radiation
therapy.
3. Status post thyroid surgery.
4. Status post hysterectomy.
5. Neuropathy.
6. Coronary artery bypass graft surgery with mitral valve
repair. The coronary anatomy is reviewed in detail in the
OMR.
ALLERGIES: The patient is allergic to Penicillin which
causes a rash and Compazine which causes neurologic symptoms.
MEDICATIONS ON PRESENTATION:
1. Protonix 40 mg p.o. once daily.
2. Tylenol 325 mg as needed every four to six hours.
3. Sublingual Nitroglycerin although the patient states that
she does not take this medication regularly.
4. Amiodarone 400 mg p.o. daily.
5. Metoprolol 12.5 mg p.o. twice a day.
6. Ambien 5 mg p.o. as needed p.r.n. for sleep.
7. Hydralazine 50 mg four times a day.
8. Levothyroxine 125 mcg once daily.
9. Warfarin 2 mg Monday, Wednesday and Friday.
10. Levofloxacin 250 mg p.o. daily as prescribed on discharge
on [**2103-1-9**].
11. Metronidazole 500 mg p.o. three times a day, again
prescribed on discharge on [**2103-1-9**].
12. Fluoxetine 40 mg p.o. once daily.
13. Erythropoietin 4000 units Monday and Friday although the
patient does not take this medication regularly.
14. Clonazepam 0.5 mg p.o. three times a day as needed for
anxiety.
15. Lorazepam, the patient could not recall the dose, but she
also uses this second benzodiazepine occasionally for
anxiety.
FAMILY HISTORY: Significant for abdominal aortic aneurysm.
SOCIAL HISTORY: The patient as reviewed in previous OMR
notes has 24 hour nursing care. She has a remote history of
tobacco use. She does not drink alcohol.
PHYSICAL EXAMINATION: Vital signs - The patient had a heart
rate of 80, blood pressure 155/70, respiratory rate 22,
oxygen saturation 99% on two liters. Generally, the patient
is tired appearing, depressed in no acute distress. She was
alert and oriented times three. Head, eyes, ears, nose and
throat is normocephalic and atraumatic. Dry mucous
membranes. The pupils are equal, round, and reactive to
light and accommodation. Extraocular movements are intact.
Neck - jugular venous distention was seven centimeters. The
thyroid was not palpable. There was no carotid bruit. Heart
regular rate and rhythm, normal S1 and S2, no extra sounds.
Lungs - She had decreased breath sounds over the lower lung
fields bilaterally. She had dullness to percussion. Abdomen
- The patient had normal bowel sounds, soft, nontender,
nondistended. Liver edge and spleen were not palpated.
Extremities - She had trace bilateral lower extremity edema.
She had multiple hematomas.
LABORATORY DATA: White blood cell count was 8.7, hematocrit
30.0, platelet count 279,000. Sodium 134, potassium 3.6,
chloride 98, bicarbonate 21, blood urea nitrogen 27,
creatinine 1.7, glucose 94.
Electrocardiogram showed normal sinus rhythm, no acute
changes.
HOSPITAL COURSE:
Psychiatry - The patient was evaluated by the psychiatry
service and shown in OMR that her Clonazepam was
discontinued. There were no further psychiatric issues. The
other medications were not changed.
Cardiopulmonary - The patient had a chest x-ray showing a
small right sided pleural effusion and a left sided pleural
effusion. She was continued on her antibiotics as described
above. Specifically, she continued her Levofloxacin and
Metronidazole.
The patient's shortness of breath was initially attributed to
possible pulmonary embolism. The patient underwent computed
tomographic angiography after echocardiogram showed pulmonary
hypertension. After having this procedure, however, the
patient was found to not have pulmonary emboli, however, a
thoracic type B aortic dissection was noted distal to the
left subclavian artery extending four to five centimeters.
The patient was transferred to the Coronary Care Unit for
blood pressure management and evaluation by Cardiothoracic
Surgery. The patient was deemed a poor surgical candidate
and in consultation with her family, the patient opted
against having any intervention other than medical
management. While in the Coronary Care Unit, the patient
underwent thoracentesis which showed a mixed
transudative/exudative picture consistent with both
congestive heart failure and parapneumonic effusion. Her
breathing was much improved following the thoracentesis.
Renal - The patient initially presented with her baseline
creatinine of 1.5, however, she did have metabolic acidosis.
She received intravenous bicarbonate with moderate
correction. However, following the angiography, her
creatinine increased to slightly over 2.0. This worsening
function peaked at a creatinine of 2.1.
As stated above, the patient's shortness of breath resolved.
She was transferred to the medical floor following removal of
her central line. After titration of beta blockade in the
Coronary Care Unit, the patient was maintained on Labetalol
100 mg twice a day for a target blood pressure initially of
120 systolic, however, because of the patient's slightly
decreased renal function, the upper limit of the target was
set at 130 mmHg. The patient remained free of chest pain
while on the medical floor. As reviewed with her family
previously, the patient wished to have a DNR/DNI order
implemented as she will not be a surgical candidate and does
not want to be intubated or undergo any aggressive measures.
The patient was evaluated by the physical therapy service who
deemed it safe for her to go home provided that her home
physical therapy be continued. The patient will also receive
continuing visiting nurse care.
MEDICATIONS ON DISCHARGE:
1. Mirtazapine 15 mg p.o. in the evening as needed for
insomnia.
2. Calcium Carbonate one gram p.o. three times a day.
3. Metoclopramide 10 mg every six hours.
4. Labetalol 100 mg p.o. twice a day.
5. Erythropoietin 4000 units subcutaneous every Monday and
Wednesday.
6. Lorazepam 0.5 to 1.0 mg every four to six hours as needed
for nausea.
7. Pantoprazole 40 mg q24hours.
8. Amiodarone 400 mg p.o. daily.
9. Levothyroxine 125 mcg daily.
10. Nitroglycerin sublingual tablets 0.3 mg every five
minutes as needed for pain times three.
11. Acetaminophen 325 mg p.o. q4-6hours as needed for pain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Name8 (MD) 7102**]
MEDQUIST36
D: [**2103-1-17**] 16:18
T: [**2103-1-17**] 16:59
JOB#: [**Job Number 100141**]
ICD9 Codes: 5119, 4280, 2762, 5849, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4088
} | Medical Text: Admission Date: [**2159-8-17**] Discharge Date: [**2159-8-17**]
Date of Birth: [**2109-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodixanol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
? ruptured pseudoaneurysm
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 53636**] is a 50 y/o s/p type A dissection repair in [**2151**]
with complicated post op course, multiple bowel surgeries and
most recently very resistent chronic VRE BSI since [**5-/2158**] who
has been off and on palliative antibiotics. He was admitted to
[**Hospital1 18**] [**7-30**] w/pre-syncope, found to have positive blood cultures
for VRE sensitive only to daptomycin, and was found to have a
pulsitile mass on his chest wall that was found to be likely a
partially thrombosed pseudoaneurysm in the right presternal
location measuring 2.7x7cm, the inferior aspect closely
associated with the ascending aorta and demonstrates an apparent
tract which was present 2/[**2158**]. At the time, the patient
refused surgical intervention. The patient reports that the
pulsatile mass has been growing in size over the last couple of
weeks and became
tender and burst tonight draining moderate amout of foul
smelling bloody fluid.
Past Medical History:
MRSA, VRE colonization
++ Type A acute aortic arch dissection, admit [**10/2152**]/[**2152**]
- suspected secondary to cocaine use
- multiple post-operative cardiac arrests
- femoral-femoral artery bypass
- subsequent CVA (watershed infarcts) --> bilateral occiptal
infarcts, optic neuropathy, blindness
- bowel ischemia s/p right hemicolectomy and ileostomy
* ileostomy reversal [**10/2154**]
* ileocolonic anastomosis resection (wound dehiscence)
* end ileostomy [**12/2153**]
* Bowel perforation on attempted ileostomy takedown in [**2154**]
* Colostomy takedown, lysis of adhesions, hernia repair,
wound revision, ileocolonic anastomosis resection, end
ileostomy,
fascial closure, VAC placement (continues with colostomy) [**3-/2157**]
- renal ischemia
* renal artery stent placement (L, [**3-/2154**])
* mid-ureteral stone --> L ureteral stent (fall/[**2153**])
* ARF due to L stone --> L percut nephrostomy tube ([**12/2154**])
- liver necrosis (>75%)
- tracheostomy --> hemoptysis (trach since removed)
- MRSA pneumonia
- VRE wound infection and bacteremia (coccyx/occipital decub
ulcer)
++ C. diff toxin in stool ([**12/2152**])
++ Klebsiella bacteriuria (early [**2155**])
++ Enterococcal bacteremia, [**1-/2156**] --> Daptomycin x6wks
++ Enterococcal bacteremia, [**3-/2156**]
++ VRE.faecium endocarditis, [**5-/2157**] and [**5-/2158**]
- tx: daptomycin x6 weeks
++ Klebsiella, Pseudomonal bacteriuria ([**5-/2157**])
- tx: ciprofloxacin x8d
++ Hypertension
++ hyperlipidemia
++ Chronic kidney disease
- prior ureteral stent
- renal artery stenting
++ Anemia
++ Myoclonus
++ aortic regurgitation with dilated LV
++ depression
Social History:
On disability currently, used to work for Caterpillar as
mechanic. Lives alone, his children visit during the weekends.
Lives in [**Location 4047**]. Denies tobacco or drug use currently. ~2
drinks/month Past history of cocaine use, precipitating aortic
dissection.
Family History:
Adopted, no history of immediate family known.
Physical Exam:
Admission Physical Exam
Temp 101.3 Pulse:73 regular Resp: 18 O2 sat: 97 on RA
B/P Right:113/58 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
[**Location 4459**]: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Murmur [**3-6**] holosystolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] ileostomy pink, large healed abdominal wall defect
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: blind R eye, otherwise grosely intact
Pulses:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
upper mid sternum 1cm opening in skin, area non pulsitile but
w/palpable thrill, draining turbid/murky bloody fluid, 2-3 cm
surrounding w/fluctuance, able to express same murky fluid.
Labs:
10.5 >----<303
22.5(21 on [**8-15**]-transfused 1u PRBC)
PT:12.9 PTT: 27.5 INR:1.1
130 106 26
----I----I----<105
4.5 16 2.4
U/A:negative
Impression:50 yo s/p type A disection repair [**2151**] w/long
standing
VRE bacteremia and recent development of pulsitile mass on chest
wall which was thought to be a partially thrombosed
pseudoaneurysm of the aorta, began draining tonight.
Plan:Need contrast study of aorta to define pseudoaneurysm.
Will
need pre contrast hydration, pre-medication vs tagged red cell
scan due to chronic kidney disease and contrast allergy
Non contrast CT scan tonight.
continue antihypertensives
NPO until plan established
FEEN:gentle hydration D5W w/150mEq bicarb at 75cc/hr
heme:transfuse 1u PRBC
continue daptomycin-consult ID in am
code status:pt wishes to be DNR/DNI
Pertinent Results:
[**2159-8-17**] 03:59AM BLOOD WBC-8.2 RBC-2.83* Hgb-7.5* Hct-22.4*
MCV-79* MCH-26.6* MCHC-33.6 RDW-16.8* Plt Ct-282
[**2159-8-16**] 10:10PM BLOOD WBC-10.5 RBC-2.85* Hgb-7.5* Hct-22.5*
MCV-79* MCH-26.2* MCHC-33.3 RDW-16.7* Plt Ct-303
[**2159-8-17**] 03:59AM BLOOD Neuts-77.5* Lymphs-16.2* Monos-2.7
Eos-2.5 Baso-1.2
[**2159-8-16**] 10:10PM BLOOD Neuts-81.1* Lymphs-13.4* Monos-2.9
Eos-1.8 Baso-0.9
[**2159-8-17**] 03:59AM BLOOD PT-12.8 PTT-27.2 INR(PT)-1.1
[**2159-8-16**] 10:10PM BLOOD PT-12.9 PTT-27.5 INR(PT)-1.1
[**2159-8-17**] 03:59AM BLOOD Glucose-98 UreaN-24* Creat-2.4* Na-135
K-4.3 Cl-109* HCO3-17* AnGap-13
[**2159-8-16**] 10:10PM BLOOD Glucose-105* UreaN-26* Creat-2.4* Na-130*
K-4.5 Cl-106 HCO3-16* AnGap-13
[**Known lastname **],[**Known firstname **] [**Medical Record Number 53647**] M 50 [**2109-7-17**]
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2159-8-17**]
2:06 AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2159-8-17**] 2:06 AM
CT CHEST W/O CONTRAST Clip # [**Clip Number (Radiology) 53652**]
Reason: eval for pseudoaneurysm
Field of view: 38
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with cocern for ruptured aortic
pseudoaneurysm
REASON FOR THIS EXAMINATION:
eval for pseudoaneurysm
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: DLrc FRI [**2159-8-17**] 4:07 AM
1. Interval decrease in size of right presternal anterior chest
wall
low-attenuation fluid collection compatible with clinically
known rupture.
There is still low-attenuation fluid that is seen tracking
posteriorly with a
neck immediately adjacent to the ascending thoracic aorta.
Overall, the
appearance within the mediastinum of this region is stable since
[**2159-7-31**].
The differential still includes the possibility of
pseudoaneurysm formation or
infection.
2. Stable 4-mm right lower lobe pulmonary nodule.
3. Bibasilar atelectasis. New nodular density in the left upper
lobe, seen
perifissurally, that is non-specific.
4. Stable cardiomegaly.
5. Right PICC now in right atrium.
Wet Read Audit # 1 DLrc FRI [**2159-8-17**] 2:37 AM
Collection has now decreased in size compatible with clinically
known rupture
with overall stable appearance of soft tissue density in the
anterior chest
wall which tracks posteriorly immediately adjacent to the aorta
as has been
described previously. New right dependent atelectasis and
nodular
opacification, likely atelectasis though infection is not
excluded.
Wet Read Audit # 2 DLrc FRI [**2159-8-17**] 3:07 AM
Collection has now decreased in size compatible with clinically
known rupture
with overall stable appearance of soft tissue density in the
anterior chest
wall which tracks posteriorly immediately adjacent to the aorta
as has been
described previously. New right dependent atelectasis and
nodular
opacification, likely atelectasis though infection is not
excluded.
Right PICC now in right atrium.
Final Report
INDICATION: Patient is a 50-year-old male with concern for
ruptured aortic
pseudoaneurysm. Evaluate for pseudoaneurysm.
EXAMINATION: NON-CONTRAST CHEST CT.
COMPARISONS: [**2159-7-31**] and [**2159-1-11**].
TECHNIQUE: Helically acquired axial images were obtained from
the thoracic
inlet to the mid abdomen without the administration of oral or
intravenous
contrast. Coronal and sagittal reformations are provided for
review.
Intravenous contrast was contraindicated secondary to chronic
renal
sufficiency and documented allergy to both iodine and gadolinium
contrast
agents.
FINDINGS:
CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST:
Since the most recent prior chest CT from [**2159-7-31**], the
anterior chest wall
low-attenuation collection in the right presternal space has now
decreased in
extent, compatible with clinically known rupture of collection.
This
low-attenuation collection now is in direct contiguity with the
skin (2:25).
Low-attenuation components continue to track posteriorly (2:26),
with a tract
or neck seen that enters the anterior mediastinum to the middle
mediastinum
adjacent to the right aspect of the sternum. This tract is
intimately
associated with the ascending aorta. Overall, the configuration
of the
posterior aspect are unchanged since examination from [**2159-7-31**].
Redemonstrated are postsurgical changes from the ascending
aortic repair with
the presence of a graft noted. The main pulmonary trunk is
enlarged measuring
up to 3.4 cm. There is stable cardiomegaly. A right approach
PICC is now
terminating within the right atrium.
There is no axillary, mediastinal, or hilar lymphadenopathy,
with a stably
prominent mediastinal lymph node in a pretracheal station
demonstrating a
fatty hilum. The central airways are patent to the subsegmental
levels.
There is dependent bilateral atelectasis with increase in
atelectasis
involving the left hemithorax. A right lower lobe 4-mm pulmonary
nodule
(series 2:26) is stable. There is a new 5 x 10-mm pulmonary
nodular density
seen perifissurally along the left upper lobe, likely
atelectasis. There are
trace bilateral pleural effusions.
This examination is not tailored for subdiaphragmatic
evaluation. The
partially imaged upper abdomen redemonstrates extensive [**Year (4 digits) 1106**]
calcification, multiple splenules in the left upper quadrant,
and an atrophic
right kidney with dystrophic parenchymal calcification.
BONE WINDOWS: The visualized osseous structures are unremarkable
with no new
suspicious lytic or sclerotic foci.
IMPRESSION:
1. Interval decrease in size of right presternal anterior chest
wall
low-attenuation fluid collection compatible with clinically
known rupture of
collection. There is still low-attenuation fluid that is seen
tracking
posteriorly immediately adjacent to the ascending thoracic
aorta. Overall,
the appearance within the mediastinum of this region is stable
since
[**2159-7-31**].
2. Stable 4-mm right lower lobe pulmonary nodule.
3. Bibasilar atelectasis and bilateral trace effusions.
4. Stable cardiomegaly.
5. Right PICC now in right atrium.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] LI
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2159-8-17**] 8:39 AM
Imaging Lab
Brief Hospital Course:
50 yo s/p type A disection repair [**2151**] w/long standing VRE
bacteremia and recent development of pulsitile mass on chest
wall which was thought to be a partially thrombosed
pseudoaneurysm of the aorta, began draining [**2159-8-16**]. He was
transferred to [**Hospital1 18**] for further evaluation. Chest contrast
study of aorta to define pseudoaneurysm was performed. Pre
contrast hydration was initiated with IV Bicarbonate for
possible CT scan with contrast vs tagged red cell scan due to
chronic kidney disease and contrast allergy .Non contrast CT
scan performed.
This patient is well known to Dr.[**Last Name (STitle) 914**] and the cardiac
surgical service. About a year ago he went over Mr. [**Known lastname 53653**]
options which basically included chronic suppressive antibiotic
treatment for his chronic graft infection/endocarditis vs redo
surgery which would involve replacement of all prosthetic
material (graft from
sinotubular junction to include the total aortic arch) plus AVR
or more likely full Bentall procedure which would most likely
entail a prolonged hospital stay and likely lead to chronic
hemodialysis postoperatively. Approximately one year ago, an
ethics consult and a long family meeting with ID and cardiac
surgery presented to discuss these options and he chose to
pursue
suppressive antibiotic therapy and was adamant about not
pursuing surgery. Dr.[**Last Name (STitle) 914**] was in agreement with that
decision as he felt he had a good understanding of the
morbidity/mortality associated with the surgery and he actually
has done quite well with this plan until his antibiotics were
discontinued
approximatley 3-4 weeks ago. This most likely allowed the
chronic well controlled infection to flair up and produce his
symptoms. His options are no different now and Dr.[**Last Name (STitle) 914**]
reiterated them to the patient and his sister, [**Name (NI) **], and they
again do not wish to proceed with surgery. He is very aware
that his infected
aortic graft/pseudoaneurysm may rutpure at any point producing
almost certain death and still does not want to pursue surgery.
ID was reconsulted for their recomendations regarding
suppressive antibiotic therapy. [**2159-8-17**] Pt was cleared for
discharge back to Twin Oaks Rehabilitative Care for further
management. Follow up appointments were advised.
Medications on Admission:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. Labetalol 200 mg Tablet Sig: 2.5 Tablets PO TID (3 times a
day).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash,itch.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
13. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO QID
(4 times a day).
14. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q48H (every 48 hours).
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
5. Labetalol 200 mg Tablet Sig: 2.5 Tablets PO TID (3 times a
day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Daptomycin 500 mg Recon Soln Sig: 680 mg Intravenous Q48H
(every 48 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - Twin Oaks - [**Location (un) 4047**]
Discharge Diagnosis:
Infected Aortic graft and native Aortic valve endocarditis (VRE)
s/p emergent Aortic Dissection repair in [**2151**].Probable fistula
from graft to presternal area.
Chronic kidney disease
Discharge Condition:
Alert & oreinted, NAD
stable
Discharge Instructions:
-Resume preadmission care.
-While hospitalized your IV antibiotics were restarted to treat
the chronic infection you have in your blood stream and on
your heart valves in hopes this will improve symptoms for a
short time.Antibiotics are palliative, not curative.
Unfortunately surgery, which isn't a viable option, is the only
option to completely eradicate infection.
-Sternal wound incision: NS wet->dry [**Hospital1 **] for life
Followup Instructions:
Per Dr.[**Last Name (STitle) 914**], no follow up with cardiac surgery necessary.
Followup Instructions:
Weekly CBC with dirreferntial/BUN/Cr/CPK results to be FAXED to
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12081**] (Infectious Disease) FAX#[**Telephone/Fax (1) 432**]
Follow UP :
Department: INFECTIOUS DISEASE
When: FRIDAY [**2159-8-31**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2159-9-13**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2159-8-17**]
ICD9 Codes: 5859, 4241, 2859, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4089
} | Medical Text: Admission Date: [**2145-10-22**] Discharge Date: [**2145-10-24**]
Date of Birth: [**2070-1-17**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Left Flank Pain
Major Surgical or Invasive Procedure:
Percutaneous Nephrostomy Tube Placement
History of Present Illness:
75 year old female with history of right staghorn calculi, colon
cancer, and hyptertension, who presented to her PCP 2 days prior
to admission with complaints of left flank pain, chills, and
decreased urine output for 3 days. Pt was started on cipro and
flagyl for presumed diverticulitis. When WBC returned high, the
patient was sent for outpatient CT scan which revealed new left
6mm obstructing stone at the urovesicular junction with mild
hydronephrosis, ureteral dilation, and perinephric stranding.
Pt was subsequently sent to [**Hospital 882**] Hospital where she was
found to have WBC 27.8, Creat 3.4, and UA with 100 WBC, + heme,
+leuk esterases. At the time her BP was 88/43 after 3L of IVF
and pt was started on dopamine and transferred to [**Hospital1 18**] and
urology team was consulted.
Past Medical History:
1. R Staghorn nephrolithiasis for 20years on ampicillin
prophylaxis and now atrophic
2. Colon CA s/p resection '[**40**]
3. Tonsillectomy
4. HTN
5. Diverticulitis
6. h/o EtOH abuse
Social History:
Pt lives with husband [**Name (NI) **] [**Telephone/Fax (1) 33105**]. Pt has 2 children
and 4 grand children. Has a remote hx of smoking (20pack years
but quit 20 years previous) and hx of EtOH abuse. She quit
drinking 9 years previous.
Family History:
NC
Physical Exam:
Physical Exam:
VS: Tc: 98.8 HR: 88 BP: 115/60 RR: 12 SaO2: 98%
on 2L NC
Gen: pleasant female lying in bed in NAD. Conversing in full
sentences and interacting appropriately.
HEENT: PERRL, EOMI, mmm
CV: RRR, S1, S2, no murmurs, rubs, gallops
Chest: CTA bilaterally
Abd: soft, NT, ND, BS+
Back: no CVA tenderness
Ext: warm, well perfused, no clubbing, cyanosis, edema
Neuro: A+O x3.
Pertinent Results:
CXR [**2145-10-22**] 12:03 AM:
1) Cardiomegaly and minor left basilar atelectatic changes.
2) Hiatal hernia.
.
[**2145-10-24**] 05:49AM BLOOD WBC-9.1 RBC-3.08* Hgb-8.9* Hct-27.3*
MCV-89 MCH-28.8 MCHC-32.6 RDW-17.9* Plt Ct-184
[**2145-10-23**] 10:32PM BLOOD Hct-26.3*
[**2145-10-23**] 04:00AM BLOOD WBC-12.9* RBC-2.93* Hgb-8.4* Hct-26.2*
MCV-89 MCH-28.8 MCHC-32.3 RDW-18.1* Plt Ct-177
[**2145-10-22**] 05:38AM BLOOD WBC-19.7* RBC-3.35* Hgb-9.7* Hct-29.7*
MCV-89 MCH-28.9 MCHC-32.6 RDW-17.6* Plt Ct-225
[**2145-10-21**] 11:40PM BLOOD WBC-25.7* RBC-3.55* Hgb-10.3* Hct-31.0*
MCV-87 MCH-29.1 MCHC-33.3 RDW-16.6* Plt Ct-206
[**2145-10-24**] 05:49AM BLOOD Neuts-67.2 Lymphs-25.0 Monos-4.3 Eos-2.8
Baso-0.7
[**2145-10-23**] 04:00AM BLOOD Neuts-84.3* Bands-0 Lymphs-11.7*
Monos-2.3 Eos-1.5 Baso-0.3
[**2145-10-22**] 05:38AM BLOOD Neuts-91.1* Bands-0 Lymphs-6.6* Monos-2.0
Eos-0.2 Baso-0.1
[**2145-10-21**] 11:40PM BLOOD Neuts-84* Bands-6* Lymphs-7* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2145-10-22**] 05:38AM BLOOD PT-13.9* PTT-28.6 INR(PT)-1.2
[**2145-10-21**] 11:40PM BLOOD PT-14.4* PTT-23.5 INR(PT)-1.3
[**2145-10-24**] 05:49AM BLOOD Glucose-90 UreaN-17 Creat-0.8 Na-139
K-3.4 Cl-109* HCO3-25 AnGap-8
[**2145-10-23**] 10:32PM BLOOD Glucose-90 UreaN-20 Creat-0.8 Na-139
K-3.5 Cl-109* HCO3-24 AnGap-10
[**2145-10-23**] 04:00AM BLOOD Glucose-87 UreaN-26* Creat-1.0 Na-142
K-3.1* Cl-113* HCO3-23 AnGap-9
[**2145-10-22**] 05:38AM BLOOD Glucose-108* UreaN-48* Creat-1.6* Na-142
K-3.5 Cl-111* HCO3-20* AnGap-15
[**2145-10-21**] 11:40PM BLOOD Glucose-85 UreaN-54* Creat-2.0* Na-141
K-2.7* Cl-109* HCO3-15* AnGap-20
[**2145-10-24**] 05:49AM BLOOD Calcium-8.4 Phos-2.1* Mg-1.5*
[**2145-10-23**] 10:32PM BLOOD Calcium-8.2* Phos-1.7* Mg-1.6
[**2145-10-23**] 04:00AM BLOOD Calcium-7.9* Phos-2.0*# Mg-1.5* Iron-14*
[**2145-10-22**] 05:38AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.8
[**2145-10-21**] 11:40PM BLOOD Calcium-7.3* Phos-3.6 Mg-1.6
[**2145-10-23**] 04:00AM BLOOD calTIBC-183* Ferritn-136 TRF-141*
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2145-10-24**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
URINE CULTURE (Final [**2145-10-23**]): NO GROWTH.
AEROBIC BOTTLE (Final [**2145-10-28**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2145-10-28**]): NO GROWTH.
.
[**Numeric Identifier 33106**] INTRO CATH OR STENT INTO URETHER [**2145-10-22**] 10:20 AM
Reason: Please place nephrostomy tube
Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with L obstructive UVJ stone, renal failure,
and urosepisis
REASON FOR THIS EXAMINATION:
Please place nephrostomy tube
HISTORY: A 75-year-old female with urosepsis, ureteral stone,
and need for decompression of the renal collecting system.
PROCEDURE/FINDINGS: The procedure was performed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]. Dr. [**Last Name (STitle) **], the staff radiologist,
was present and supervising throughout. After the risks and
benefits of the procedure were discussed with the patient and
informed consent was obtained, the patient was placed prone on
the angiography table. Her left flank was prepped and draped in
the standard sterile fashion. 400 mg of intravenous
Ciprofloxicin was administered. The skin and subcutaneous
tissues in the left flank region were anesthetized with 10 cc of
1% Lidocaine. Using ultrasound guidance, attempts were made to
advance a 22-gauge Chiba needle into a posterior lower pole
calyx. After several attempts, however, this proved
unsuccessful. The patient was then given 40 cc of 60% Optiray
intravenously. Using fluoroscopy, a new 22-gauge Chiba needle
was advanced through an anesthetized region in the left flank
into an opacified middle pole calyx. After the stylet was
removed, urine was aspirated confirming our position within the
renal collecting system. The urine sample was sent for culture.
An antegrade nephrostogram was then performed via hand injection
of nonionic contrast. This revealed a mildly dilated collecting
system with complete obstruction identified at the level of the
distal ureter. A .018 guide wire was advanced through the Chiba
needle into the proximal ureter under fluoroscopic
visualization. The skin entry site was incised with a #11 blade
scalpel. The access needle was exchanged for a 6-French
Accustick sheath with inner dilator and metallic stiffener. Upon
entry into the renal parenchyma, the metallic stiffener was
removed. The Accustick sheath and inner dilator were advanced
over the wire until the tip was positioned in the proximal
ureter. The guide wire and inner dilator were removed. A .035
[**Last Name (un) 33107**] wire was then advanced through the Accustick sheath into
the distal ureter. The [**Last Name (un) 33107**] wire could not be advanced beyond
the area of obstruction into the bladder. At this time, the
Accustick sheath was exchanged for a 6-French 23 cm bright-tip
angiographic sheath. With the sheath tip positioned in the
proximal ureter, a 5-French Kumpe catheter was advanced through
the angiographic sheath into the distal ureter. Using the
[**Last Name (un) 33107**] wire, attempts were made to traverse the area of
obstruction. Again, this was unsuccessful and the [**Last Name (un) 33107**] wire
was exchanged for a .035 angled glidewire.
Using this wire, in combination with the 5-French Kumpe
catheter, the area of obstruction was successfully passed. With
the glidewire positioned in the bladder, beyond the area of
obstruction, the Kumpe catheter was exchanged for a 5-French
vertebral catheter. The glidewire was then exchanged for a .035
super-stiff Amplatz wire. At this time, the vertebral catheter
and 6-French angiographic sheath were removed. An 8-French 24 cm
internal/external nephroureteral stent was then advanced over
the Amplatz wire into the bladder. The super-stiff Amplatz wire
was removed. The catheter pigtails were formed and locked in the
bladder and in the right renal pelvis. A hand injection of
nonionic contrast confirmed the appropriate positioning of the
nephroureteral stent. The catheter was secured to the skin using
a #0 silk suture. A Stat- Lock device was applied, followed by a
dry sterile dressing. The catheter was placed to external bag
drainage and may be capped in approximately 24 hours.
COMPLICATIONS: None.
MEDICATIONS: 1% Lidocaine. 400 mg intravenous Ciprofloxicin. 2
mg of Versed and 100 mcg of Fentanyl were administered in
intermittent doses with continuous monitoring of vital signs by
the nursing staff.
CONTRAST: 90 cc of 60% Optiray.
IMPRESSION:
1. Antegrade nephrostogram revealed mild left hydronephrosis
with a complete obstruction identified at the level of the
distal ureter, secondary to stone presence.
2. Successful placement of a 24 cm 8 French internal/external
nephroureteral stent via a left posterior middle pole calyx. The
catheter has side holes extending throughout its length and was
placed to external bag drainage. The catheter may be capped for
internal drainage in approximately 24 hours.
Brief Hospital Course:
75 year old female with right staghorn calculi for >20 years and
new left obstructing calculi with hydronephrosis, ureteral
dilation and perinephric stranding associated with increasedd
WBC count, tachycardia, hypotension refractory to fluids and
increased creatinine.
.
1. Sepsis: Although pt has no fever and no tachypnea, pt does
have an elevated white count, with tachycardia as well as a
positive UA suggesting pylonephritis and urosepsis.
.
A). Source was most likely urosepsis with positive UA, and
obstructing stone by CT scan. She was treated with broad
spectrum antibiotics with cefepime and cipro. Urology was
already consulted as was IR. A percutaneous nephrostomy tube was
placed [**10-22**] by IR with resultant good urine output.
.
B). Hemodynamics: Pt had hypotension temporarily requiring
pressors and IVF to bring up CVP. Pressors were successfully
weaned. She had been mentating appropriately suggesting mental
status would be an appropriate measure.
.
2. Acute Renal Failure: It was secondary to obstructive stone
lesion (pt already with atrophic R kidney, now presenting with
obstructive lesion in L kidney). No history of renal
insufficiency as per patient. The percutaneous nephrostomy tube
was placed and the patient's creatinine improved with fluid
hydration.
.
3. Anemia of chronic decrease with decreased hematocrit over
past 9 months (HCT 36 in [**1-6**])plus possible blood loss from
nephrostomy stent placement and IVF this admission. The patient
has a history of colon cancer with a normal colonoscopy last
year. Iron studies were normal and the patient was guaiac
negative.
.
4. Hypertension was controlled on metoprolol.
.
The patient was discharged in good condition with follow up in
urology clinic with Dr. [**Last Name (STitle) 9125**] [**Telephone/Fax (1) **]. She was restarted on
prophylactic amoxicillin as an outpatient.
Medications on Admission:
1. ASA 81mg once daily
2. Atenolol 25mg once daily
3. Amoxicillin 250mg once daily
4. MVI
5. Recent cipro/flagyl
.
All: sulfa -> jaundice
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 6 days.
Disp:*20 Tablet(s)* Refills:*0*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
7. Amoxicillin 250 mg Capsule Sig: One (1) Capsule PO once a
day: Start amoxicillin after finished taking the final 10 days
of the ciprofloxacin.
8. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO three times a
day for 2 weeks: start after completion of ciprofloxacin course.
Take 2 hours before or 2 hours after antacid therapy.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
nephrolithiasis with secondary hydronephrosis
septic shock
pyelonephritis
iron deficiency anemia
ARF
secondary:
h/o R Staghorn nephrolithiasis for 20 years on ampicillin
prophylaxis and now atrophic
Colon CA s/p resection '[**40**]
Tonsillectomy
HTN
Diverticulitis
h/o EtOH abuse
Discharge Condition:
stable, tolerating oral diet, afebrile, ambulating without
difficulty
Discharge Instructions:
Continue with prior outpatient medications. Continue with
Ciprofloxacin to complete a total of 14 days and then resume
your regular dose of amoxicillin. Notify your doctor in case of
recurrent nausea, abdominal pain, blood in stools, diarrhea,
fevers, back pain, or blood in your urine. Call your doctor or
return to the ED in case of recurrent fevers, increasing or
decreasing urine output, change in color/quality/odor of the
nephrostomy urine, or pain with urination.
Please call Dr. [**Last Name (STitle) **] tomorrow and arrange to go to the laboratory
for follow up testing of your chemistry panel, calcium,
magnesium, and blood counts and phosphorous in the next two days
and see Dr. [**Last Name (STitle) **] this week. Start iron supplementation for iron
deficiency anemia after completion of ciprofloxacin course.
Followup Instructions:
Schedule follow up with Dr. [**Last Name (STitle) **] in Urology this week. Call
tomorrow to schedule an appointment.
Follow up with Dr. [**Last Name (STitle) **] this week. Call tomorrow to arrange for
laboratory testing: chemistry panel, calcium, magnesium, blood
counts and phosphorous before your appointment.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 0389, 5849, 5990, 2762, 2859, 2768, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4090
} | Medical Text: Admission Date: [**2148-2-23**] Discharge Date: [**2148-2-27**]
Date of Birth: [**2079-1-15**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
Bilateral knee pain
Major Surgical or Invasive Procedure:
Bilateral total knee arthroplasty
History of Present Illness:
Mr. [**Known lastname 12303**] has had end stage degenerative joint
disease of both knees. He presents for definitive treatment.
Past Medical History:
OA
Family History:
NC
Physical Exam:
Gen-Alert/oriented, NAD
VS- 100.5, 140/70, 80, 20, 96%RA
CV-RRR
Lungs-CTA bilat
Abd-soft NT/ND
Ext-Bilat knees:incision clean/dry/intact, without evidence of
infection, +[**Last Name (un) 938**]/FHL/AT, +DPP, +sensation. Bilaterally
Pertinent Results:
[**2148-2-23**] 06:03PM GLUCOSE-125* UREA N-19 CREAT-0.9 SODIUM-142
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-24 ANION GAP-16
[**2148-2-23**] 06:03PM WBC-14.5*# RBC-3.45* HGB-11.2* HCT-33.4*
MCV-97 MCH-32.5* MCHC-33.6 RDW-13.7
Brief Hospital Course:
Patient was admitted on [**2148-2-23**] for elective total knee
arthroplasty. Consent and medical clearance was obtained prior
to surgery. Surgery went without complications, please see
op-note. Patient had an epidural placed prior to surgery for
pain control. Post-op patient was transferred to the unit for
observation, patient was hypotensive post-op to 120-83/78-46.
HCt had dropped from 39-33. Patient was given 2units and taken
to the unit for observation. Patient was stabalized and
transferred to the orthopedic floor on [**2148-2-24**] without events.
Epidurad was d/c'ed [**2-24**] and lovenox was started for
anti-coagulation. Patient continued to progress. Pain remained
controlled with oral pain medication. Patient did have low grade
temp on [**2-25**] UA/cxr/wound check were all negative. Patient also
had hct drop to 23 on [**2148-2-26**] but was stable. Patient was
transfused 2 units PRBC. Patient remained stable asymptomatic.
Patient continued to progress. Patient was discharged in stable
condition.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once
a day for 2 weeks.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Center
Discharge Diagnosis:
Bilateral knee osteoarthritis
Discharge Condition:
stable
Discharge Instructions:
Please cont with weight bearing as tolerated bilateral legs.
Range of motion as tolerated. Oral pain medication as needed.
Lovenox for anti-coagulation x2weeks. Cont with physical
therapy. Please call/return if any fevers, increased discharge
from incision, or trouble breathing.
Physical Therapy:
Activity: Ambulate
Knee immobilizer: while in bed PROM 0-60 degrees every two hours
alternating between legs / at night knee immobilizers / WBAT
Treatments Frequency:
-[**Month (only) 116**] leave incision open to air.
-Please do not soak or scrub incision. Please pat incision dry
after getting wet.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1113**]
Date/Time:[**2148-3-1**] 11:10
Completed by:[**2148-2-27**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4091
} | Medical Text: Admission Date: [**2182-9-6**] Discharge Date: [**2182-9-10**]
Date of Birth: [**2111-6-19**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Rifampin
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Fever, malaise.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 65215**] is a 71 year old male nursing home resident with a
history of C6 fracture, recent admission for urosepsis, VRE
infection, MRSA wound infection, DVTs, pulmonary embolus,
urinary retention with chronic indwelling foley, CAD s/p CABG,
diastolic CHF, diabetes, and hypertension. Taken to ED from
nursing home after one day history of fever, lethargy--noted at
NH to be hypoxic with O2 sat 87 on room air. On presentation to
[**Name (NI) **], pt febrile to 102, HR 100-110, BP in low 90's, RR 22 with O2
sat 92-95 on 4L NC. Initial ABG 7.48/31/77, lactate 2.1. Given
1 L fluid bolus with brief normalization of pressure but then
SBP to 90's again. Lactate 3.4, CBC revealed WBC of 24.3 with
8 bands. Pt given 1 g cefepime, rebolused with fluids, and
received central line. Started on levophed. Subsequent lactate
to 1.5. Repeat WBC 18.1 with no bands. Repeat ABG 7.37/39/100.
Pt transferred to MICU for further managmement.
.
Of note, the patient had an [**8-2**] admission for UTI with sepsis:
Mr.
[**Name13 (STitle) **] was started empirically on Linezolid, Ceftazidime, and Flagly
based on his history of multi drug resistant infections and
urine culture grew pseudomonas and E. coli which was only
intermediately susceptible to ceftazidime. He was started on
Meropenem with satisfactory result.
Past Medical History:
1. MDR E. Coli and Pseudomonal Catheter Associated Sepsis/UTI
2. Acute Renal Failure.
3. Urinary Retention.
4. Meatal Tear.
5. Traumatic Comminuted C7 Verterbral Fracture [**2182-1-2**]
6. ORIF/Laminectomy/Instrumentation/Posterior Fusion [**2182-1-23**]
7. CSF Leak - Wound infection s/p drainage and dural repair
[**2182-2-9**]
8. Incision and drainage and hardware exchange [**2181-2-12**]
9. MRSA Meningitis/MRSA Pneumonia
10. Diastolic Heart Failure.
11. Non-ST Elevation Myocardial Infarction
12. Coronary Artery Disease s/p CABG x 3
13. Left Occipital Stroke vs MRSA Cerebritis
14. Pulmonary Embolism/RLE DVT - Provoked
15. Non-Sustained Ventricular Tachycardia
16. Hypersensitivity Desquamative Dermatitis (Rifampin vs
Vancomycin)
17. BUE Paresis - mild, BLE paresis L>R.
18. GI Bleed.
19. Nosocomial LLL Pneumonia
20. Anemia - multifactorial: Illness, blood loss, CKD.
21. Stage III Sacral Ulcer.
22. MRSA/VRE Colonization
23. Candidemia
24. Pseudomonal line sepsis.
25. Diabetes Mellitus Type II.
26. Hypertension
27. Hypercholesterolemia
28. L3-L4 Fusion
29. BPH
30. Chronic Kidney Disease Stage III with Proteinuria (baseline
cr
Social History:
Former tobacco use - quit 25 years ago, quit alcohol 25 years
ago. Nursing home resident. Married, wife is health care
proxy.
Family History:
NC
Physical Exam:
T 97.2 HR 100-105 BP 112/57 RR 20 O2 99-100 on 100% NRB
Gen: Elderly male Caucasian, sleepy but arousable.
Eyes: PERRL, sclerae anicteric
Mouth: MMM, no lesions
Neck: Supple, negative Brudzynski, no bruits, neck veins flat
Chest: Crackles at bases, no wheeze, fair air movement.
Cor: RR nl s1s2 no mrg
Abd: G-tube in place, flat, NT/ND. Absent bowel sounds.
Ext: Warm, distal pulses nl, R boot in place.
Pertinent Results:
[**2182-9-6**] 05:45PM BLOOD WBC-24.3*# RBC-4.25* Hgb-12.8*# Hct-37.0*
MCV-87 MCH-30.0 MCHC-34.5 RDW-18.6* Plt Ct-220
[**2182-9-7**] 11:57AM BLOOD WBC-11.8* RBC-3.17* Hgb-9.6* Hct-28.1*
MCV-89 MCH-30.2 MCHC-34.1 RDW-18.2* Plt Ct-132*
[**2182-9-7**] 05:14AM BLOOD Glucose-170* UreaN-74* Creat-1.6* Na-150*
K-4.7 Cl-119* HCO3-24 AnGap-12
Brief Hospital Course:
Pt was admitted to the Medical ICU for UTI/sepsis with low BP
and a ? of pneumonia. He is a 71 year old gentleman from
nursing home with history of recent urosepsis, chronic foley,
MRSA infections (pneumonia, meningitis), CAD, DM II,
hypertension admitted for sepsis/septic shock likely secondary
to pneumonia, urinary tract infection or both. ID was
consulted, and given his extensive nosocomial infection history,
it was decided to empirically start the patient on meropenem and
linezolid. Pt hemodynamically improved on abx, with pressors
rapidly weaned off. Resp status improved quickly as well. His
lactate, WBC are trended back to within normal limits. Urine
cultures returned as MDR E. Coli sensitive to meropenem.
.
1) Septic shock: See also above. Pt was maintained at CVP 8-12
using fluid boluses, MAP> 65, uop > 30. Pt was weaned off
pressors on HD#2. Pt was eventually also weaned off NRB. Pt was
transfused at a Hct below 28 as per MUST protocol (also history
of CAD). Underlying cause was likely pneumonia vs. UTI. Sputum
grew MDR E coli sensitive to Meropenem as mentioned above. Ucx
from [**9-7**] grew Pseudomonas. Sensitivities were pending on
discharge. Antibiotic selection was complicated by h/o MDR UTI,
MRSA, VRE and vancomycin allergy. Pt was started on meropenem
and Linezolid and should complete a 14 day course. 10 more days
to be completed after discharge. Pt was afebrile and
hemodynamically stable on discharge. It is recommended to follow
up on the sensitivities of Pseudomonas growing from his urine
cx.
.
2) Acute renal failure, Cr 2.1 from 0.9 but quickly trending
down to baseline again. Thought to have been prerenal based on
urine lytes, likely secondary to inadequate perfusion. Renal
function was stable on discharge.
.
3) Anemia, 9 point hct drop on admission. Transfused for goal of
28 (sepsis, CAD history). Pt had stable Hct above 30 on
discharge.
.
4) History of CAD, s/p CAB: Pt was continued on aSA, statin,
fondaparinux. Hct goal of 28 (initially 30) while ongoing
sepsis. Antihypertensives were held until patient was
hemodynamically stable again. Then pt was restarted on ACEI and
BB.
.
5) Diastolic CHF: Was monitored with serial CXR. Also on resp
monitor while on fluids. Held ACEi and beta-blocker until septic
shock fully resolved. Then restarted again after that.
.
6) H/o DVT, Pulmonary Embolus: continued fondaparinux.
.
7) DM II: Humalog sliding scale, tight control while infected.
Glargine 5U at bedtime. Last FSBG were 210, 175, 125.
.
8) Sacral decubitus, doesnt appear to be likely source of
infection. Was monitored regularly. Wound care was consulted. Pt
was continued on zinc and vitamin supplementations. Pt also
developed erythema and tenderness around both heels towards the
end of his stay. Continued wound care of these areas is
recommended.
.
9) Hypernatremia: Resolved after free water flushes via G-tube.
Natrium of 143 on discharge.
.
10) Pain control, chronic R leg pain (ulcers). continued
gabapentin. Also lidocaine patch locally.
.
11) GU: Pt known to have BPH. Pt was continued on finasteride.
Pt has chronically Foley placed. UA showed 21-50 RBC. It is
recommended to follow up with his urologist as an outpatient. A
cystoscopy and possibly a suprapubic catheter are to be
considered.
.
12) FEN, Pt was kept on tube feeds. Nutrition was consulted. Pt
was continued on zinc and vitamin supplementations. I/Os were
even on discharge.
.
13) Ppx: Lansoprazole, fondaparinux, bowel regimen
.
14) Access: R IJ (was d/c'ed on [**9-9**]), PIV, PICC placed on [**9-9**]
.
15) Code: Full
Medications on Admission:
1. Ursodiol 300 mg PO BID.
2. Gabapentin 200 mg daily.
3. Folic Acid 1 mg daily
4. Aspirin 325 mg daily
5. Ascorbic Acid 90 mg/mL Drops 500 mg Daily.
6. Zinc Sulfate 220 mg Daily
7. Senna 8.6 mg PO BID.
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, daily
9. Metoprolol Tartrate 50 mg PO BID.
10. Fondaparinux 2.5 mg/0.5 mL subcutaneous daily
11. Docusate Sodium Liquid 100 mg PO BID
12. Lisinopril 5 mg PO HS.
13. Bisacodyl 10 mg Tablet, Delayed Release [**Hospital1 **] PRN.
14. Lansoprazole 30 mg daily
15. Atorvastatin 10 mg daily
16. Insulin Sliding Scale
17. Finasteride 5 mg Tablet Daily
18. Doxycycline Hyclate 100 mg twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
1. Sepsis
2. E. coli Pneumonia
3. Pseudomonas UTI
Secondary Diagnosis:
1. CAD
2. DMII
3. HTN
Discharge Condition:
Afebrile. Hemodynamically stable. Tolerating PO.
Discharge Instructions:
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath or any other concerning
symptoms.
Please take all your medications as directed.
Please keep you follow up appointments as below.
Followup Instructions:
Please follow up with your primary care doctor (FINE,[**Doctor Last Name **] H.
[**Telephone/Fax (1) 65335**]) in [**12-17**] weeks from now.
ICD9 Codes: 0389, 5990, 5849, 4280, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4092
} | Medical Text: Admission Date: [**2124-12-30**] Discharge Date: [**2125-1-6**]
Date of Birth: [**2050-11-25**] Sex: F
Service: Medicine
CHIEF COMPLAINT: Shortness of breath/respiratory failure.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 18920**] is a 74-year-old
woman with a history of chronic obstructive pulmonary
disease, end-state, on home oxygen with a FEV1 of 35%, and
multiple previous admissions over the past several months for
chronic obstructive pulmonary disease flares with pneumonia;
initially admitted with a cough and increasing respiratory
distress at home. She was initially treated with antibiotics
and prednisone and found to be in increasing respiratory
distress and transferred to the Medical Intensive Care Unit
for trial support of BiPAP. However, the patient declined
BiPAP in the unit stating that she no longer wished to
prolong her life. She was lucid, alert, and rational per the
Medical Intensive Care Unit at this point, and per her
family.
At this point the goals for the patient's care were changed
to maximization of comfort. The decision was made to return
the patient to the floor.
PAST MEDICAL HISTORY: (Significant for)
1. Severe chronic obstructive pulmonary disease, oxygen
dependent with multiple flares in the past several months.
2. Chronic pneumonias.
3. Osteoporosis.
4. Gastroesophageal reflux disease.
5. Anxiety.
MEDICATIONS ON ADMISSION: Medications on arrival to the
floor were Colace, Serevent, Flovent, levofloxacin, heparin,
Protonix, Combivent, and morphine drip.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were
satting at 90% to 97% on 6 liters nasal cannula with a
temperature of 98.6, a heart rate of 90, a blood pressure of
130/70. In general, in no acute distress at this time,
although thin and tired-appearing. Heart rate and rhythm
were regular, with a normal first heart sound and second
heart sound. Her lungs were significant for having slight
wheezing, bilateral crackles at the bases, and very poor air
movement. The abdomen was soft, nontender, and nondistended.
She had trace edema in the lower extremities.
Neurologically, she was alert and oriented and appropriate.
HOSPITAL COURSE: After being transferred to the floor the
patient's entire family arrived and a discussion regarding
her prognosis and the appropriate course to be taken was
made. The patient's wishes were explicit that she wished to
be comfort measures only and did not wish to continue. The
family agreed with this, and the decision was made at this
time to withdraw all care with the exception of comfort
medications including a morphine drip and oxygen by nasal
cannula.
After discontinuation of the albuterol and Atrovent
nebulizers and her steroids, her pulmonary status rapidly
declined. She was kept comfortable on a morphine drip with
boluses as needed. Her family remained with her throughout
the stay. After approximately 48 hours, the patient passed
away comfortably. At this time the family declined a
postmortem examination.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease.
2. Pneumonia.
[**Name6 (MD) **] [**Name8 (MD) 5647**], M.D. [**MD Number(1) 18922**]
Dictated By:[**Name8 (MD) 4733**]
MEDQUIST36
D: [**2125-1-7**] 10:58
T: [**2125-1-13**] 09:11
JOB#: [**Job Number 18923**]
ICD9 Codes: 486, 2768, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4093
} | Medical Text: Admission Date: [**2132-9-22**] Discharge Date: [**2132-10-2**]
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
hip fracture
Major Surgical or Invasive Procedure:
ORIF of R. hip.
PEG placement
History of Present Illness:
82 yo woman with Alzheimer's dementia, h/o PE in [**2130**] on
coumadin(but INR 1.1 on admission), osteoporosis, h/o chronic
back pain with T10/T12/L1 comp fx and L5/S1 disc herniation,
chronic pain with multiple recent admissions for somnolence [**12-19**]
narcotics, and hx asp pna, who was admitted from NH s/p fall.
Per reports, the patient was watching TV and then was found on
hands and knees on the floor, but had no witnessed fall. She was
c/o R LE pain.
.
In ED, VS 96.6 88 134/86 18 96%RA. Right hip showed minimally
displaced fracture of the femoral neck. CXR showed LLL opacity
concerning for early pna vs atelectasis. She received a total of
12 mg of Morphine, Levofloxacin 500 mg IV (given ? of asp pna),
Phenergan, Anzemet given for episode of emesis. At this point
the pt became somewhat somnolent, and the APG attg noted a new ?
facial droop. It was determined that she needed a head CT prior
to the OR. Her oxygen saturation (baseline 93-96% on RA) was
93-94% on RA, but reportedly dropped to the 80s although there
is a ? of whether this was a poor tracing. She received
naloxone for her mental status which resulted in a transient
improvement. She was then intubated for her head CT (which was
neg) and transferred to the MICU for further management. Upon
intubation there was some question of whether gastric contents
vs. sputum were sxned from her ETT.
Past Medical History:
1. Alzheimer's Dementia
2. Severe back pain: MRI [**2132-2-15**] showing T10, T12, L1
compression
fractures, L5-S1 discherniation, mild spinal stenosis, and mod
foramenal narrowing. On fentanyl patch at baseline, with
multiple admissions for altered mental status in setting of
narcotics.
3. pulmonary embolism [**2131-8-17**] at OSH.
4. Moderate aspiration on video swallow study on [**2132-1-31**]
5. GERD
6. Hypothyroidism
7. Anemia
8. HTN
9. Aspiration PNA last admit to [**Hospital1 18**] [**8-20**]
Social History:
Lives alone in [**Hospital3 **]. No kids. HCP is [**Name (NI) **] [**Name (NI) 52782**],
phone numbers below. Her 2 brothers and one sister live in
[**Country 19828**]. Smoking: none ETOH: rare (heavy in the past to treat her
pain per notes) Illicit drugs: none
Family History:
Family history negative for stroke. Sister has questionable
event
but was diagnosed as not-stroke.
Physical Exam:
Vitals: T: 99.7, BP: 115/64, HR: 87
Vent: AC 450x14 (breathing 17), fio2 100%, peep 5
Gen: thin chronically ill appearing woman, intubated and
sedated, not responding to voice/painful stimuli
HEENT: NC, AT, perrl, no clear facial droop although difficult
to see as ETT/tape in the way
Neck: JVD approx 6 cm
CHEST: coarse upper airway sounds bilaterally anteriorly
CV: regular, nl S1S2, [**12-23**] HSM at LSB
Abd: + BS, soft NT, NT, no organomegaly
EXT: no LE edema, bilateral erythema from ankles to upper calves
Neuro: intubated/sedated, unarousable to stimuli (on propofol)
Pertinent Results:
Admission Labs:
[**2132-9-22**] 12:45PM PT-12.9 PTT-28.0 INR(PT)-1.1
[**2132-9-22**] 11:20AM GLUCOSE-109* UREA N-34* CREAT-1.2* SODIUM-140
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-25 ANION GAP-18
[**2132-9-22**] 11:20AM CALCIUM-9.2 PHOSPHATE-3.0 MAGNESIUM-1.7
[**2132-9-22**] 11:20AM WBC-14.5* RBC-3.41* HGB-9.3* HCT-27.7*
MCV-81* MCH-27.2 MCHC-33.5 RDW-16.9*
[**2132-9-22**] 11:20AM NEUTS-91* BANDS-0 LYMPHS-3* MONOS-1* EOS-1
BASOS-0 ATYPS-4* METAS-0 MYELOS-0
[**2132-9-22**] 11:20AM HYPOCHROM-OCCASIONAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL SCHISTOCY-OCCASIONAL
Pertinent Labs/Studies:
Microbiology:
Urine :
[**2132-9-22**]: >100K yeast
[**2132-9-22**]: < 10K org/ml
Blood:
[**2132-9-22**]: NGTD
[**2132-9-24**]: NGTD
Sputum:
[**2132-9-22**]: Gram: 2+ GPC, 1+ [**Month/Day/Year **]. Cx-sparse OP flora
[**2132-9-24**]: Gram: >25 PMN, no microorgansimas cx: NGTD
.
Radiology:
[**2132-9-22**]: CHest Pa/Lat - The heart size is normal, and there is
no mediastinal or hilar lymphadenopathy. Previously reported
patchy opacity at the right lung base has cleared in the
interval with only minimal residual linear opacity remaining in
this area. However, there is a questionable new area of patchy
opacification peripherally in the left lower lobe as compared to
previous study. The bones are diffusely demineralized. There
are stable compression
deformities in the lower thoracic spine.
.
[**2132-9-22**]: Portable Chest - There has been interval placement of
an
endotracheal tube with the tip at the level of the clavicles.
The cardiac silhouette, mediastinal, and hilar contours are
normal. The pulmonary vasculature is normal. Both lungs are
clear without consolidations or effusions. The surrounding soft
tissue and osseous structures reveal severe osteopenia and
degenerative changes along the thoracic spine. There is no free
air under bilateral hemidiaphragms.
.
[**2132-9-24**]: Right Hip: FINDINGS: A single intraoperative AP
radiograph of the pelvis was obtained demonstrating interval
bipolar hemiarthroplasty of the right hip with good alignment.
Skin staples are noted overlying the lateral pelvis. Diffuse
osteopenia is noted. There is a left femoral axis venous
catheter. The left hip joint is unremarkable.
IMPRESSION: Status post right bipolar hemiarthroplasty, in good
alignment.
Discharge Labs:
[**2132-10-2**] 06:00AM BLOOD WBC-10.3 RBC-3.73* Hgb-10.4* Hct-30.8*
MCV-83 MCH-28.0 MCHC-33.8 RDW-16.2* Plt Ct-521*
[**2132-9-25**] 05:14AM BLOOD Neuts-75.8* Lymphs-19.7 Monos-1.4*
Eos-2.8 Baso-0.4
[**2132-10-2**] 06:00AM BLOOD Plt Ct-521*
[**2132-10-2**] 06:00AM BLOOD Glucose-99 UreaN-16 Creat-0.7 Na-138
K-4.5 Cl-102 HCO3-28 AnGap-13
[**2132-9-27**] 08:10AM BLOOD CK(CPK)-66
[**2132-9-29**] 06:15AM BLOOD proBNP-3335*
[**2132-10-2**] 06:00AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.1
Brief Hospital Course:
#. Right hip fracture: Patient was admitted to MICU after
intubation in the ED awaiting repair for right hip fracture. The
patient was on anticoagulation therapy with coumadin on
admission with an INR of 1.5 at it's peak. The patient was given
IV vitamin K and FFP for reversal of anticoagulation. The
patient was noted after admission to have small Hct drop form
27.7 to 23.5 for which she was given PO 1U PRBCs with
appropriate bump. Upon successful reversal of anticoagulation,
the patient was taken to the OR two days after admission to the
MICU with successful right hemiarthroplasty of the right hip.
Intraoperatively and perioperatively the patient received 400mg
Fentanyl and did not require any transfusions per report from
operating team. The patient was trasnferred back to the MICU for
ongoing care and was started on lovenox 40mg SC qd as
recommended by ortho (alternatively could use SC Hep tid as
well).
On the floor, the Lovenox was increased to 40 mg SC BID, a
therapeutic dose, due to concern over prior PE in [**2130**]. This was
continued without incident, although she was briefly changed to
IV Heparin before and after her PEG was placed. She will be
discharged with plan to continue Lovenox until she is
therapeutic on Coumadin (i.e. 2 days after her INR is >2.0). PT
was started and proceeded smoothly.
.
#. ID - The patient was admitted to the MICU intubated for
airway protection in setting of mental status changes after
receiving morphine, but with additional concern towards
aspiration given some vomiting. The patient's chest film on
admission did not demonstrate any definite infiltrates or
consolidations. Additionally the patient did not develop any
leukocytosis. However, on the evening of admission the patient
did have a fever with additional temp spike to 102 the am of her
operation. The patient had a UA which was significant for small
leuk esterase, many bacteria and > 50WBC. Therefore, the night
prior to her operation the patient was started on levofloxacin
25mg IV q12, which was increased to 50mg the following day.
Urine cultures were remarkable for only yeast however without
any appreciable growth. The patient addiitonally had blood
cultures none of which demonstrated any growth. Sputum cultures
x 2 were sent with gram stain remarkable for 2+ GPC and 1+ [**Year (4 digits) **],
however with only sparse oropharyngela flora growing in
cultures.
Blood Cx drawn [**9-22**], however, grew out [**Month/Day (4) **] which eventually
were determined to be Clostridia. Patient was started on
Cefipime and Flagyl IV. She remained afebrile and without
elevated WBC throughout her stay once the antibiotics were
started. Further blood cxs were all negative. It is unclear
whether the [**Name (NI) **] was "real" or a contaminant. She will be D/C'd
on a 14 day course of po Cipro/Flagyl (D/C day [**5-29**]).
.
#. CV: Patient was mildly hypertensive, but on transfer from
MICU to floor she became persistently hypotensive, with SBP
80-90. The hypotension was of unclear etiology. Most likely
hypovolemia, as FeNa < 1%, Uop responded to fluids. Heart
failure unlikely given nl CXR, lack of elevated JVP or LE edema,
but BNP>3000. She had some EKG changes (apparently new Q waves
in the precordial leads) but was ruled out for MI. Concern for
sepsis but no new O2 requirement, not tachycardic, no fevers.
[**Last Name (un) **] stim test wnl. ABG was normal. Echo done showed some
diastolic dysfunction, but EF 65 and no other abnormality. Over
the course of 48 hours she received several liters of NS, both
in bolus and continuous form, and finally her blood pressure
stabilized and urine output improved. For the remained of her
hospital stay, she was normotensive with adequate urine output.
Toprol and HCTZ were held.
.
#. Heme: On the floor, the patient was persistently anemic. She
stayed just above her transfusion goal of 28, however after
receiving several liters of fluid her HCT dropped to 25 and then
was stable. On [**9-29**] she was transfused 1 Unit of pRBC's [**9-29**],
and she remained with a HCT>30 for the duration of her stay.
.
#. Nephrology: Patient had approximately 48 hours of low urine
output in setting of above mentioned hypotension. Probably
pre-renal, w/ FeNA .37%. Urine sediment shows no evidence of
ATN. After receiving fluids, her urine output improved
dramatically and remained [**Doctor First Name **].
.
#. FEN: There was significant concern for aspiration PNA, and
she was fed via NG tube. In the course of a speech and swallow
consult, Ms. [**Known lastname 28624**] [**Last Name (Titles) 59101**] aspirated Custard, became hypoxic
and developed an additional O2 requirement (2L to 4L). Gi was
consulted, and in discussions with her health care proxy it was
determined that she needed a PEG. This was done without
complication on [**10-1**]. She tolerated the procedure and
subsequent tube feeds well before discharge.
.
#. Alzheimer's Dementia. The patient was continued on her
outpatient dose of Aricept.
.
#. Hypothyroidism. Patient was continued on her outpatient dose
of Levoxyl 75 mcg po daily. Repeat TSH testing was considered
but deferred given inability to interpet the findings well in an
acutely ill patient.
Medications on Admission:
1. Levothyroxine 75 mcg daily (recently increased after TSH 8.7
on [**2132-9-9**])
2. Fentanyl patch 150 mcg q 72 hr
3. Miacalcin Nasal
4. Calcium/Vit D [**Hospital1 **]
5. Senna 1 tab [**Hospital1 **]
6. Aricept 10 mg po daily
7. Coumadin 2 mg about q 4th day based on INR
8. Vitamin C
9. tylenol 1000 mg po q 6 hr
10. Lidoderm 5% patches on 12hrs/off 12 hrs
11. Toprol 50 mg daily
12. Prevacid 30 mg po daily
13. HCTZ 25 mg po daily
14. MVI
15. FeSO4 325 mg po daily
PRN: Trazodone, Maalox, Guaifenesin, Dulcolax
Discharge Medications:
1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Transdermal
every seventy-two (72) hours.
4. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Transdermal every
seventy-two (72) hours.
5. Miacalcin 200 unit/Actuation Aerosol, Spray Sig: One (1)
Nasal once a day.
6. CALCIUM 500+D 500-125 mg-unit Tablet Sig: One (1) Tablet PO
once a day.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): Please adjust dose to INR 2-2.5.
10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day: Please
hold if SBP<120, HR<60.
12. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
14. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID:PRN
as needed for constipation.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H:PRN as needed for shortness of breath or wheezing.
16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): Please give until INR>2.0, then give for
2 more days and discontinue.
18. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
19. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
20. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H:PRN as needed for nausea.
21. Trazodone 50 mg Tablet Sig: One (1) Tablet PO QHS:PRN as
needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Aspiration pneumonia. Right hip fracture. Gram negative rod
bacteremia. Hypotension. Alzheimer's Dementia. Anemia.
Hypothroidism.
Discharge Condition:
Aspiration pneumonia resolving. Right hip fracture healing. Gram
negative rod bacteremia improved. Hypotension resolved. Anemia
improving. Hypothyroidism stable. Alzheimer's Dementia stable.
Discharge Instructions:
Please take all medications as directed. Please finish your 7
day course of Ciprofloxacin and Flagyl.
Please continue physical therapy on your right hip.
Please call your primary care doctor or return to the emergency
room for shortness of breath, chest pain, bleeding, feeling like
you may pass out, fevers, severe abdominal pain or hip pain,
signs of redness or infection from your hip or gastric tube, or
any other concerns.
Patient is being discharged currently on tube feeds of
Probalance at 25 cc/hr. Please increase at a rate of 10 cc Q6H
as tolerated to goal of 55 cc/hr. Please flush PEG with 50 ml of
water Q6H, and check for residual Q4H. Hold feeds for residual
of >150 cc.
Please continue daily sub-cutaneous injections of Lovenox until
your INR is 2.0. At that point, continue Lovenox for 2 more
days, and then you may stop it and just take Coumadin, 2.5 mg
QHS. Please adjust Coumadin dose as needed to goal INR of
2.0-2.5.
Please do daily cleansing around the PEG site with Hydrogen
Peroxide followed by 1 layer of gauze under the bumper.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2132-10-21**] 2:30
You have an appointment with your orthopedist, Dr. [**Last Name (STitle) 1005**], on
Tuesday, [**10-14**] at 11:40am on the [**Location (un) **] of the [**Hospital Ward Name 23**]
Building, [**Hospital Ward Name 516**]. Please call [**Telephone/Fax (1) 1228**] if you need to
change this appointment.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5070, 7907, 5990, 2859, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4094
} | Medical Text: Admission Date: [**2190-3-4**] Discharge Date: [**2190-3-9**]
Date of Birth: [**2114-7-18**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Fall down stairs with neck and back pain
Major Surgical or Invasive Procedure:
[**3-4**] Closed reduction an splinting bilateral radial fractures
History of Present Illness:
This is a 75 year old woman s/p mechanical fall down 15 stairs
and was found at bottom of stairs; reportedly was down for ~9
and found by son. She was unable to move due to pain. She had a
bowel movment but was aware this and was not incontinent. No
reported LOC. Transported to [**Hospital1 18**] for further care.
Past Medical History:
Osteoporosis
COPD
Social History:
pt is widowed and has 1 child- [**Doctor Last Name 122**]. [**Doctor Last Name 122**]
states checking in with mother daily, helps her with daily
errands but states that otherwise, pt is independent and without
any serious medical or mental health issues.
Family History:
n/a
Pertinent Results:
IMAGING:
[**3-4**]: CXR: Widened mediastinum with acute left fourth rib
fracture. No evidence of pneumothorax
[**3-4**] CT Head: large frontal subgaleal hematoma. no definite
intracranial bleed
[**3-4**] CT C spine: communited fx of the base of the C2 with
extension into b/l transverse foramen, mild posterior
retropulsion of C2 fx fragments and fracture of right C2 facet.
Nondisplaced fx of C3. Right C6 posterior element fracture. C7
burst fracture and loss of height with fracture line extending
into right C7 pars/ facet. possible epidural hematoma.
[**3-4**]: CT C/A/P: Multiple thoracic transverse process fractures.
T7 comminuted compression fx with fx extending into posterior
elements with minimal retropulsion. T8 mild compression fx. Left
4th, 5th rib fx. L2 loss of height. Renal mass measuring 2.4 x
2.4 cm concerning for RCC
[**3-4**]: UE X ray: both the right and left wrists demonstrate
intra-articular extension and impaction of comminuted distal
radius fractures with dorsal angulation and slight dorsal
displacement. Both also demonstrate ulnar styloid process
fractures. In addition there are suspected avulsion fractures of
the bilateral triquetral bones. The left humerus and shoulder
are grossly intact
[**3-4**]: LE X rays: No fracture or dislocation is evident. The
regional soft tissues are unremarkable
[**3-4**]: UE x ray post reduction: Improved alignment of distal
radial
fractures bilaterally. On the right, a large osseous fragment
lies along volar aspect of distal carpal row, donor site
unclear, possibly hamate fracture
[**2190-3-4**] 10:58PM LACTATE-2.4*
[**2190-3-4**] 04:11PM GLUCOSE-182* LACTATE-4.9* NA+-146 K+-3.8
CL--98* TCO2-27
[**2190-3-4**] 04:11PM HGB-15.4 calcHCT-46
[**2190-3-4**] 04:00PM UREA N-22* CREAT-1.1
[**2190-3-4**] 04:00PM TSH-1.4
[**2190-3-4**] 04:00PM T4-8.9
[**2190-3-4**] 04:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2190-3-4**] 04:00PM WBC-21.3*# RBC-4.83 HGB-14.3 HCT-43.6 MCV-90
MCH-29.5 MCHC-32.7 RDW-13.6
[**2190-3-4**] 04:00PM PLT COUNT-303
[**2190-3-4**] 04:00PM PT-11.3 PTT-20.8* INR(PT)-0.9
[**2190-3-4**] 04:00PM FIBRINOGE-405*
Brief Hospital Course:
She was admitted to the Trauma service. Neurosurgery was
consulted for her spine fractures which were managed non
operatively. She was fitted for a TLSO brace with a cervical
extension; this is to be worn at all times. She will follow up
in 1 month in [**Hospital 4695**] clinic for repeat spine imaging. Her
neurologic status is intact, she moves all extremities but is
limited by pain.
Orthopedics was consulted for her bilateral radial fractures and
these were closed reduced and casted. She may weight bear only
when using the platform walker, otherwise should not bear weight
on both wrists.
Her home medications were restarted, a regular diet was also
started for which initially she had a poor appetite. Marinol was
started and her appetite has since improved significantly.
She was evaluated by Physical therapy and is being recommended
for rehab after her acute hospital stay.
Medications on Admission:
Albuterol, Lipitor, Alendroate, Diltiazem, Fluticasone,
Montelukast, Prednisone, Ranitidine, Calcium carbonate, Vit D
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
Wheezing.
5. Alendronate 70 mg Tablet Sig: One (1) Tablet PO 1X/WEEK (MO).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
8. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Diltiazem HCl 300 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed
for constipation.
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. Calcium 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
16. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall
Frontal subgaleal hematoma
C2 comminuted fracture
C3 nondisplaced fracture
T7,T8 compression fracures
Rib fractures on left [**4-5**]
Bilateral radial fractures
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:
CTLSO brace needs to be worn at all times.
WBAT b/l lower extremities
Non-weight bearing b/l upper extremities
Continue to eat nutritious meals and drink nutritional
supplements to optimize your healing
Followup Instructions:
Follow up next Thursday with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP orthoepdics
for your radial fractures. You will need to call [**Telephone/Fax (1) 1228**]
for an appointment time.
Follow up in 1 month with Dr. [**Last Name (STitle) 4696**], Neurosurgery for a
repeat spine CT scan. Call [**Telephone/Fax (1) 1669**] for an appointment.
Follow up with Dr. [**Last Name (STitle) 3748**] in [**Hospital 159**] clinic after discharge from
rehab. Call for the appointment at [**Telephone/Fax (1) 4697**].
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4095
} | Medical Text: Admission Date: [**2131-10-2**] Discharge Date: [**2131-10-6**]
Date of Birth: [**2085-9-17**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 46 year-old man
with a history of diabetes, hypertension,
hypercholesterolemia with no prior history of coronary artery
disease who presented to the Emergency Department at [**Hospital1 1444**] with substernal chest pain.
He reports that the pain started at 4:00 p.m. the day prior
to admission. He describes the pain as pressure, 10 out of
10 lasting for minutes. He experienced shortness of breath
and diaphoresis with the chest pain, but no nausea, vomiting,
dizziness or palpitations. There were no alleviating factors
at home, but the pain was relieved with nitroglycerin once in
the Emergency Department. Electrocardiogram in the Emergency
Department showed anterior ST elevations myocardial
infarction, quite large in leads V1 through V4. The patient
became hypotensive to the 70s. Zol was placed. The patient
stated he had severe pain and vomited. He was intubated for
agitation and airway prophylaxis. He was then given
thrombolytics and [**Female First Name (un) **] placed due to congestion in the
catheterization laboratory. He was then taken to the
catheterization laboratory.
PAST MEDICAL HISTORY: Diabetes, hypertension,
hypercholesterolemia.
MEDICATIONS ON ADMISSION: 1. Pravachol 40 mg po q day. 2.
Amaril 4 to 8 mg po b.i.d. 3. Metformin 500 mb po b.i.d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Diabetes, coronary artery disease and
hypertension.
SOCIAL HISTORY: The patient denies tobacco use, occasional
alcohol. He is a gas station owner.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs on admission
blood pressure 110/71. Heart rate 88. Respiratory rate 14.
Sating 99% on room air. The patient had a regular rate and
rhythm with a 3+ systolic murmur at the left lower sternal
border. Lungs were clear bilaterally. The patient
demonstrated no edema.
LABORATORIES ON ADMISSION: The patient was initially
hyperkalemic, but was given Kayexalate in the Emergency
Department and his potassium came down. His hematocrit was
44.2, white count was 8.0. CK in the Emergency Department
was 192, MB fraction 5, troponin less then 0.3.
Chest x-ray showed central vascular clouding and low lung
volumes, but was not significant for no other cardiopulmonary
process. Catheterization report, LMCA no significant
disease. Left anterior descending coronary artery 40%
proximal, 50% mid, 60% distal lesions. Left circumflex 40%
mid, 40% obtuse marginal one, right coronary artery 80%
osteal, posterior descending coronary artery 90% distal RPL.
Proximal and mid left anterior descending coronary artery
were stented, note of hypokinetic anterior wall.
Echocardiogram demonstrated 30% ejection fraction. There was
severe hypokinesis at the anterior septum and anterior free
wall, moderate hypokinesis at the lateral wall, mild
hypokinesis of the inferior septum and inferior free wall,
and extensive apical akinesis. There was focal hypokinesis
at the apical free wall of the right ventricle as well.
HOSPITAL COURSE: The patient's chest pain was controlled
with morphine. His cardiac enzymes were measured as follows
[**Telephone/Fax (1) 45635**], 3923, 1551. Troponin was greater then 50. The
patient vomited multiple times during weaning trials,
therefore he was quickly extubated the morning after he was
intubated. He did very well. He was covered with a five day
course of Levofloxacin and possible aspiration pneumonia, but
his white blood cell count did not increase and the patient
did not spike a fever. The patient was mildly hypotensive in
the 90s for much of his hospital course therefore he was beta
blocked, but no ace inhibitor was started. This will be
deferred to outpatient cardiology follow up. The patient
received a signal average electrocardiogram with the
following results, QRS duration 100, duration of HFLA signals
30 milliseconds, RMS voltage 44, mean voltage 31. The
patient is pain free, albeit deconditioned on the day of
discharge. He was felt to be safe for discharge by physical
therapy. On telemetry the patient showed occasional ectopy
via premature ventricular contractions and occasional
ventricular trigeminy. His beta blocker was increased. The
patient will follow up with Dr. [**Last Name (STitle) **] as well as Dr. [**Last Name (STitle) 45636**]
his primary care physician at the [**Name9 (PRE) **] Clinic.
DISCHARGE MEDICATIONS: Atenolol 25 mg po q.d., Coumadin 5 mg
po q.d., 10 mg po q.d., Plavix 75 mg po q.d. times thirty
days, aspirin enteric coated 325 mg po q.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Doctor Last Name 27717**]
MEDQUIST36
D: [**2131-10-5**] 17:41
T: [**2131-10-10**] 09:32
JOB#: [**Job Number **]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4096
} | Medical Text: Admission Date: [**2103-11-3**] Discharge Date: [**2103-11-30**]
Date of Birth: [**2040-6-6**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
EVD placement [**2103-11-3**]
Trach placement
PEG placement
History of Present Illness:
This is a 63 year old gentleman with history of testicular
cancer and resection who was found unconsious at home on his
toilet at approximately 1000. The patient was found by his wife
who last saw him at 0630am. The patient reportedly has been
experiencing syncopal events daily but has not sought medical
treatment. The patient was brought to [**Hospital 47255**]
intubated and was given fentanyl 100 mcq, succinycholine 150 mg,
and etomidate 10 mg for intubation at approximately 1020 am. A
Head Ct at [**Hospital **] revealed an extensive acute
intercranial hemorhage within the suprasellar cistern and within
the ventricles most prominently the left lateral ventricle is
expanded. The patient was transferred here for further care.
The
patient is not accompanied by family at the time of this exam.
Past Medical History:
testicular cancer with resection-unknown date
Social History:
married. Wife not present at the time of this exam.
Family History:
NC
Physical Exam:
O: BP: 191/71 HR: 91 R:20 O2Sats:50% FIO2 500x20
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:2.5 NR EOMs:unable to test
Neck: not tested
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated GCS: 3T
Orientation: Not oriented
Recall/Language: unable to test
Cranial Nerves:
I: Not tested
II: Pupils 2.5 mm NR mm bilaterally. Visual fields- non able to
test
III, IV, VI: Extraocular movements unable to test
V, VII: Facial strength/sensation unable to test
VIII: Hearing-unable to test
IX, X: Palatal elevation-unable to test
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius-unable to test
XII: Tongue-unable to test
Motor: No movement in upper extremities to pain. Posturing in
lower extremities to pain
Sensation:unable to test
Babinski's: Toes mute
Coordination: unable to test
Upon Discharge:
Awake, Alert, EO spont. PERRL. Mouthing words. No RUE mvmt. BLE
withdrawl, LUE spont and purposeful.
Pertinent Results:
CTA HEAD [**2103-11-3**]:
1. Basal ganglia hemorrhage extending to the ventricles with
ventriculomegaly. The ventricular size appears to have slightly
increased
since the previous CT examination from outside hospital.
2. CT angiography demonstrates no evidence of aneurysm,
stenosis, or
occlusion or abnormal vascular structures but tortuous
intracranial arteries
are seen.
3. New intubation with blood products in the left sphenoid sinus
and
nasopharynx as well as retained secretions.
CT HEAD W/O CONTRAST [**2103-11-4**]:
Stable appearance of left basal ganglonic parenchymal
hemorrhage,
intraventricular hemorrhage, and scattered foci of subarachnoid
hemorrhage. Status post right transfrontal ventriculostomy
catheter placement, with decompression of the right and minimal
change of the left lateral ventricle.
MRI BRAIN W/WO CONTRAST [**2103-11-7**]:
Intraventricular hemorrhage, status post EVD placement with
interval
improvement in hydrocephalus. No abnormal enhancement. No
abnormally
enhancing mass, or acute territorial infarct is seen. As this
study was not done as an MRA, evaluation for aneurysm is
limited. The patient's recent CTA examination is a better
evaluation for this. Scattered foci of diffusion restriction
described above, most consistent with subacute shower of emboli.
CT HEAD W/O CONTRAST [**2103-11-8**]:
Redemonstration of intracranial hemorrhage predominantly
intraventricular,
although also seen in the left at the caudate as well as
subarachnoid
locations. The overall volume of blood is decreased from the CT
done on
[**2103-11-4**] and when accounting for differences in
technique appears
minimally changed from the MR done on [**2103-11-7**]. The
size of left
temporal [**Doctor Last Name 534**] has also decreased.
CT HEAD W/O CONTRAST [**2103-11-10**]:
Overall slight decrease in size of the temporal horns with
unchanged blood products seen on the previous CT of [**2103-11-8**].
No significant new abnormalities.
CT HEAD W/O CONTRAST [**2103-11-11**]:
Interval evolution of previously seen hemorrhage, without
dramatic regression or progression since yesterday's study. No
evidence of
new hemorrhage.
CT Head [**2103-11-21**]:
Marked interval resorption of intraventricular and left caudate
hemorrhage
since the most recent study.
CT Head [**2103-11-22**]:
IMPRESSION:
Stable layering of intraventricular hemorrhage and left caudate
hemorrhage
with stable mass effect on the left basal ganglia. Stable mild
rightward
shift of midline structures. No new hemorrhage.
Stable prominence of the third ventricle.
Small amount of air within the right temporal [**Doctor Last Name 534**].
LABS:
[**2103-11-29**] 06:11AM BLOOD WBC-9.3 RBC-3.01* Hgb-9.0* Hct-26.6*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.9 Plt Ct-218
[**2103-11-30**] 04:13AM BLOOD WBC-10.0 RBC-2.84* Hgb-8.6* Hct-25.0*
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.1 Plt Ct-238
[**2103-11-29**] 06:11AM BLOOD PT-17.8* PTT-59.9* INR(PT)-1.6*
[**2103-11-29**] 06:11AM BLOOD Plt Ct-218
[**2103-11-29**] 02:39PM BLOOD PTT-57.1*
[**2103-11-29**] 10:02PM BLOOD PTT-73.9*
[**2103-11-30**] 04:13AM BLOOD PT-19.0* PTT-60.9* INR(PT)-1.7*
[**2103-11-30**] 04:13AM BLOOD Plt Ct-238
[**2103-11-30**] 09:55AM BLOOD PTT-67.3*
[**2103-11-29**] 06:11AM BLOOD Glucose-120* UreaN-31* Creat-0.5 Na-145
K-3.5 Cl-110* HCO3-28 AnGap-11
[**2103-11-30**] 04:13AM BLOOD Glucose-118* UreaN-30* Creat-0.6 Na-145
K-4.1 Cl-110* HCO3-29 AnGap-10
[**2103-11-29**] 06:11AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.0
[**2103-11-30**] 04:13AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0
Brief Hospital Course:
63 y/o M with significant past medical history presents after
being found unresponsive on the toilet by wife. Unknown how long
patient was down and he was transferred to [**Hospital3 15402**] ED where
head CT showed ICH. He intubated was transferred to [**Hospital1 18**] for
further neurosurgical workup. Once at [**Hospital1 **], he was sedated on
propofol, exam poor. Pupils were 2.5 and non reactive, + cough,
+gag, +corneals, but no movement of extremities to noxious
stimuli. Repeat head CT revealed a basal ganglia hemorrhage with
IVH extension into the L lateral, 3rd, and 4th ventricle. He was
also noted to be hypertensive with a SBP of 220 when off
sedation. His exam off sedation was poor revealing nonreactive
pupils and extensor posturing in BLE. Patient was placed back on
propofol and nicardipine drip started to reduce SBP. An EVD was
placed at bedside with opening pressure of 15. The drain was
leveled to 15cm H2O and ICP was stable at 8. TPA was also
administered Q8H. On [**11-4**], patient was spiking temperature to
101.6, he was pancultured and CXR revealed pneumonia. He was
started on triple antibiotics for treatment.
On [**11-5**] he continued to receive tpa and exam was noted to be
improving, he was intermittently following commands on the left.
Neurology was consulted and recommended a MRI to rule out
underlying lesion. An MRI was performed on [**2103-11-7**] showing
intraventricular hemorrhage, status post EVD placement with
interval
improvement in hydrocephalus. There was no abnormally enhancing
mass, or acute territorial infarct is seen. On [**11-6**] a family
meeting was held and it was noted the patient would likely
prefer independent care post-hospitalization, but further
discussion of the plan of care was deferred to later. There was
significant serosanguinous oozing from the EVD site on [**11-6**]. On
[**11-7**] the patient underwent bronchoscopy for hemoptysis which
was unrevealing. On [**11-8**] he had recurrent temperature spikes
and the patient was cultured, including a CSP specimen which
demonstrated no growth. The patient underwent percutaneous
tracheostomy placement on [**11-9**]. tPA through the EVD had been
initiated a few days prior given poor drainage and concern for
clotting, but this was discontinued on [**11-9**]. A clamp trial was
performed on [**11-10**], but increasing ICP was noted and the the EVD
drain was re-opened to 15 cmH20. On [**11-11**] his EVD had improved
drainage, his ICPs remained in the 7-10 range and a re-attempt
at clamp trial was performed at 15:30 the afternoon of [**11-12**]
which also proved unsuccessful. The patient had also been
experiencing hypernatremia a few days prior to [**11-12**], which
resolved with free water flushed through his Dobhoff tube along
with 0.45% normal saline infusions.
On [**2104-11-14**] the patient was placed on continuious EEG which
showed diffuse encephalopathy. The patient's exam remained poor,
he would have some spontaneous movement on his left side but he
would not follow commands, his eye opening was mininmal.
Multiple meetings were had with the family in regards to goals
of care. Initially the family considered making the patient CMO.
However, his exam started to improve and he started mouthing
words. He received a trach on [**11-19**]. He was given a third
clamping trial on [**11-20**] which went well and again on [**11-22**] a
clamping trial proved that his ICPs were stable. Thus, on [**11-22**]
the EVD was removed and a post-removal head CT revealed a stable
exam without hydrocephalus or significant change in shift. His
neurologic status remained stable.
On [**11-24**] keppra was discontinued. Patient has been having
periods of apnea, difficult to wean to trach mask. He continues
to require CPAP intermittently given respiratory muscle atrophy
and central apneic episodes. He remained tachypneic during the
day on [**11-26**] and a DVT was found on extremity ultrasound. The
patient began heparinization treatment for his DVT. Otherwise
his neurologic exam remained unchanged.
On [**11-27**] he was transitioned to trach mask and remained stable
for 24 hrs and was transferred to the Step Down Unit on [**11-28**]. On
[**11-30**] patient did not meet Step Down Unit criteria and became
floor status. On [**11-30**] he was offered a bed at an extended care
facility and was discharged.
Medications on Admission:
None
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. acetaminophen 650 mg/20.3 mL Suspension Sig: One (1) PO Q6H
(every 6 hours) as needed for pain/fever.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for const.
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. warfarin 5 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1
doses.
8. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): PTT
40-60, INR 2-2.5.
9. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic Q3H (every 3 hours).
10. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
12. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Basal Ganglia hemorrhage with IVH extension
DVT
VAP
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2103-11-30**]
ICD9 Codes: 431, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4097
} | Medical Text: Admission Date: [**2190-8-18**] Discharge Date: [**2190-8-26**]
Date of Birth: [**2142-10-16**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Cefazolin / Vicodin / Oxycodone
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Metabolic acidosis.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a 47y/o F with a PMH of DM, EtOH abuse, C.
parapsilosis R knee septic arthritis/osteomyelitis recently
admitted with Delirium tremens/PRES now presenting with
hypotension, hypoxia and acute renal failure in the setting of
recent C. diff colitis.
.
The patient was admitted on [**6-16**] - [**6-22**] with C parapsilosis
septic knee joint and underwent debridement and drainage and
discharged home on fluconazole.
.
She was then readmitted [**2190-7-4**] - [**2190-7-19**] with AMS in the setting
of EtOH withdrawal. Because of very high BPs in MICU (probably
due to severe DTs) and MRI findings, the diagnosis of Posterior
Reversible Leukoencephalopathy (PRES) was made. Infectious w/u
of CNS was negative with negative CSF and blood cx. Upon
aggressive BP reduction and control of EtOH withdrawal the
patient's mental status significantly improved.
.
The patient was discharged home from rehab on [**8-7**]. Pt reports
she began drinking again daily after returning home from rehab.
She was seen in [**Hospital 5498**] clinic on [**8-9**] and found to have a
BP of 90/58 and pulse of 40. Her metoprolol was decreased to
50mg Q 12 from Q 6 dosing.
.
She presented to OSH on [**8-14**] with nausea, vomiting and diarrhea
X 1 day after finishing a course of vancomycin for C. diff
colitis. Reports diarrhea started on day of presentation with
[**7-7**] BM over 24 hrs. Reported emesis and inability to take po.
She was admitted to the ICU. Vancomycin was restarted and IV
flagyl started. She was found to be hypotensive with SBP 85/49
and WBC of 17.9. ABG 7.18/18/126 on RA. K 2.8. AG23. Cr 3.4. She
received IV and po bicarb. HCT decreased to 24 and she was given
2U PRBC. BP improved with volume resuscitation, did not require
pressors. She was evaluated by Nephrology and felt to have ATN.
GI performed an EGD demonstrating gastritis. She developed
respiratory distress the evening prior to transfer with ABG
7.17/30/74 on 4L. She was started on BiPAP then transitioned to
6L NC prior to transfer.
.
She in now admitted to the ICU for further management. On
arrival to the ICU, the patient is in no acute distress. Denies
any complaints. Sating well on [**1-1**] L.
Past Medical History:
Type 2 diabetes since age 25. Insulin-dependent
Peripheral artery disease s/p bypass-left lower extremity
Hypertension
Hypercholesterolemia
Hepatitis C
C. parapsilosis right knee arthritis s/p open biopsy and
synovectomy on [**6-16**] currently on fluconazole
Alcohol Abuse
Social History:
30 pack year smoking history, quit five years ago. Per my
interview no current alcohol or drug use but per neurology
interview she generally drinks [**1-1**] - 1 pint of "100 proof"
daily. Last drink was at least one day prior to admission. No
history of DTs or withdrawal seizures. Also smokes marijuana
daily. Lives with her husband and 8 year old child. Works as a
cash administrator.
Family History:
No known history of early neurologic deficits.
Physical Exam:
Vitals: T 98.5 BP 128-134/59-61, HR 96-106, RR 12, O2 96% 2L
Gen: dishelved appearing
HEENT: PERRLA, EOMI, dry MM
Pulm: CTAB, no WRR
CV: RRR, nl S1/S2, no MRG
Abd: soft, non-distended, NABS, diffuse mild TTP
Extrem: no LE edema, R knee with minimal swelling, grossly
limited ROM secondary to pain
Neuro: alert, oriented to self, does not recall recent events,
speech spont & fluent, moving all ext.
Vitals on day of discharge:
T98.2
HR 61
BP 146/58
RR 20
99% SpO2 RA
Pertinent Results:
[**2190-8-18**] 11:32PM TYPE-ART PO2-76* PCO2-26* PH-7.36 TOTAL
CO2-15* BASE XS--8
[**2190-8-18**] 11:32PM LACTATE-1.1
[**2190-8-18**] 09:09PM GLUCOSE-221* UREA N-42* CREAT-2.1* SODIUM-143
POTASSIUM-3.2* CHLORIDE-114* TOTAL CO2-14* ANION GAP-18
[**2190-8-18**] 09:09PM CALCIUM-6.7* PHOSPHATE-3.7 MAGNESIUM-1.8
[**2190-8-18**] 04:59PM TYPE-ART PO2-50* PCO2-25* PH-7.32* TOTAL
CO2-13* BASE XS--11
[**2190-8-18**] 04:03PM CK-MB-12* MB INDX-0.7 cTropnT-0.03*
proBNP-[**Numeric Identifier 6597**]*
[**2190-8-18**] 04:03PM ALBUMIN-2.9* CALCIUM-5.9* PHOSPHATE-4.2
MAGNESIUM-1.9
[**2190-8-18**] 04:03PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2190-8-18**] 03:35PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2190-8-18**] 02:38PM GLUCOSE-267* UREA N-43* CREAT-2.4*#
SODIUM-142 POTASSIUM-2.9* CHLORIDE-111* TOTAL CO2-12* ANION
GAP-22*
[**2190-8-20**]
Knee Oblique/AP/lat
Slightly decreased soft tissues in the right suprapatellar
region but no
significant changes in the alternating sclerotic and lucent
regions of distal femur, patella, and proximal tibia. Stable
soft tissue density posterior to the right femur.
[**2190-8-21**]
CXR
Increased opacity is seen in the left lung field mid and upper
regions.
Otherwise stable appearance to the right PICC line and other
bilateral
infiltrates noted. No blunting of the CP angles. I do not see
any definite
cavitation at this time.
.
[**2190-8-19**]
Echo
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-10mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Focal thickening at the tip of
the right coronary cusp might have increased slightly. No masses
or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is small
vegetation on the mitral valve (0.3cmx0.3cm) (clip [**Clip Number (Radiology) **]) at the
coaptation point. An eccentric, posteriorly directed jet of Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2190-7-5**], the
mild mitral regurgitation is new with a small vegetation seen on
the anterior leaflet at the coaptation point
.
[**2190-8-24**] BLOOD WBC-9.5 RBC-3.11* Hgb-9.0* Hct-27.2* MCV-87
MCH-28.8 MCHC-33.0 RDW-14.6 Plt Ct-350
[**2190-8-24**] BLOOD Glucose-126* UreaN-15 Creat-1.2* Na-143 K-3.0*
Cl-108 HCO3-24 AnGap-14
[**2190-8-22**] BLOOD CRP-30.4*
[**2190-8-22**] BLOOD ESR-80*
.
[**8-22**] MRI knee w/ and w/o contrast:
Again seen is a moderately large knee joint effusion with
enhancement of the residual synovium and/or joint capsule.
Numerous subcentimeter susceptibility artifacts anterior to the
extensor mechanism and in the anterior joint space are unchanged
and likely related to previous surgery. Note is made of fluid
extending outside the joint capsule, extending into the
subcutaneous fat, along the lateral and posterolateral aspect of
the knee (ser 6, im 18), unchanged from the prior study.
Cortical erosion of the articulating surfaces of the tibia as
well as
enhancement of the tibial plateau is unchanged and likely due to
a combination of osteomyelitis, bone infarct, and secondary
osteoarthritis. Bone marrow edema, enhancement, and erosion
along the posterior aspect of the patella is unchanged and are
likely related to osteomyelitis, infarct, osteoarthritis, and an
abutting bone fragment. Bone marrow signal alteration and linear
areas of enhancement in the femoral condyles is unchanged and
may be related to osteomyelitis and/or bone infarcts. Again seen
is cortical irregularity and some areas of cortical disruption
along the femoral condyles.
No definite intraosseous or subcutaneous abscesses.
IMPRESSION:
1) The overall appearance is unchanged compared with [**2190-5-12**]. No
change in
bone marrow signal abnormalities in the femoral condyles, tibial
plateau,
proximal tibial metaphysis, and posterior patella, which likely
reflects some combination of osteomyelitisand/or residual edema
from treated osteomyelitis, bone infarcts, and secondary
osteoarthritis. No new areas of enhancement or bone marrow
edema.
2) Moderately large joint effusion, unchanged since [**2190-7-15**].
.
[**8-23**] Renal ultrasound:
FINDINGS: The right kidney measures 12.6 cm. The left kidney
measures 12.3
cm. No mass, stone or hydronephrosis is demonstrated within the
kidneys.
There is a trace right pleural effusion. The bladder is
moderately distended without focal mass lesion detected within.
IMPRESSION:
1. No hydronephrosis.
2. Trace right pleural effusion.
Labs on [**8-26**]/9:
WBC 9.7
Hb 8.7
Hct 27.2
Plt 395
Na 144
K 3.3
Cl 110
HCO3 24
BUN 15
Cr 1.5
Gluc 81
Ca 8.9
Mg 1.9
Phos 4.6
.
HCV VIRAL LOAD (Final [**2190-8-25**]):
487,000 IU/mL.
.
Brief Hospital Course:
Patient admited to the ICU and then transferred to the floor.
Right knee C.Parapsilosis septic arthritis/osteomyelitis -
started diflucan on [**6-16**] but noncompliant. Knee exam appears
stable, MRI generally unchanged; [**Month/Year (2) **] did not feel it
clinically warranted tapping. As renal function increased over
MICU stay, ID advised increasing diflucan dose. Now on [**6-11**]
months of PO fluconazole. To follow-up with [**Month/Year (2) 1957**] and ID as
outpatient.
.
Possibe endocarditis: Echo showed small new vegatation on
anterior leaflet of mitral valve. Not present on TEE from early
[**Month (only) 205**]. Discussed with cardiology and reviewed imaging together;
follow-up in approximately 3 weeks with TTE to see if change in
imaging (appointment as outpatient). No TEE necessary at this
point in time. Patient has never been bacteremic or fungemic. No
new murmur auscultated, no [**Doctor Last Name **] spots or other findings
suggestive of embolic disease seen by optho consult.
.
Acute renal failure with hypokalemia, hypomagnesemia, and
metabolic acidosis: Hx NSAID abuse. Gap and non-gap acidosis on
admission, initially thought to be secondary to diarrhea,
however low bicarbonate persisted beyond diarrhea cessation with
associated hypokalemia, hypochloremia, hypernatremia. This
raised the question of RTA, but that is/was problem[**Name (NI) 115**] to
invoke in setting of ARF. Renal consulted. Pt treated with
bicarb and then bicarb normalized. She continued to have some
hyperchloremia, likely due to IVF which had previously been
given. Hypokalemia corrected with repletion ?????? may also be [**2-1**]
prolonged diflucan course or alcohol abuse. Renal advised
starting potassium citrate ?????? not on formulary, switched to
Bicitra; then d/c'd bicitra as renal function and acid/base
status improved. Renal advised PO potassium and magnesium daily,
and regular checks of electrolytes (chem 10) and renal function.
.
Possible UTI ?????? urine culture showed 10-100,000 klebsiella
species. Started Ciprofloxacin, 7 day course (last day [**8-25**]).
.
Clostridium dificile colitis: Pt started on treatment course
for C. difficile from OSH. Unclear how compliant pt has been
with treatment course, and c.diff +ve at OSH so decided to
restart a treatment course here. Initially on vanc/flagyl.
C.diff culture negative x2 here in hospital. No diarrhea since
admission. Now just PO vancomycin (last day [**8-27**]).
.
Hypoxemic respiratory failure: possibly combination of dCHF,
aspiration, reactive airway disease. CXR shows findings
consistent with volume overload; expiratory wheezes [**2-1**] COPD vs
cardiogenic. Had 02 requirement, successfully weaned with
initial autodiuresis then minimal lasix. Pt irritated by
albuterol nebs, used atrovent nebs with good effect. Aspiration
precautions. Patient weaned down to room air, SpO2 100% at
discharge and without SOB.
.
Hypertension: had been hypotensive in setting of prolonged
diarrhea, dCHF, decreased PO intake. Held antihypertensives, but
then pressures were persistently elevated. So treated with
metoprolol, clonidine, amlodipine, with dose adjustment as
needed. Lisinopril continued to be held due to ARF, during
hospitalization. If continues to be hypertensive, suggest that
next med to be added/changed would be the addition of an ACE
inhibitor, ie; lisinopril (was on 40mg daily, would start at
10mg daily and titrate up, as tolerated by creatinine). Plan to
titrate down the clonidine, over 3 days, by halving dose each
day (continuing tid though).
.
Alcohol Abuse with hx DTs/PRES:
Diazepam per CIWA protocol. Got Zyprexa in ICU to provide some
sedation with decreased benzo load and clonidine. SW consulted.
No s/s of withdrawal while on floor. Discussed alcohol cessation
with patient.
.
Diabetes mellitus, type II, poorly controlled: continued lantus
and insulin SS, with adjustments to treat hyperglycemia
throughout hospital course. continue on sliding scale, and
adjust as needed to treat blood sugars.
.
Hypernatremia: corrected with free water drinking and D5W via
IV. Etiology unclear; perhaps hyperaldosterone state - please
follow-up renin and aldosterone level tests, sent from [**Hospital1 18**] on
the patient - or renal tubular acidosis are questionable.
Encourage free water drinking/hydration.
.
Hypokalemia, hypomagnesemia: unclear etiology, perhaps due to
alcohol or renal disease. Started daily PO potassium and daily
PO magnesium, with regular electrolyte checks. Again, please
follow-up on renin and aldosterone level tests on this patient,
sent out from [**Hospital1 18**] laboratory.
.
Hypocalcemia - Pt had transient hypocalcemia raising question of
hypoPTH or pseudohypoPTH, however PTH level wnl and hypocalcemia
resolved with repletion.
.
OUTSTANDING LABS: renin, aldosterone, drawn [**8-24**] at [**Hospital1 18**]
Medications on Admission:
AMLODIPINE - 5 mg daily
FLUCONAZOLE - 400 mg daily
FOLIC ACID - 1 mg daily
HYDRALAZINE - 25 mg Tablet Q 6 hrs
HYDROCHLOROTHIAZIDE - 25 mg daily
IBUPROFEN - 800 mg Tablet - Q 8 hours
INSULIN GLARGINE - 100 unit/mL Solution - 18 units qAM to 45
units qPM
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, daily
LISINOPRIL - 40 mg daily
METOPROLOL TARTRATE - 50 mg Tablet Q12
OMEPRAZOLE 20mg Q12
VANCOMYCIN - 250 mg Capsule - Q 8 - stop [**2190-8-12**]
ZOLPIDEM 10 mg QHS
VITAMIN D-3 - 2,000 unit Tablet - 50,000 IU weekly
Discharge Medications:
1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): The last day to take this medicine is [**2190-8-27**].
2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
3. Petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for dry skin, such as forearm.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): Please continue until
patient is ambulating regularly.
5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for for sleep.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) for 1 days: Please give this dose for one day, 8/28/9, as
we are tapering her down.
8. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Potassium Chloride 20 mEq Packet Sig: Two (2) PO DAILY
(Daily).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten
(10) ML Intravenous PRN (as needed) as needed for line flush.
15. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous
qachs: Please follow the attached sliding scale. Adjust as
needed for control of blood sugar.
16. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO three times a
day for 1 days: Please give this dose for one day, on [**8-28**]/9, as
we are tapering down her dose.
17. Clonidine 0.1 mg Tablet Sig: 0.5 Tablet PO three times a day
for 1 days: Please give this dose on [**2190-8-29**], as we are tapering
down this medicine. This will be the final day of treatment with
clonidine.
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day as needed for pain: Please
apply for maximum of 12 hours out of a 24 hour period.
19. Outpatient Lab Work
Please check chemistry 7, calcium, magnesium, phosphate, on
Friday [**8-27**], and adjust repletion of electrolytes as
necessary.
20. Outpatient Lab Work
Please follow-up outstanding renin and aldosterone levels,
ordered from [**Hospital1 18**], on this patient.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 6598**] manor Extended Care facility
Discharge Diagnosis:
C.difficile colitis
Acute Renal Failure
Knee fungal ([**Female First Name (un) **]) septic arthritis and osteomyelitis
Hypoxic respiratory failure
Metabolic acidosis
Hypokalemia
Hypernatremia
Hypocalcemia
Hypomagnesemia
Diabetes, insulin-dependent
Hypertension
Discharge Condition:
Afebrile, diarrhea resolved, creatinine improved, knee pain at
baseline, ambulating with assistance and walker. Feels eager to
leave hospital.
Discharge Instructions:
You were admitted to the hospital with diarrhea due to a
bacteria called c.difficile. Because of the dehydration due to
the diarrhea, your kidneys were injured. As we rehydrated you,
and treated your diarrhea with an antibiotic called vanocmycin,
your diarrhea went away and your kidney function improved back
to approximately your baseline. We continued you on the
antibiotics you were on for your right knee infection
(fluconazole) - the infectious disease team saw you and
recommended that you continue on that antibiotic for between
6-12 months; they will explain the specific course to you when
you go to your next appointment with them. For your knee pain,
physical therapy saw you and recommended that you go to rehab.
Your breathing was initially dificult so you were on oxygen, but
as that improved you were weaned down to room air. Your
potassium and magnesium levels were frequently found to be low,
so we started you on pills for those. Your sodium was frequently
high, so we encourage you to drink water to stay hydrated.
.
Please call your doctor or return to the hospital if you develop
a fever >100.4, chest pain, shortness of breath, abdominal pain,
re--occurrence of diarrhea, worsening right knee pain, or other
symptoms that concern you.
.
Please continue the oral fluconazole antibiotic (to treat your
knee infection) daily until you see the infectious disease
doctor, Dr. [**Last Name (STitle) 438**], and then you will still continue that
medicine for 6-12 months.
.
Please continue to avoid drinking alcohol.
.
We have changed your blood pressure medication regimen so that
now you are taking the following medications:
-clonidine
-amlodipine
-toprol XL
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD (Orthopedics) - Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2190-9-1**] 11:30
.
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2190-9-1**] 11:10
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD (Infectious disease).
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2190-9-3**] 9:30
.
Transthoracic echocardiogram. Date and time: [**9-9**] at
11am. Location: [**Hospital Ward Name 2104**] [**Location (un) **], [**Hospital Ward Name 516**], [**Location (un) 3387**]. Phone number: [**Telephone/Fax (1) 62**]
Completed by:[**2190-8-26**]
ICD9 Codes: 5849, 2762, 2760, 5990, 4019, 2720, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4098
} | Medical Text: Admission Date: [**2147-9-7**] Discharge Date: [**2147-9-27**]
Date of Birth: [**2083-2-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / Metformin
Attending:[**First Name3 (LF) 4963**]
Chief Complaint:
Mental Status Changes
Major Surgical or Invasive Procedure:
- intubation
- central line placement
- a-line placement
History of Present Illness:
64 year old women with history of mental retardation, MRSA
pneumonia, bipolar disorder and CHF presenting with a five day
history weakness, tremors and altered mental status. She feels
her symptoms began three weeks ago when she was started on
metformin and glipizide for DM control. She was taken off these
medications three days prior to admission. She describes tremors
and a fear of falling which have left her bed bound for the last
five days. She feels generally weak and has been having diarrhea
and polyuria. Her po intake has also decreased over the last
week. Per her and her caregivers, she has been increasingly
confused and agitated as well. Her PCP recommended coming to the
ED for evaluation.
.
In the ED, vitals were 98.1, BP 101/57, HR 74, R 18, 96% RA. FS
was 118. Labs demonstrated Lithium level 2.2, hyperkalemia,
hyponatremia and acute renal failure. She was given kayexelate,
insulin and glucose for her hyperkalemia with slight improvement
to 6.0. She had a transient hypotensive episode to SBP 89/33 and
received a 500 cc bolus and 8 mg IV Decadron for presumed
adrenal insufficiency. She responded and did not require any
further BP support. She received levofloxacin, flagyl and
vancomycin given leukocytosis and relative hypotension and was
transferred to the MICU for furhter monitoring.
Past Medical History:
1) Asthma
- PFTs [**6-22**] FEV1 0.54 (27%), FVC 0.57 (21%), FEV1/FVC 130% c/w
restrictive defect
2) Mental retardation
3) ?temporal lobe epilepsy: this diagnosis has been questioned
in the past
4) h/o MRSA PNA requiring intubation [**6-22**]: Pt was found down in
respiratory failure; etiology was unclear, but possible
contributors included OSA-associated hypercapnia, aspiration,
and congestive heart failure
- [**8-23**] CTA (technically limited): No central/lobar PE.
Improvement in previously-noted opacities in right lung.
5) Obstructive sleep apnea:
- [**9-22**] sleep study with titration of CPAP to 19 cm with 4L O2.
6) Bipolar disorder: currently on lithium and Seroquel
7) Hypertension
8) [**Location (un) 3484**] disease: diagnosis is unclear
9) Osteoarthritis
10) GERD
11) h/o CHF:
- EF [**5-23**] (limited): [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 100312**] dilated, RA moderately dilated,
asc aorta mildly dilated, 1+ MR, mod pulm artery systolic HTN.
12) Morbid obesity
Social History:
Lives in [**Hospital3 **] in Brookeline with visiting services.
Ambulates with a walker. No tobacco, alcohol, or other drug use
Family History:
cancer NOS in mom and dad
no HTN
no DM
Physical Exam:
vitals: 147/72, 76, 20, 93% 2L
General: pleasant female, MR, a+o X 3, no distress
HEENT: RERRL, OP clear, EOMI
Neck: obese, nontender, FROM
Car: RRR no murmur
Resp: [**Month (only) **] BS bilat--ant/lat exam
Abd: obese, soft, nontender +BS
Ext: no edema, erythematous rash on left shin
Neuro: MAE, A+OX3, does not cooperate with exam
Pertinent Results:
[**2147-9-7**] 11:40PM POTASSIUM-6.0*
[**2147-9-7**] 11:30PM GLUCOSE-104 UREA N-57* CREAT-2.1* SODIUM-129*
POTASSIUM-6.4* CHLORIDE-96 TOTAL CO2-27 ANION GAP-12
[**2147-9-7**] 09:56PM COMMENTS-GREEN TOP
[**2147-9-7**] 09:56PM LACTATE-1.0
[**2147-9-7**] 09:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2147-9-7**] 09:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2147-9-7**] 09:40PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2147-9-7**] 09:40PM URINE HYALINE-[**2-20**]*
[**2147-9-7**] 07:30PM GLUCOSE-100 UREA N-60* CREAT-2.3* SODIUM-126*
POTASSIUM-6.2* CHLORIDE-93* TOTAL CO2-28 ANION GAP-11
[**2147-9-7**] 07:30PM estGFR-Using this
[**2147-9-7**] 07:30PM LITHIUM-2.2*#
[**2147-9-7**] 07:30PM WBC-11.2*# RBC-4.10* HGB-12.4 HCT-36.7 MCV-90
MCH-30.2 MCHC-33.7 RDW-17.0*
[**2147-9-7**] 07:30PM NEUTS-85.2* LYMPHS-11.5* MONOS-1.9* EOS-1.2
BASOS-0.1
[**2147-9-7**] 07:30PM PLT COUNT-299
Brief Hospital Course:
A/P: 64F h/o bipolar on lithium, MR, CHF, DM2, admitted with
ARF, hyperkalemia, hyponatremia, elevated lithium level, now
attempting to wean off vent.
.
# Hypercarbic respiratory failure: Pt with chronic respiratory
acidosis likely [**1-20**] OSA/pulmonary HTN, asthma. In setting of ARF
[**1-20**] diarrhea, poor PO, likely triggered inability to eliminate
H+ and related worsening uncompensated respiratory acidosis.
Goal pCO2 = 65, as pt is likely obligate rapid shallow breather
at baseline given obesity. Attempt wean to PS 8/PEEP 8, with
diuresis to improve respiratory mechanics.
- First few days of ICU admission pt. was maintained on home
regimen of CPAP while sleeping and nasal cannula / room air
while awake
- [**Hospital **] hospital day 4 pt. with increasing somnolence and
increased positive fluid balance as renal function worsened and
thus increased biPAP requirement -> pCO2 continued to climb and
pt. intubated. Pt. underwent slow wean over the next 2 weeks ->
coupled with return of renal function, subsequent diuresis, and
treatment of MSSA pneumonia -> pt. completed 14 day course of
Vancomycin as she has pcn allergy
- [**9-19**] extubated in am and doing well -> tolerating CPAP
overnight and NC during the day.
Pt reports being complaint at home with her nebulizer, CPAP as
well as O2 nasal canula. During the day she uses her O2 by NC
most of the time.
.
# Acute renal failure: Cr 1.3, with baseline 0.8-1.0.
- Cr elevated on admission and 18-24 hours later pt. stopped
making urine. Renal was consulted and initially pt did not
respond to lasix. During this time pt. given some fluids and
kidneys slowly recovered on their own. Pt. had Cr. back to
normal level and we started lasix -> now Cr stable at 1.3, pt.
making adequate amounts of urine and processing meds
appropriately
-Initially held further diuresis as overall fluid balance per
physical exam seemed to be even. Diuresis started with 20 mg
lasix PO on medical floor again as pt's renal function o
baseline. Pt need weekly check of her renal function as long as
Lithium treatment continues.
.
# Intermittent low - grade temps: vancomycin as above [**1-20**] sputum
MSSA. Completed full 5 day azithromycin course. pt. had central
venous line placed which was removed once 14 day course of vanco
was complete. She remained afebrile after above.
.
# Bipolar d/o: Titrated lithium per ARF, now at lithium 150mg
QHS, with quetiapine 100mg PO TID, quetiapine 350mg PO HS.
Lithium level was elevated on arrival - 2.0 and psych / renal
advised that HD was not needed for lithium. We held lithium
until level was <1.0 with return of renal function. Restarted
lithium and following daily levels. Pt. will need to follow-up
with primary psychiatrist for further medication alterations. Pt
needs 2-3 times weekly Lithium levels check until stabilized on
this regiment for 3-4 weeks,.
.
# CHF: continued with lasix 20 mg daily as above
.
# DM2: Continued on humalog insulin SS q6h. Pt. with history of
reaction to oral hypoglycemics. Pt refused taking oral
antidiabetic but is now agreeing to take glipizide 2.5 mg [**Hospital1 **].
Will need follow-up with PCP and further dose adjustment.
Uncertain about capacity to learn how to use insulin.
.
# Asthma: Continued on home regimen of albuterol and
ipratropium.
.
# Decubitus ulcer -> on air mattress for much of her icu stay.
sacral decub dressed daily - stage I.
.
# FEN: [**Doctor First Name **] diet
.
# Full code
Medications on Admission:
Metformin 500mg [**Hospital1 **]--stopped X 3 days
Glipizide 2.5mg [**Hospital1 **]--stopped X 3 days
Prilosec 20mg daily
Loperamide 4mg 4 times daily PRN
Seroquel 300mg TID + 350mg qHS
Lithium 150mg TID
Ibuprofen 600mg 4 times daily
Furosemide 20mg daily
Lisinopril 2.5mg daily
Folic Acid 1mg daily
Singular 10mg daily
Atrovent Neb 4 times daily
Pulmicort
Discharge Medications:
1. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. Quetiapine 100 mg Tablet Sig: 3.5 Tablets PO HS (at bedtime).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
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. Lithium Carbonate 150 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)).
9. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
solution Inhalation Q4H (every 4 hours) as needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) solution
Inhalation Q6H (every 6 hours) as needed.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. GlipiZIDE 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**]
Discharge Diagnosis:
- acute renal failure
- hypercarbic respiratory distress
- MSSA pneumonia
- CHF exacerbation
- h/o bipolar
- h/o diabetes
- h/o asthma
Discharge Condition:
- good
Discharge Instructions:
- you should take all medications as instructed
- some of your medications have been changed -> please note
these changes
- you need to follow-up with you primary care doctor in the next
week
chills, nasuea, vomiting, chest pain, shortness of breath,
inability to urinate or urinating more than normal, change in
mental status, or any other concern
Followup Instructions:
**it is very important for you to keep the following
appointments**
- you need to follow-up with your primary care doctor within one
week of discharge -> this is for post-hospitalization follow-up,
medication review, blood testing for medication levels, and
diabetes management.
- you need to follow-up with your primary psychiatrist within
one week of discharge for post-hospitalization eval and
medication adjustment.
.
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] NP/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2147-11-20**] 12:00
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2147-11-20**] 12:00
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2147-11-20**] 11:40
ICD9 Codes: 5849, 2761, 2762, 4280, 2767, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4099
} | Medical Text: Admission Date: [**2159-4-9**] Discharge Date: [**2159-4-15**]
Date of Birth: [**2102-2-23**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: Right breast cancer.
PHYSICAL EXAMINATION: Unremarkable.
SUMMARY OF THE HOSPITALIZATION COURSE: The patient is a 57-
year-old female who has a history of right breast cancer.
She underwent a right mastectomy with axillary dissection and
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5884**] flap reconstruction, this occurred on [**2159-4-9**]. The
patient tolerated the procedure well. She was kept in the
recovery room for 24 hours. The details of the operation can
be found in the operative note. She was kept in the recovery
room for 24 hours for flap monitoring. There was return of
good blood flow to the flap. She was transferred to the
floor. She was in the hospital for 4 days.
She was discharged on [**2159-4-15**] without any difficulties. Her
Foley was removed over the interim, 2 of her JP drains were
removed, and she was ambulating and tolerating a regular
diet. She is to follow up with Dr. [**First Name (STitle) **] in 1 week. Her
discharge medications include Keflex and Percocet for pain,
and for drain removal in 1 week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 39103**]
Dictated By:[**Last Name (NamePattern4) 51569**]
MEDQUIST36
D: [**2159-8-6**] 12:53:14
T: [**2159-8-6**] 13:40:47
Job#: [**Job Number 51570**]
ICD9 Codes: 4019, 2449 |
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