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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4100
} | Medical Text: Admission Date: [**2170-6-5**] Discharge Date: [**2170-6-7**]
Date of Birth: [**2104-9-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 11974**]
Chief Complaint:
VT ablation
Major Surgical or Invasive Procedure:
[**2170-6-5**] Percutaneous ablation of VT focus
History of Present Illness:
65 yo M w/ PMH of CAD s/p anterior and inferior MI, ischemic
cardiomyopathy with EF of 30% ([**12/2167**]), Atrial fibrillation (on
dofetilide and coumadin), Ventricular tachycardia (s/p ICD
placement with multiple ICD shocks), DM II who was admitted to
the cath lab today for VT ablation. Patient has a prolonged
history of VT starting in [**2161**] with monomorphic VT and s/p ICD
placement then. Since placement he has been shocked multiple
times, once for atrial tachycardia and most recently in [**3-/2170**]
for sustain monomorphic VT in the setting of grocery shopping
and it was nonresponsive to antitachycardia pacing at 188. He
has since developed post-traumatic stress disorder due to the
multiple shocks. He has been previously treated for his afib
with amiodarone however developed transaminitis and therefore
was switched to dofetilide. He was evaluated by Dr. [**Last Name (STitle) **] as an
outpatient who recommended a trial of VT ablation in the cath
lab.
Today the patient underwent VT ablation with ablation around the
inferior scar where he had 2 inducible pathways. His course was
complicated by poor LV function in the cath lab and required
placement of an Impella.
On arrival to the floor the patient had already had the Impella
device removed. He was alert and interactive, slightly
confused. He denied chest pain or difficulty breathing and
reported that he would like to talk with his wife.
On 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 is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
#CAD s/p AMI and IMI (remote)
#Ischemic systolic heart failure with EF of 25% ([**1-/2168**])
#Moderate MR
#Atrial Fibrillation- has been trialed on amiodarone however
failed [**1-25**] transaminitis, currently on dofetilide
#Ventricular tachycardia- diagnosed in [**2161**] with monomorphic VT
with R axis at cycle length of 340msec. [**2170-3-25**] ED visit for
monomorphic VT at a rate of 188 beats per minute that failed to
terminate with two ATP therapies and required an ICD shock
#s/p Dual chamber ICD placed ([**Company 2267**]) in [**2161**] and
generator replaced in [**2164**]
#PTSD from ICD shocks
#Diabetes Mellitus
#HTN
#HLP
#Gout
#GAVE- with GI bleed in [**3-/2170**] s/p cauterization
Social History:
Spanish speaking. Originally from [**Male First Name (un) 1056**].
Jehovah's witness and does not accept tranfusions. Separated
from his wife & lives alone. Wife will accompany to procedure
via the ride.
Family History:
+ h/o heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 96.0, BP 120s/60s, HR 79-83, RR 13, O2 sat 100% 4L NC
GENERAL: NAD. Oriented x1 person only.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: unable to sit up due to groin sites, JVD not seen lying
flat
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. no murmurs, + S3. No thrills, lifts.
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.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx1, CNII-XII intact, 5/5 strength biceps, triceps,
knee/hip flexors/extensors
.
DISCHARGE PHYSICAL EXAM:
afebrile, BP 100-130s/80s, HR 80s, saturations 100% RA
exam unchanged
Pertinent Results:
ADMISSION LABS:
[**2170-6-5**] 07:42AM BLOOD WBC-7.3 RBC-4.01* Hgb-11.5* Hct-33.4*
MCV-83 MCH-28.6 MCHC-34.4 RDW-18.6* Plt Ct-194
[**2170-6-5**] 07:42AM BLOOD PT-17.1* INR(PT)-1.6*
[**2170-6-5**] 07:42AM BLOOD Glucose-179* UreaN-17 Creat-1.1 Na-123*
K-5.6* Cl-90* HCO3-25 AnGap-14
PERTINENT REPORTS:
[**2170-6-5**] Cardiovascular C.CATH
Technical
Anesthesia: Local and General
Specimens: None
Estimated Blood Loss: <50 cc
Interventional Details:
The primary operator was Dr. [**Last Name (STitle) **] [**Name (STitle) **] with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] as
the secondary operator proctoring the case. Obtained access in
the left common femoral artery. Inserted a 6 French Sheath and
using a "Preclose Technique" two Perclose AT devices were
deployed without complication after an initial Perclose needles
did not capture. Antiiotics were preadministered. The sheath
was exchanged for the 13 French Impella Sheath. An [**Doctor Last Name **]-1
Catheter was used to cross into the LV using a Straight wire.
The catheter was then used to exchange for the 0.18" Abiomed
Impella delivery wire with an appropriate curve to avoid trauma
to the LV Apex. The Impella device was inserted without
incident
and with a flow of 2.0 L on P8. The VT ablation was completed
(see separate report). The Impella device was removed. The
sheath was then removed and the Perclose sutures cinched down
acheiving complete hemostasis. The patient tolerated the
procedures including Impella removal, without complication.
[**2170-6-6**] CTA ABDOMEN AND PELVIS
PRELIMINARY READ: No retroperitoneal hematoma
DISCHARGE LABS:
[**2170-6-7**] 05:50AM BLOOD WBC-8.3 RBC-2.94* Hgb-8.6* Hct-25.1*
MCV-85 MCH-29.3 MCHC-34.5 RDW-18.3* Plt Ct-132*
[**2170-6-7**] 05:50AM BLOOD PT-40.2* PTT-32.6 INR(PT)-3.9*
[**2170-6-6**] 02:31PM BLOOD Ret Aut-1.5
[**2170-6-7**] 05:50AM BLOOD Glucose-122* UreaN-16 Creat-1.1 Na-129*
K-4.1 Cl-97 HCO3-28 AnGap-8
[**2170-6-6**] 02:31PM BLOOD LD(LDH)-272* TotBili-0.3
[**2170-6-7**] 05:50AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.8
[**2170-6-6**] 02:31PM BLOOD Hapto-43
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
Mr. [**Known lastname **] is a 65 year old male with history of ischemic
systolic heart failure (LVEF 30%) and recurrent monomorphic VT
s/p ICD who presents to the CCU s/p VT track ablation in the EP
lab. He transiently had an Impella device placed during the VT
ablation of his inferior wall scar. He tolerated the procedure
well and was transferred to the CCU for close monitoring.
ACTIVE PROBLEMS
# Ventricular tachycardia (VT) s/p ICD: His VT has been
monomorphic and he had inducible VT in 2 places around his
inferior wall scar. He underwent ICD implantation in [**2161**] and he
has been shocked multiple times over the years with
post-traumatic stress syndrome as a result. He underwent
ablation of these tracts in the EP lab on [**2170-6-5**] with transient
use of Impella device. He tolerated the procedure well and was
transferred to the CCU for further monitoring. Dofetilide was
restarted on transfer at home dose 500 mg [**Hospital1 **] and patient was
noted to be comfortable and appropriately atrially paced
throughout his stay.
# Hyponatremia: Na low at 123 on admission. Improved to 130
later in the day and was 133 morning after procedure without
intervention. Drifted back down. Appeared euvolemic so likely
related to heart failure.
CHRONIC PROBLEMS
# CAD: Patient with history of AMI and IMI with resultant heart
failure and ICD placement. He denied chest pain and EKG was
without evidence of ischemia. We continued valsartan 80 mg [**Hospital1 **],
carvedilol 25 mg [**Hospital1 **], and atorvastatin 40mg daily. He is not on
antiplatelet therapy due to history of GIB.
# Chronic systolic heart failure: Due to CAD as above, last LVEF
30% in [**2167**], and he is s/p ICD placement in [**2161**]. He had no
evidence of decompensation. We continued his valsartan 80mg [**Hospital1 **],
carvedilol 25mg [**Hospital1 **], lasix 40mg daily and spironolactone 25mg
daily.
# Afib: Continued patient's dofetilide and carvedilol. He was
noted to be atrially paced during his stay. Warfarin was held
prior to ablation, and was restarted following procedure.
# HTN: Well controlled during stay, continued home
antihypertensive regimen.
# HLD: Continued atorvastatin 40 mg daily.
# Diabetes: on metformin at home, A1c consistently in the 7s.
Metformin was held during stay and insulin sliding scale was
used. He was restarted on metformin on discharge.
TRANSITIONAL ISSUES:
- f/u with cardiology about ICD device checks
Medications on Admission:
AMMONIUM LACTATE - 12 % Cream - apply to feet twice a day
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth
once
a day for cholesterol
BENZONATATE - 200 mg Capsule - 1 Capsule(s) by mouth four times
a
day as needed for cough
CARVEDILOL - 25 mg Tablet - 1 (One) Tablet(s) by mouth twice a
day
CLONAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth one in am, and 2
qhs as needed for anxiety
DOFETILIDE - (Not Taking as Prescribed: put on hold as of [**6-1**])
-
500 mcg Capsule - 1 Capsule(s) by mouth q 12 h
ECONAZOLE - 1 % Cream - apply [**Hospital1 **] to rash on back and chest x 6
weeks disp at least 60gram tube
FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 1 puff each
nostril once a day for allergies/running nose
FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day for swelling and blood pressure
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day for
diabetes (also called GLUCOPHAGE)
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 (One) Tablet(s) by mouth once a day generic fine
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth q o d
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - Apply twice daily to
affected areas for up to 2 weeks/month max twice a day as needed
for AVOID face and folds
VALSARTAN [DIOVAN] - 80 mg Tablet - 1 Tablet(s) by mouth twice a
day
WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth as directed last dose pre procedure Thurs INR
3.5 friday
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - test
twice a day
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
PEG 400-PROPYLENE GLYCOL [LUBRICANT EYE (PEG-PEG 400)] - (Not
Taking as Prescribed: ran out) - 0.3 %-0.4 % Drops - 1 drop(s)
each eye three times a day
SENNOSIDES-DOCUSATE SODIUM - 8.6 mg-50 mg Tablet - 1 OR 2
Tablet(s) by mouth at bedtime as needed for constipation
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Carvedilol 25 mg PO BID
Please hold for SBP < 90, HR < 50
3. Dofetilide 500 mcg PO Q12H
chronic dose. Does not need ecg 2 hours after each dose
4. Furosemide 40 mg PO DAILY
Please hold for SBP < 90
5. Spironolactone 25 mg PO DAILY
Please hold for SBP < 90
6. Valsartan 80 mg PO BID
Please hold for SBP < 90
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Clonazepam 1-2 mg PO BID:PRN anxiety or insomnia
Take 1 tab in the morning or 2 tabs at night as needed for
anxiety or insomnia
9. Pantoprazole 40 mg PO Q24H
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Multivitamins 1 TAB PO DAILY
12. Senna 1 TAB PO DAILY:PRN constipation
13. Warfarin 2 mg PO DAILY16 Start: In am
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Ventricular tachycardia
Secondary diagnosis:
Coronary artery disease
Heart failure
Hypertension
Dyslipidemia
Diabetes
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital for a procedure to help
prevent dangerous heart rhythms. You tolerated the procedure
well and were monitored closely in the ICU and on the cardiology
floor afterwards. You are now ready to go home. We made one
change to your medications: hold your Coumadin for today and
tomorrow. Resume your usual dose of Coumadin on Saturday and
otherwise continue all your other medications as previously
prescribed. It is important to follow up with your regular
doctors as we have scheduled below. It has been a pleasure
taking care of you!
FOr your heart failure diagnosis: Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 3 days or 5 lbs in
2 days, follow a low salt diet.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2170-6-20**] at 10:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2170-6-20**] at 10:30 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: THURSDAY [**2170-6-21**] at 9:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**2169-7-12**]:20
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 62**])
[**Hospital Ward Name 23**] [**Location (un) 436**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
ICD9 Codes: 4271, 2761, 4280, 4019, 4240, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4101
} | Medical Text: Admission Date: [**2126-3-28**] Discharge Date: [**2126-4-8**]
Date of Birth: [**2064-9-10**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
patient was playing tennis with his friends, while reaching the
ball fell backwards, striking back of his head on ground.GCS
upon arrival to ED was 15, alert, awake, following commands,
vomiting multiple times in ED. CSF leakage noted [**Last Name (un) 834**] his left
ear.Patient admiited to Neuro ICU on [**2126-3-28**].
Major Surgical or Invasive Procedure:
Lumbar drain
History of Present Illness:
patient was playing tennis with his friends, while reaching the
ball fell backwards, striking back of his head on ground.GCS
upon arrival to ED was 15, alert, awake, following commands,
vomiting multiple times in ED. CSF leakage noted [**Last Name (un) 834**] his left
ear.Patient admiited to Neuro ICU on [**2126-3-28**].
Past Medical History:
BPH, NIDDM, HTN
Social History:
MARRIED, has a son
Family History:
noncontributary
Physical Exam:
vital signs; Temp 100.2 Hr 78, BP 210/P, RR 18 100%
alert awake, follows comands, NAD.
HEENT: CSF leakage left ear.
NECK ;In collar.
CHEST: CTA A/P
CVS: RRR, NO M/G/R
ABD;soft , nontender, bowel sounds present.
EXT: warm , no edema BLE
NEURO: alert awake, oriented x3 , language fluent, PERRLA, CN
II-XII grossly intact, face symmetric tongue midline, normal
bulk bilaterally, full stength. sensation intact to light touch
T/O.Reflexes 2+ toes, downward. coordination intact.
Pertinent Results:
[**2126-3-28**] 10:42PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2126-3-28**] 10:38PM GLUCOSE-218* LACTATE-3.0* NA+-141 K+-4.8
CL--106
[**2126-3-28**] 10:38PM HGB-11.1* calcHCT-33 O2 SAT-99 CARBOXYHB-0
MET HGB-0
[**2126-3-28**] 10:34PM FIBRINOGE-312
[**2126-3-28**] 10:34PM PT-13.5 PTT-18.4* INR(PT)-1.2
Brief Hospital Course:
Patient S/P fall with basal skull fracture, right frontal
contusion, bilateral smal SDH admitted on [**3-28**] to neuro ICU.
Left ear CSF leakge was present upon arrival which required
lumbar drain, also followed by trauma ICU team.while in ICU stay
patient had an 4 beat NSVT, cardiology seen, echo showed
EF>55%, mild LVH. Bilateral lower extremity ultrasound showed
superficial thorombosis. Bilateral lower extremity ultrasound
to be repeated in two weeks.Patient no longer has left ear CSF
leakage. Doing well, low grade temp present.Pneumonia found on
chest xray and was started on Levofloxacin for 10d. Fevers
cleared.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
basilar skull fracture
small right frontal pole contusion.
Bilateral small subdural hematoma.
Discharge Condition:
neurologically stable.
Discharge Instructions:
Report any mental status changes, leakage from ear, fever
greater then 101.
Followup Instructions:
Follow up in 6 weeks with Dr.[**Last Name (STitle) 739**] and Head CT. Call for
an appointment at [**Telephone/Fax (1) 3571**].
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2126-4-8**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4102
} | Medical Text: Admission Date: [**2174-1-4**] Discharge Date: [**2174-1-19**]
Date of Birth: [**2132-2-29**] Sex: F
Service: MEDICINE
Allergies:
Nevirapine / Abacavir / Ampicillin / Tylenol / Zidovudine
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
increased lower extremity swelling. Concern about ability to
care for self at home.
Major Surgical or Invasive Procedure:
L femoral central line, R internal jugular central line, CVVH
History of Present Illness:
41F with advanced HIV/AIDS (last CD4 5 in [**8-23**], unknown viral
load) and cardiomyopathy (EF 20%) who was recently hospitalized
at [**Hospital1 18**] [**Hospital Ward Name **] for bibasilar pneumonia for which she
completed a full 2 week course of levo and flagyl. She is a
poor historian. She notes having leg swelling at that time and
was discharged to home 2 days ago with [**Male First Name (un) **] stockings. She says
she has been wearing her [**Male First Name (un) **] stockings since leaving the
hospital. She returned to the ED last night with complaints of
continued leg swelling and feeling week for the last two weeks.
She denies SOB, DOE, orthopnea, PND. She denies eating fast food
or salty foods, but then states she has been eating chicken
noodle soup from a can. She denies fever/chills. Denies cough
but has been spitting up clear fluid that looks like saliva.
Denies dysphagia. She has only got half of her prescriptions
since discharge from hospital, and says she has taken Bactrim,
immodium, digoxin, and pain medication. She does not know the
name, number, or type of HAART drugs that she takes, and only
identifies Bactrim as her "HIV medicine."
.
In the ER the patient received 10IV lasix, and a femoral line
was placed (she has VERY difficult access and last picc just
d/ced two days ago).
.
She denies feeling unsafe at home (although by report last night
this is her reason for admission). States she has her daughter
and [**Name (NI) 269**] to help her. She has occasional abdominal pain across
the top of her abdomen nad occasional associated nausea, but
none right now. No other complaints.
Past Medical History:
HIV/AIDS - h/o PCP x 2, MAC, cervical dysplasia, HSV anal
ulcers. CD4 ct 5 in [**2173-8-19**], viral load unknown
cardiomyopathy - EF 20% [**2173-12-28**]
new renal insufficiency since [**2173-11-18**] with baseline cr mid
2s
depression
asthma
Social History:
Divorced. Lives in apartment with 13 yo daughter. [**Name (NI) **] [**Name2 (NI) 269**] at
home. Pt reports feeling safe at home. Ambulates with walker.
Denies tobacco, alcohol, or other drug use.
Family History:
CAD: mother died age 57 MI
Physical Exam:
VS 97.7 112/68 18 on room air (O2 sat not yet checked)
Gen: sitting up in bed, very quiet speaking, NAD, pleasant
HEENT: NCAT
Neck: no LAD, no JVD
Cor: s1s2, +s3, no r/g/m, tachy
Pulm: CTA, decreased BS at B bases L>R, very mild crackle at R
base
Abd: soft, NTND, +bs, no hsm
Ext: [**Male First Name (un) **] stockings on, 2+PT pulses, 1+ pitting edema through, R
femoral line line in place, sanguinous drainage on dressing,
stockings to knees
Skin: no rashes
GU: foley catheter wtih yellow urine in bag
Pertinent Results:
-BNP 64,499. Digoxin 0.8. Creatinine 2.1 (lower than new
baseline since [**Month (only) **]). Hct 27.5 ( above baseline). Albumin
2.2.
-CXR: persistant bibasilar pna with persistant bilateral
effusions.
-Echo LVEF 20%, small-mod pericardial effusion with no
tamponade, global hypokinesis on [**2173-12-28**]
Brief Hospital Course:
Ms. [**Known lastname 31473**] is a 41 yo woman with end stage AIDS, HIV
cardiomyopathy with last EF [**12-24**] <20%, and HIV nephropathy with
very low UOP and nephrotic range proteinuria who was
hospitalized in [**Month (only) 1096**] for 3 weeks with bibasilar pneumonia
for which she was given a 2 week course of levo/flagyl. She was
discharged with stable LE edema and on an HIV salvage regimen
consisting of 5 HAART meds. She returned to the hospital one
day after discharge complaining of possible increased LE edema,
which was found to be unchanged from prior on exam. She seemed
to feel "unsafe" at home but was unable to elaborate on that.
Cultures from previous hospitalization returned at that time
with [**Doctor First Name **] in sputum and stool and she was started on treatment.
.
Five days after admission, the patient was prepared for
discharge to a [**Hospital1 1501**] with HIV specialty floor, when she complained
of new onset SOB, RR 30s-40s x hours, and eventual hypoxia. ABG
revealed lactic acidosis with lactate of 16 and ph of 7.19. FS
at that time was 24. This was all believed to be lactic acidosis
caused by HIV meds (zidovudine) interfering with mitochrondrial
function. She recieved 1 amp NaHCO3, 1 amp D50 and 500 cc NS
bolus.
.
She was transferred to the ICU, where she required CVVH for
lactic acidosis and D10 for hypoglycemia. She developed
multi-system organ failure, including liver failure, increased
oliguria, pancreatitis, and hemolysis. She responded well to
CVVH and after family meeting CVVH was discontinued and decision
was made not to restart dialysis of any sort even if her lactic
acidosis were to recur. She was treated with aztreonam and
vanco by levels for bilateral pneumonia. The patient expressed
an interest in going to hospice. A palliative care consult was
ordered and pt was transferred to floor.
.
The patient's 13 year old daughter is not aware of her mother's
HIV status and the patient has not been forthcoming about her
current prognosis. A family meeting with the patient, Drs.
[**Last Name (STitle) 31478**] and [**Name5 (PTitle) 31479**] social worker [**Name (NI) 30513**], the patient's
daughter [**Name (NI) 31480**], her daughter's cousin, and Ms. [**Known lastname 31476**]
sister-in-law. At this meeting the family was updated on the
patient's generally poor prognosis. The pt decided that she
would like to go to hospice, and understood the goals of
hospice. The pt was seen by Palliative care and she was placed
in a hospice of her choice. The pt stated she would like to
complete the course of PO antibiotics which were started in the
MICU. Her central line was pulled, uneventfully, on the day of
discharge. The patient was discharged on cefpodoxime and
azithromycin for 4 days to complete her course of antibiotics
for pneumonia. The pt will be continued on her digoxin for heart
failure, ipratropium nebulizer for shortness of breath, Bactrim
for PCP prophylaxis, [**Name9 (PRE) 31481**] for hyperphosphatemia secondary to
renal failure and lasix for shortness of breath and painful
lower extremity edema.
.
The pt reported that she will inform her family of the tranfer
to the hospice facility. Her brother was present for this
conversation.
Medications on Admission:
(unclear which meds pt was taking for the 2 days between
discharge from hospital and this admission but she reports not
missing any Bactrim doses)
(HAART meds are "salvage Tx")
bactrim
megace 40 qday
ritonavir 200 [**Hospital1 **]
lamivudine 100 qday
zidovudine 300 [**Hospital1 **]
tipranavir 500 [**Hospital1 **]
tenofovir 300qwed, sat
loperamide 2mg qid prn diarrhea
digoxin 125mcg qOd
azithromycin 600mg qwed
bactrim ss qday
oxycodone [**4-27**] q6h prn pain
protonix 40qday
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO qday prn as needed
for shortness of breath or painful edema.
7. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 4 days.
8. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2542**] - [**Hospital1 1474**]
Discharge Diagnosis:
HIV/AIDS
Cardiomyopathy (EF 20%) [**2173-12-28**]
New renal insufficiency (baseline Cr 2s)
GERD
Asthma
Depression
Discharge Condition:
Stable
Discharge Instructions:
You are being transferred, at your request, to a hospice. Goals
of care are to continue meds by mouth that will help you feel
better or prevent further infections, but no IV's, labs, or
fingersticks will done.
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2174-1-18**]
ICD9 Codes: 486, 4254, 2762, 5849, 5859, 2875, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4103
} | Medical Text: Admission Date: [**2109-10-21**] Discharge Date: [**2109-10-26**]
Date of Birth: [**2040-6-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2109-10-21**]:
1. Coronary artery bypass grafting x3 with left internal mammary
artery to left anterior descending coronary artery; reverse
saphenous vein single graft from the aorta to the first obtuse
marginal coronary artery; reverse saphenous vein single graft
from the aorta to the posterior descending coronary artery.
2. Full left-sided Maze procedure with resection of left atrial
appendage using the Atricure synergy bipolar RF system and the
cryo cath.
3. Patent foramen ovale closure.
4. Epicardial LV lead x2.
History of Present Illness:
69 year old male who was hospitalized at [**Hospital3 3765**] in
[**Month (only) **] with a GI bleed. An endoscopy revealed gastric ulcers
which were attributed to NSAIDs and a positive H. pylori. He was
treated with cessation of NSAIDs antibiotics for the H. pylori.
A repeat endoscopy showed resolution of the ulcers. During this
admission a cardiac evaluation was done. A nuclear stress test
showed a moderate size, severe, partially reversible inferior
wall defect. A coronary CTA showed an elevated calcium score in
the territory of the left anterior descending artery. The
cardiac workup was done due to patient feeling shortness of
breath, chest tightness and weak while cycling at the gym. He
states he is in his normal state of health. He was referred for
a cardiac catheterization for furter evaluation and was found to
have three vessel coronary artery disease. He is now being
referred to cardiac surgery for revascularization.
Past Medical History:
Paroxysmal Atrial Fibrillation
Hyperlipidemia
Hypothyroidism
Peripheral neuropathy
GERD
H. pylori
Gastric Ulcer
Right eye optic nerve damage as a child
Social History:
Occupation:Video transfer work
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-21**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Family History:Premature coronary artery disease:
Father MI < 55 [x]x2 Mother < 65 []
Physical Exam:
Pulse:54 Resp:16 O2 sat:99/RA
B/P Right:146/73 Left:137/73
Height:5'7" Weight:150 lbs
General:
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 [x]
Neuro: Grossly intact [x]
Pulses: all palpable 2+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2109-10-21**] ECHO
PRE-CPB:1. The left atrium is mildly dilated. No thrombus is
seen in the left atrial appendage.
2. A patent foramen ovale is present.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal.
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild to moderate ([**12-16**]+) aortic regurgitation is seen.
There is a small central jet and a small jet between the left
and right coronary cusps.
7. Trivial mitral regurgitation is seen.
8. There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. AV pacing. Preserved
biventricular systolic function post cpb. LVEF = 60%. 1+ AI,
trace MR. [**First Name (Titles) **] [**Last Name (Titles) 14205**] remnant is ligated. The pfo flow is trivial
post repair. Aortic contour is normal post decannulation.
[**2109-10-26**] 06:30AM BLOOD WBC-4.7 RBC-3.14* Hgb-9.8* Hct-29.1*
MCV-93 MCH-31.1 MCHC-33.6 RDW-13.1 Plt Ct-212#
[**2109-10-26**] 06:30AM BLOOD Glucose-101* UreaN-26* Creat-0.8 Na-136
K-3.7 Cl-98 HCO3-30 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 22325**] was admitted to the [**Hospital1 18**] on [**2109-10-21**] for
surgical management of his coronary artery disease. He was taken
directly to the operating room where he underwent coronary
artery bypass grafting to three vessels, a PFO closure,
placement of left ventricular leads and a MAZE procedure. Please
see operative note for details. Postoperatively he was taken to
the intensive care unit for monitoring. He later awoke
neurologically intact and was extubated. He was slowly weaned
from pressors. Free water was restricted due hyponatremia. He wa
transfused for postoperative anemia. On postoperative day two,
he was transferred to the step down unit for further recovery.
He was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. Pradaxa was started for
anticoagulation for atrial fibrillation.
Mr. [**Name14 (STitle) 22326**] continued to make steady progress and was
discharged home on postoperative day 5. He is scheduled to
follow-up with Dr. [**Last Name (STitle) 914**], his cardiologist and his primary
care physician.
Medications on Admission:
ALENDRONATE 70 mg weekly Saturday morning
ATENOLOL 25 mg once a day
ATORVASTATIN 20 mg once a day
FLECAINIDE 100 mg three times a day
LEVOTHYROXINE 150 mcg once a day
OMEPRAZOLE 20 mg twice daily
ASPIRIN 81 mg daily
COENZYME Q10 [CO Q-10] [**Hospital1 **] 300 in am and 400 in pm
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] 1000 Daily
Magnesium 500mg Daily
Vitamin C 500mg [**Hospital1 **]
Calcium 1000mg [**Hospital1 **]
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
Disp:*45 Tablet(s)* Refills:*2*
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. 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*
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
Disp:*40 Tablet(s)* Refills:*0*
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Packet Sig: Two (2) PO once a day
for 7 days.
Disp:*14 20 mEq* Refills:*0*
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
s/p coronary artery bypass grafts
coronary artery disease
Paroxysmal Atrial Fibrillation
Hyperlipidemia
Hypothyroidism
Peripheral neuropathy
gastroesophageal reflux
h/o Gastric Ulcer
Right eye optic nerve damage as a child
Spinal operation [**2106**], [**2107**] thoracic and lumbar
s/p cataract surgery
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication
Goal INR
First draw
Results to phone fax
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]on [**2109-11-25**] at 1:30pm in the
[**Hospital **] Medical Office Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]. Wound
check in same locale on [**2109-10-31**] at 11am
Cardiologist:Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2109-11-19**] at 1pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 22327**] [**Name (STitle) 22328**] ([**Telephone/Fax (1) 21640**]) in [**3-19**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2109-10-26**]
ICD9 Codes: 2761, 2724, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4104
} | Medical Text: Admission Date: [**2195-4-18**] Discharge Date: [**2195-5-9**]
Date of Birth: [**2147-7-10**] Sex: F
Service: MICU
SUMMARY OF HOSPITAL COURSE: The patient is a 47-year-old
female with multiple medical problems who was transferred from
[**Hospital3 417**] Hospital to [**Hospital1 188**] on [**2195-4-18**] with acute renal failure bacteremia
of unknown origin. She had a long, complex hospital course
involving intubation, cardiopulmonary failure, need for
dialysis, and sepsis. Ultimately, after a prolonged,
difficult course, the patient expired on [**2195-5-9**] at 7:00
p.m. and was pronounced dead. The family agreed to an
autopsy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern4) 99534**]
MEDQUIST36
D: [**2195-7-27**] 16:14:18
T: [**2195-7-29**] 09:11:22
Job#: [**Job Number 99535**]
ICD9 Codes: 5845, 5185, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4105
} | Medical Text: Admission Date: [**2199-2-4**] Discharge Date: [**2199-2-15**]
Date of Birth: [**2175-5-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Decannulation of tracheal tube
Major Surgical or Invasive Procedure:
[**2-6**] Flexible bronchoscopy and revision of tracheostomy site and
replacement of a 7.0 [**Last Name (un) 295**] adjustable tracheostomy tube.
[**2-7**] Flexible bronchoscopy
History of Present Illness:
Mr. [**Known lastname **] is an unfortunate 24 y/o male with severe mental
retardation and history of tracheobronchomalacia whose
tracheostomy tube fell out at home. He was seen in the
[**Hospital3 2783**] emergency department, where the tube was
unable to be reinserted secondary to stenosis of the
tracheostomy, so he was intubated and transferred to [**Hospital1 18**] for
repalcement of trach tube.
Past Medical History:
PMH:
1.diphtheria static encephalitis at 2mo old
2.infantile spasms progressing to refractory seizure d/o
seizure history, as documented by [**Hospital1 18**] Neurology:
h/o chronic seizure d/o which started as infantile spasms and
progressed to refractory seizures. Per father, at baseline,
patient has spastic movements of his arms and legs. He has
about 3 seizures per day, which consist of his "arms and mouth
stiffening," and twitching movements of his mouth. During his
[**Hospital3 1810**] [**Location (un) 86**] hospitalization [**9-29**], he was found
to have a dilantin level of 37.3 and phenobarbital level of
23.5; his dilantin was held until levels became non-toxic and
the dose was then decreased to 100 mg PO qam and 125 mg PO
qpm. His dilantin level prior to [**Hospital1 18**] transfer was 14.6.
3.s/p VNS in [**2193**]
Social History:
Mother - healthy
Father - seizure disorder - 0-3 seizure/day. His seizures are
manifest as generalized tonic events with arm and leg stffening
and facial grimacing movements. These episodes typically last
1-2 minutes and self resolve. The
family uses Diastat prn seizure> 5 minutes. Father is not sure
if patient has ever had an episode of status epilepticus or
required ICU stay for his seizures.
Family History:
non-contributory
Physical Exam:
On admission:
VS T 99, HR 108, BP 162/105, RR 14, 100% on vent (settings not
recorded)
Gen: Intubated, sedated
HEENT: NC/AT, PERRLA
Neck: supple
Chest: Coarse breath sounds B/L, intubated
Heart: S1S2 RRR
Abd: Soft, NT/ND, + Gtube
Ext: no C/C/E, no rash
Pertinent Results:
[**2199-2-4**] 08:50PM WBC-13.7*# RBC-4.10* HGB-12.3* HCT-35.7*
MCV-87 MCH-29.9 MCHC-34.3 RDW-14.2
[**2199-2-4**] 08:50PM GLUCOSE-90 UREA N-12 CREAT-0.6 SODIUM-139
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
[**2199-2-4**] 08:50PM PLT COUNT-397
*****[**2-4**] CHEST XRAY: AP PORTABLE CHEST: There has been interval
repositioning of the endotracheal tube which terminates below
the thoracic inlet approximately 4-5 cm above the carina.
Otherwise there has been no appreciable change in appearance of
the chest. The lungs are clear. Left mainstem bronchial stent
and vagal nerve stimulator are unchanged.
IMPRESSION: Repositioning of endotracheal tube which is now
below thoracic inlet 4-5 cm above the carina
*****[**2199-2-6**] OPERATIVE REPORT:
PREOPERATIVE DIAGNOSIS: Respiratory failure.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURES: Flexible bronchoscopy and revision of
tracheostomy site and replacement of a 7.0 [**Last Name (un) 295**] adjustable
tracheostomy tube.
ASSISTANT: Dr. [**First Name4 (NamePattern1) 915**] [**Last Name (NamePattern1) **]
ANESTHESIA: General endotracheal.
IV FLUIDS: 700.
ESTIMATED BLOOD LOSS: Minimal.
INDICATION FOR PROCEDURE: Mr. [**Known lastname **] is a 23-year-old
gentleman who has tracheal stenosis and tracheomalacia and
has been dependent on a tracheostomy tube. This fell out and
he needed a replacement. He had been intubated endotracheally
from the mouth and in the interim his tracheostomy site
closed. Therefore, he returns to the operating room for
revision of the site.
PROCEDURE IN DETAIL: The patient was positioned supine with
his arms tucked and a roll behind his back with his neck
extended. I did flexible bronchoscopy through the
endotracheal tube and I could see that there was a fair
amount of granulation tissue at the left mainstem bronchus.
There was very severe malacia. We then dilated with a
hemostat the previous tracheostomy site. I was able to undo
the contraction of the scar by bluntly spreading the
granulation tissue which was formed underneath the epithelial
layer. Once I got down to the anterior wall of the trachea I
placed the tip of the hemostat through the anterior tracheal
wall at the level of the previous tracheotomy. I could
visualize this through the bronchoscope placed via the
endotracheal tube once I pulled the endotracheal tube back to
just below the cricoid cartilage.
I then serially dilated the tract using Hegar dilators. We
placed these under direct bronchoscopic vision so as not to
injure the posterior tracheal wall. We started with the
smallest dilator and worked our way up to the 37 size. After
removing this, I then easily slid in the [**Last Name (un) 295**] trache tube.
I then bronchoscoped through the trache tube and saw that it
was approximately 4 cm above the carina. Of note, the
granulation tissue at the left mainstem bronchus was fairly
encroaching on the airway and I was unable to get a good view
of the left mainstem with the pediatric scope.
We then anchored the trache flange to the skin using 0
Prolene. There was minimal bleeding. I was present for the
entire procedure.
***** [**2199-2-7**] BRONCHOSCOPY:
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 75261**]
ASSISTANT: [**First Name8 (NamePattern2) 74204**] [**Name8 (MD) **], M.D.
PROCEDURE PERFORMED: Flexible bronchoscopy.
INDICATION: Mr. [**Known lastname **] [**Last Name (Titles) 1834**] tracheostomy revision and was
found to have left main stem bronchial obstruction.
PROCEDURE IN DETAIL: Informed consent was obtained from the
patient's mother. Flexible bronchoscopy was performed through
the newly placed tracheostomy tube. Evaluation of the airways
revealed normal right main stem bronchus and right upper
lobe, right middle lobe, and right lower lobe segmental
bronchi. On the left, the takeoff for the left main stem
bronchus appeared to be completely occluded with a
combination of granulation tissue and malacia. The
bronchoscope could not be advanced into the left main stem
bronchus to visualize the stent that has been placed there
before. Following this, the procedure was terminated and the
bronchoscope was withdrawn. The patient tolerated the
procedure without any complications.
***** [**2199-2-13**] PICC LINE PLACEMENT:
PICC line placement
CLINICAL INDICATION: Bacteremia and pneumonia.
RADIOLOGISTS: Drs. [**Last Name (STitle) **], [**Name5 (PTitle) 15785**] and [**Name5 (PTitle) 2492**]. Dr. [**Last Name (STitle) 2492**],
the Attending Radiologist, supervised the entire procedure.
TECHNIQUE: Using sterile technique and local anesthesia, the
right brachial vein was punctured under direct ultrasound
guidance. Hard copy ultrasound images were obtained before and
after venous access documenting vessel patency. There was
difficulty advancing the guidewire past the axillary vein,
therefore, a small amount of contrast was injected into the
right brachial vein, demonstrating complete occlusion of the
subclavian vein with multiple collaterals. A peel-away sheath
was then placed over the guidewire and a 4 french single-lumen
PICC line measuring 7 cm in length was placed through the
peel-away sheath with its tip positioned in the axillary vein
under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest. The
peel-away sheath and guidewire were then removed. The catheter
was secured to the skin, flushed, and a sterile dressing
applied. The patient tolerated the procedure well. There were no
immediate complications. Total dose was 11 cGy/cm2 and total
fluoro time was 0.8 minutes.
IMPRESSION: Complete occlusion of the distal right subclavian
vein with ultrasound and fluoroscopically guided right brachial
PICC line with final internal length of 7 cm and the tip
positioned in the axillary vein. If more permanent venous access
is desired, central access after vein mapping can be considered.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the ICU from the Emergency Department
on [**2199-2-4**]. Interventional pulmonology attempted to reinsert
the trachestomy the next day but was unsuccessful secondary to
stenosis of the stoma. Thus on [**2-6**] he was taken to the OR,
serial dilations of the stoma were performed, and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 295**]
tracheostomy tube was inserted. Please see operative report
dictated [**2199-2-6**] for complete details of the procedure. On the
next day bronchoscopy was performed, which revealed that his
left mainstem bronchus was completely occluded with granulation
tissue/malacia, which could not be passed by the scope. A
discussion was conducted with his family, and the decision was
made not to intervene on the stenosis.
On [**2199-2-8**] Mr. [**Known lastname **] [**Last Name (Titles) 28316**] a fever to 104 degrees, so was pain
cultured and started on empiric antibiotic treatment with
ciprofloxacin, vancomycin, and cefepime. His respiratory and
blood cultures grew out pseudomonas that was sensitive to
ciprofloaxin and cefepime, so the Vancomycin was discontinued.
His fever curve gradually trended down, and he was weaned to 50%
trach. A PICC line was attempted on his R side but could not be
advanced past the axillary vein secondary to occlusion of the R
subclavian. He was transferred to the floor on [**2199-2-13**].
On the floor Mr. [**Known lastname **] continued to do well and was tolerating
his trach mask. His femoral line was DC'd on [**2-15**] and he was
discharged to home with home services.
Medications on Admission:
Clonazepam, Topamax, Lansoprazole, Ipratropium/albuterol,
Diazepam, Phenytoin, Lorazepam, Phenobarbital, Miconazole,
Dulcolax, Albuterol
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution [**Month/Year (2) **]: [**11-11**] mL PO Q6H
(every 6 hours) as needed for fever, pain.
2. Topiramate 100 mg Tablet [**Month/Year (2) **]: Two [**Age over 90 **]y Five (225)
mg PO QAM (once a day (in the morning)).
3. Topiramate 100 mg Tablet [**Age over 90 **]: Two [**Age over 90 1230**]y (250) mg PO
QPM (once a day (in the evening)).
4. Clonazepam 1 mg Tablet [**Age over 90 **]: Two (2) Tablet PO QAM (once a day
(in the morning)).
5. Clonazepam 1 mg Tablet [**Age over 90 **]: Three (3) Tablet PO QPM (once a
day (in the evening)).
6. Phenobarbital 30 mg Tablet [**Age over 90 **]: Two (2) Tablet PO BID (2
times a day).
7. Phenytoin 100 mg/4 mL Suspension [**Age over 90 **]: Eight (8) mL PO Q12H
(every 12 hours).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
9. Ciprofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
12. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2
times a day) as needed for constipation.
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: One
(1) ML Intravenous DAILY (Daily) as needed.
Disp:*50 ML(s)* Refills:*0*
14. Cefepime 2 gram Recon Soln [**Last Name (STitle) **]: Two (2) grams Injection Q12H
(every 12 hours) for 6 days.
Disp:*24 grams* Refills:*0*
15. Lorazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6)
hours as needed for anxiety.
16. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed.
Discharge Disposition:
Home With Service
Facility:
Excel Home Care, Inc
Discharge Diagnosis:
Tracheobronchomalacia
Mental retardation
Seizure disorder
Diptheria encephalitis
Pseudomonas bacteremia
Discharge Condition:
Stable.
Discharge Instructions:
Please call or return to the hospital if you have any of the
following:
* Shortness of breath or persistently increased respiratory rate
* Fever to 101 degrees or chills
* Any other symptoms that are concerning to you.
You may resume your tube feeds and home medications as before.
You will receive 2 antibiotics, Cefepime and Ciprofloxacin,
through an IV until [**2-21**].
Followup Instructions:
Please contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 3020**] to schedule a followup
appointment in [**2-24**] weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2199-2-15**]
ICD9 Codes: 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4106
} | Medical Text: Admission Date: [**2163-4-20**] Discharge Date: [**2163-5-3**]
Date of Birth: [**2098-1-5**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
? wound ischemia.
Major Surgical or Invasive Procedure:
Quentin Catheter removal
PROCEDURE: Sharp debridement of sacral decubitus wound at
the bedside.
History of Present Illness:
This is a 65 y/o gentleman s/p TAAA
repair on [**2163-2-15**], complicated by mesenteric ischemia and
paraplegia, s/p exlap, left colectomy, open abdomen on [**2163-2-22**],
s/p washout, resection of proximal rectum on [**2163-2-23**], s/p trans
seg colectomy, end colostomy, GJ, closure w mesh on [**2163-2-24**], s/p
perc trach on [**2163-3-4**], s/p STSG on [**2163-3-17**]. The patient was
discharged to [**Hospital3 **] on [**2163-3-25**]. Over the past month,
the patient has improved clinically, including stopping HD 2
weeks ago. The patient now presents to the [**Hospital1 18**] ED with a ?
bullous area of the upper pole of the abdominal wound and
hypotension. The patient was taken off midodrine at Rehab and
was
then started on lopressor. With the new medication change, the
patient had low blood pressure. The patient is afebrile,
mentating, and is no acute distress.
Past Medical History:
PAST MEDICAL HISTORY: HTN, Inc chol, pos smoker, COPD,
osteoarthritis Homocystine, increase PSA
PAST SURGICAL HISTORY: s/p prostate bx - [P]
Social History:
SOCIAL HISTORY: NA. Pos smoker, pet dog, married with children,
wine distrubuter, retired a yr ago
Family History:
FAMILY HISTORY: father and Uncle pos AAA
Physical Exam:
Vital Signs: Temp: 98.1 RR: 20 Pulse: 52 BP: 104/54
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, abnormal: Open abdominal wound
with good granulation, visible peristalsis, RLQ ostomy pink.
Rectal: Not Examined.
Extremities: No femoral bruit/thrill, No RLE edema, No LLE
Edema,
No varicosities, No skin changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
LUE Radial: P.
RLE Femoral: P. PT: P.
LLE Femoral: P. DP: P. PT: P.
DESCRIPTION OF WOUND: Abdomen: good granulation, visible
peristalsis, packing at LLQ, 3cm area of bluish bullous area at
upper pole of wound
Pertinent Results:
[**2163-5-3**] 07:10AM BLOOD
WBC-14.9* RBC-3.25* Hgb-10.1* Hct-30.6* MCV-94 MCH-31.1
MCHC-33.0 RDW-16.8* Plt Ct-422
[**2163-5-3**] 07:10AM BLOOD
PT-12.9 PTT-27.8 INR(PT)-1.1
[**2163-5-3**] 07:10AM BLOOD
Glucose-103* UreaN-31* Creat-0.8 Na-138 K-4.8 Cl-105 HCO3-28
AnGap-10
[**2163-5-3**] 07:10AM BLOOD
Calcium-9.0 Phos-3.4 Mg-2.0
[**2163-4-22**] 01:46PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2163-4-22**] 9:13 am TISSUE Site: ULCER Source: sacral
ulcer.
GRAM STAIN (Final [**2163-4-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND
SINGLY.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
Reported to and read back by [**First Name8 (NamePattern2) 89585**] [**Last Name (un) 89586**] #[**Numeric Identifier 89587**] @1446,
[**4-22**].
TISSUE (Final [**2163-4-26**]):
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..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
PROBABLE ENTEROCOCCUS. MODERATE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH.
ANAEROBIC CULTURE (Final [**2163-4-26**]): NO ANAEROBES ISOLATED.
[**2163-4-26**] 3:55 am STOOL CONSISTENCY: LOOSE Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2163-4-26**]):
Feces negative for C.difficile toxin A & B by EIA.
CTA:
Endoscopy capsule is seen within the cecum. Other findings,
including open
abdomen, subcapsular liver hematoma/seroma, pleural effusions,
and bibasilar atelectasis are unchanged. As seen previously, the
[**Female First Name (un) 899**] does not fill but the SMA and Celiac axes are patent.
VIDEO SWALLOW:
FINDINGS: Barium passes freely through the oropharynx and
esophagus without evidence of obstruction. There was no gross
aspiration or penetration. For details, please refer to speech
and swallow division note in OMR.
IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy.
Brief Hospital Course:
[**2163-4-20**]
65M s/p TAAA repair, c/b paraplegia and mesenteric ischemia
requiring left colectomy and colostomy, abdominal wall closure
with split-thickness skin-grafts. Presents with concerns of
discoloration at the superior aspect of his wound felt to be
benign and hypotension likely discontinuation of his midodrine
and initiation of beta-blockers. Pt. otherwise stable
Pt admitted to VICU
Resumed cipro / fluconazol / flagyl through out the hospital
course.
Pan cx'd
CT SCAN obtained:
IMPRESSION:
1. Stable appearance of the thoracoabdominal aortic graft, with
a small
amount of fluid collection surrounding the graft.
2. Status post total colectomy and right lower quadrant
ileostomy, without
bowel obstruction or secondary signs of mesenteric ischemia.
Evaluation for
ischemia is limited due to the lack of intravenous contrast.
3. The tracheostomy tube and central lines are in optimal
position.
4. Secretions within the trachea, concerning for aspiration.
Complete
collapse of the left lower lobe with abrupt cutoff of the left
lower lobe
bronchus, question mucous plug versus aspiration.
5. Bilateral moderate-sized pleural effusions, with associated
right basilar
atelectasis, slightly larger since the prior study.
With the discontinuation of BB and middorone hypotension
resolved.
Pt abdominal wound not infected
Transplant consulted for abdominal wound. Nothin to do.
[**2163-4-21**]
Wound / Ostomy consult obtained for osteo care
Nutrition Consult obtained for TF
Pace maker interrogated
Pt noticed to have large decubitus ulcer. Plastic Surgery
Consulted. Dr [**Last Name (STitle) **].
Pt found to be anemic, 2 units PRBC's given. Free water given
for Na.
[**2163-4-22**]
Plastic Surgery recommended q 2hr turns, nutrtion optimization,
[**Last Name (un) **] Air Bed, Performed sharp debridment bedside, CX taken. DOES
NOT LOOK INFECTED. Recommended wet to dry dressing changes [**Hospital1 **].
Free water given for Na.
PT evaluation
SQ heperin stopped, fundaperinox started.
[**4-23**]
cx's pending
bp stable off midarone
hypernatremia - c/w flushes
speech and swallow consult - recommended video swallow
IV antibiotics continued
[**4-24**]
cx's
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
PROBABLE ENTEROCOCCUS. MODERATE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH.
ID consulted, keep same antibiotics, no change
BP stable off midarone
hypernatremia - c/w flushes
[**2163-4-25**]
HIT negative, pt with low platelets. [**Doctor First Name **] sent
NA improving
TF clamped for egd vs scope
HCT still low, blood at osteum site. GI consulted. TF held for
possible scope. Pt recieved CTA to rule out aortic enteric
fistula, fundaperinox held for scope. Pt given NAHCO3 for renal
protection
CTA:
1. Moderate bilateral pleural effusions.
2. Limited evaluation for contrast exacerbation into the bowel
due to the
presence of oral contrast from a prior examination.
3. Unchanged left flank simple fluid collection.
4. The balloon of the GJ tube appears to be inflated outside the
stomach
wall. Clinical correlation recommended.
Hypernatremia improving with free water flushes.
Pt found tohave increase in BUN to 120, Renal consulted
Video swallow completed:
IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy.
B/L lower extremity swelling, LENIS ordered
IMPRESSION: No evidence of deep vein thrombosis in either leg.
[**2163-4-26**]
GI EGD:
Mild diffuse gastritis
G-J tube without abnormality at internal bumper
Otherwise normal EGD to second part of the duodenum
Pt hct stable
IV antibiotics
pt preped for GI scope
TF clamped for GI scope
NA improving with fresh water flushes
HIT positive
[**4-27**]
GI SCOPE:
Few flecks of melena in the right colon
Normal colonic mucosa
Normal ileal mucosa to 20cm from IC valve
Otherwise normal colonoscopy to terminal ileum
NA improving with fresh water flushes
BUN decreaseing
HCT low 2 units PRBC's given
TF resumed
IV antibiotics continued
renal recs: for NA D5, BUN improving
GI do to capsule study.
[**2163-4-28**]
Melena remains in ostomy, both EGD and colonoscopy negative.
Capsule study (p)
IV antibiotics continued
TF held untill capsule passes, reglan started to help motility
[**2163-4-29**]
Pt does not pass capsule, KUB obtained LUQ can see capsule
IV antibiotics continued
Perma cath removed per renal, no longer requiring dialysis
Decided to restart TF to help pass the capsule.
Repeat KUB, capsule in RLQ. GI thinks capsule is lodged near
stricture. This was probably the site of GI bleed
HCT stable, Tagged redblood scan if pt rebleeds
[**2163-4-30**]
IV AB continued
TF
awaiting capsule to pass
HCT stable, Tagged redblood scan if pt rebleeds
GI recommend CT Enterogram to check capsule, slowly passing
[**5-1**] - [**5-2**]
CT enterogram:
Endoscopy capsule is seen within the cecum. Other findings,
including open
abdomen, subcapsular liver hematoma/seroma, pleural effusions,
and bibasilar
atelectasis are unchanged. As seen previously, the [**Female First Name (un) 899**] does not
fill but the
SMA and Celiac axes are patent.
GI signs off, awaiting capsule to pass, No need to retrieve,
slowly passing
IV AB continued
TF
HCT stable, Tagged redblood scan if pt rebleeds
[**5-3**]
Pt stable for DC
Medications on Admission:
ASA 81', Symbicort 2 puffs [**Hospital1 **], Chlorhexidine swish and spit
[**Hospital1 **], Cipro 250 [**Hospital1 **] MW, Santyl qdaily to coccyx, Ferros sulfate
300BID, Diflucan 400 MWF, Lasix 20 [**Hospital1 **], Insulin 10U qAM, Insulin
Regular Ativan 1mg qHS/0.5mg prn, Nephlex daily, Juven 1 pkt
[**Hospital1 **], ranitidine 150', Tiotropium 18mcg IH daily, trazodone 100
qHS, Xenaderm ointment [**Hospital1 **], Flagyl 250 TID, Tylenol 650 elixir
Q6hr prn, Mucomyst prn, Benadryl 10ml [**Hospital1 **],
Lipase/Protease/Amylase [**Hospital1 **]
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for .
7. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for .
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. paroxetine HCl 10 mg/5 mL Suspension Sig: One (1) PO DAILY
(Daily).
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for .
11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for .
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. insulin
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale
Q6H
Humalog
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-119 mg/dL 0 Units
120-159 mg/dL 2 Units
160-199 mg/dL 4 Units
200-239 mg/dL 6 Units
240-279 mg/dL 8 Units
> 280 mg/dL Notify M.D.
14. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Flagyl 250 mg Tablet Sig: One (1) Tablet PO three times a
day.
16. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO every other
day: Mon / Wends / Fri.
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
18. fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1)
Subcutaneous once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Care
Discharge Diagnosis:
Dehydration
Hypotension
Hypernatremia
HTN, inc chol, COPD,
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Please adhere to rehab protocol
Please call if you have any of the following:
Abdominal pain
Abdominal swelling
Nausea and vomiting
Vomiting blood
Difficulty swallowing
Diarrhea
Constipation
Blood in stool
Black stool
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2163-6-13**] 9:00
Please call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 3121**]. Schedule an
appoinment when you are safely able to come to the office.
Completed by:[**2163-5-3**]
ICD9 Codes: 2760, 4019, 2720, 3051, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4107
} | Medical Text: Admission Date: [**2133-1-15**] Discharge Date: [**2133-1-23**]
Date of Birth: [**2089-10-27**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Right internal jugular insertion [**2133-1-16**]
EGD with banding [**2133-1-16**]
Paracentesis [**1-16**], [**1-19**], and [**1-22**]
History of Present Illness:
43 year old woman with alcoholic cirrhosis complicated by
ascites/SBP, encephalopathy with grade 3 esophageal varices and
hepatorenal syndrome as well as alcoholic hepatitis, who
presented with dyspnea. She described being "unable to catch her
breath," and not related to worsening ascites as her abdomen is
soft. She reviously has not needed her albuterol more than ~
annually and she took 3-4 puffs, 3-4 times yesterday. The
patient denies dyspnea on exertion but endorses orthopnea
(baseline 6 pillows) and paroxymal nocturnal dyspnea.
The patient had been recently admitted to [**Hospital1 18**] 2/14-27/[**2132**] for
alcoholic hepatitis with encephlopathy and hepatorenal syndrome.
Her Etoh hepatitis was addresss with steroids and NJT placement
(subsequently DC'd). The patient's diuretics had been stopped
due to HRS. She successfully weaned from octreotide and
midodrine. Creatinine was 0.9 at the time of discharge. The
patient called the Liver Center today endorsing significant
dyspnea and some respiratory distress. Given concern for volume
overload vs. infection, she was brought in by EMS to [**Hospital1 18**] ED.
She denies chest pain, abdominal pain, fevers/chills,
lightheadedness, cough, rhinorrhea, lower extremity edema. She
continue to have nasal congestion from dry, bleeding mucosa. CXR
was not concerning for pneumonia or effusion. EKG showed normal
sinus rhythm with isolated T wave inversion in III. She did have
leukocytosis to WBC 18.1 (from [**9-29**]) with worsened left shift.
Hct 35.1, slightly increased from 30; INR 1.9, slightly improved
from 2.5; Na 131, stable from 128-131; TBili 17.2 from 22,
slightly improved.
She was treated for a URI and at 5am on [**2133-1-15**] she had ~ 1L of
hemetemesis during a BM. VSS. She tells me this has never
happened before.
Past Medical History:
-Alcohol cirrhosis - diagnosed 6 years ago, complicated by
esophageal varices (Grade 3 on EGD [**2129**] at [**Hospital6 28728**]
Center), ascites, SBP (treated at [**Hospital3 7362**] [**2129**]), recent
encephalopathy. Also with portal gastropathy and recent
hepatorenal syndrome
-GERD
-E. coli bacteremia/sepsis
Social History:
-Tobacco history: At least 25 years
-ETOH: Started drinking at 11 years old, by 18 years old was
taking [**1-18**] drinks daily X 15 years. Recently 1-2 drinks/week.
-Illicit drugs: Cocaine use from 18 years old until [**2130-6-17**].
No history of IVDU, tattoos or transfusions.
-Home: Married for 1.5 years, now divorced. Living with a
partner for 5 years.
Family History:
Prostate cancer, myocardial infarction, diabetes. Sister has
depression, hypothyroidism. Aunt with scleroderma.
Physical Exam:
Admission VS: T98.2, BP121/69, HR71, RR20, 100% on RA supine.
98% on
RA sitting. 95% on RA with ambulation.
Early AM VS: 97HR, 98/60, 96 RA
GENERAL: Chronically ill appearing, NAD, alert and oriented X3.
Jaundiced. Pleasant, cooperative, tearful.
HEENT: Sclera icteric. MMM. Normal oro/nasopharynx.
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness appreciated.
EXTREMITIES: No edema, cyanosis, ecchymosis.
Pertinent Results:
Admission Labs:
[**2133-1-15**] 01:00PM BLOOD WBC-18.1* RBC-3.19* Hgb-12.2 Hct-35.1*
MCV-110* MCH-38.2* MCHC-34.8 RDW-17.6* Plt Ct-62*
[**2133-1-15**] 01:00PM BLOOD PT-19.7* PTT-27.8 INR(PT)-1.9*
[**2133-1-15**] 01:00PM BLOOD Glucose-206* UreaN-31* Creat-0.9 Na-131*
K-4.6 Cl-100 HCO3-21* AnGap-15
[**2133-1-15**] 01:00PM BLOOD ALT-85* AST-120* CK(CPK)-27* AlkPhos-302*
TotBili-17.2*
[**2133-1-15**] 01:00PM BLOOD Lipase-280*
[**2133-1-15**] 01:00PM BLOOD CK-MB-2 cTropnT-<0.01
[**2133-1-16**] 04:25AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9
[**2133-1-16**] 06:09PM BLOOD Lactate-2.0
Discharge Labs:
[**2133-1-23**] 05:35AM BLOOD WBC-7.1 RBC-2.97* Hgb-10.6* Hct-30.0*
MCV-101* MCH-35.6* MCHC-35.2* RDW-20.0* Plt Ct-40*
[**2133-1-23**] 05:35AM BLOOD PT-25.0* PTT-39.3* INR(PT)-2.4*
[**2133-1-23**] 05:35AM BLOOD Glucose-112* UreaN-30* Creat-1.0 Na-132*
K-3.9 Cl-99 HCO3-23 AnGap-14
[**2133-1-23**] 05:35AM BLOOD ALT-44* AST-68* LD(LDH)-200 AlkPhos-200*
TotBili-13.5*
[**2133-1-23**] 05:35AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.8
Microbiology:
[**2133-1-16**] 5:30 pm URINE Source: Catheter.
**FINAL REPORT [**2133-1-17**]**
URINE CULTURE (Final [**2133-1-17**]): NO GROWTH.
[**2133-1-17**] 3:05 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2133-1-18**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2133-1-18**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2133-1-16**] 6:24 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2133-1-16**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
CXR [**1-15**]:
IMPRESSION: No evidence of acute disease. Low lung volumes with
minor
basilar atelectasis. Non-specific air-fluid levels in the
epigastric region.
EGD [**2133-1-16**]:
Normal mucosa in the duodenum
Varices at the fundus
Erythema and mosaic appearance in the body and fundus compatible
with portal hypertensive gastropathy
Esophageal ring
Varices at the mid esophagus
Varices at the lower third of the esophagus (ligation)
Otherwise normal EGD to third part of the duodenum
Echo [**1-16**]:
Extremely limited image quality. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function appears
grossly normal (LVEF>55%). PA pressure could not be determined
due to extremely suboptimal image quality
Brief Hospital Course:
Primary Reason for Hospitalization:
43 year old woman with decompensated alcoholic
cirrhosis/hepatitis complicated by ascites, encephalopathy and a
history of SBP and HRS with known grade 3 esophageal varices on
subtherapeutic nadolol presenting with dyspnea, with course
complicated by esophageal variceal bleed.
Active Issues:
# Hemetemesis: Pt had a sentinel variceal bleed with 1L of
hematemesis while on the hepatobiliary service. She was
transferred to the MICU where a central line was placed, PRBC's
were typed and screened and she was intubated for EGD. On EGD
she was found to have 4 non-bleeding grade III esophageal
varices that were all successfully banded. She was then
extubated and had no subsequent hematemesis or melena. She
received a total of 5 units pRBCs. She was transferred to the
floor with stable Hct. She received 3 days of ocreotide and
pantoprazole gtt, and she was started on PO pantoprazole,
carafate, and ciprofloxacin for SBP ppx. She was continued on
nadolol. Her prednisone for acute alcoholic hepatitis was
discontinued. She will need repeat EGD in 2 weeks.
# Dyspnea: Pt initially presented with dyspnea of unknown
etiology which resolved. Thought likely [**12-18**] worsening ascites
since her breathing improved with large volume paracentesis.
Alternatively she may have underlying reactive airway disease
(is current smoker and uses albuterol inhalers at home). She
received 3 large volume paracenteses during hospitalization, and
will likely require periodic taps as an outpatient to improve
her symptoms.
Chronic Issues:
# Alcoholic hepatitis: Recent episode and diagnosed last
admission. She had received approx 2 weeks of prednisone
therapy, however this was discontinued [**12-18**] variceal bleed.
# Alcoholic cirrhosis: She was continued on lactulose.
Diuretics were held in setting of GI bleed and restarted after
her Hct remained stable. Her MELD score was 26 on discharge.
# # H/o EtOH - Last drink >2 ago. She had no signs of
withdrawal. She was continued on PO thiamine/folate.
# Non-occlusive portal vein thrombus: Seen on US during previous
admission, non-occlusive, no current indication for
anticoagulation.
# Anemia/thrombocytopenia: Stable, likely due to chronic liver
disease/splenic sequestration.
Transitional Issues:
-Medication changes: She was started on lasix 40mg daily,
spironolactone 100mg daily, pantoprazole 40mg daily, sucralfate
1g QID x14 days total.
-She is scheduled to follow up with Dr. [**Last Name (STitle) 7033**] in clinic on
[**2133-1-28**].
-She is scheduled for EGD on [**2133-2-6**] for repeat banding of
varices.
-She maintained full code status.
Medications on Admission:
* Folic acid 1mg daily
* Multivitamin daily
* Ciprofloxacin 250mg daily
* Ferrous sulfate 325mg daily
* Thiamine 100mg daily
* Lactulose 30mL three times daily
* Nadolol 20mg daily
* Prednisone 40mg daily
* Omeprazole 20mg daily
* Albuterol sulfate 90mcg/actuation 1-2 puffs daily PRN sob,
wheeze
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
4. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Take at least once daily and titrate to [**1-19**] bowel
movements daily.
7. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
all care vna of greater [**Location (un) **]
Discharge Diagnosis:
Acute anemia due to GI bleed
Cirrhosis
Alcoholic hepatitis
Esophageal varices
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 18732**],
You were admitted to [**Hospital1 18**] because you were having difficulty
breathing. While you were here you had a bleed from your
esophageal varices. You were transferred to the ICU and had an
endoscopy to band your varices and stop the bleeding. You were
started on medications to control the bleeding, and your blood
counts remained stable.
Please note the following changes to your medications:
-START sucralfate 1g 4 times daily - take for 7 days
-CHANGE omeprazole to pantoprazole 40mg daily
-START lasix 40mg daily
-START spironolactone 100mg daily
We made no other changes to your medications. Please continue
taking the rest of your medications as prescribed by your
outpatient providers.
You will need a repeat endoscopy as an outpatient for re-banding
of your varices. We would also like you to follow up in the
liver clinic. Please see below for your appointment times.
It has been a pleasure taking care of you at [**Hospital1 18**] and we wish
you a speedy recovery.
Followup Instructions:
It is recommended that you establish care with a Primary Care
Physician [**Name Initial (PRE) 176**] 2 weeks. If you need assistance finding a PCP
outside the [**Name9 (PRE) 86**] area, your local hospital or healthcare
center can be a resource.
Department: LIVER CENTER
When: WEDNESDAY [**2133-1-28**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GI-WEST PROCEDURAL CENTER
When: FRIDAY [**2133-2-6**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 2851, 5849, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4108
} | Medical Text: Admission Date: [**2153-6-5**] Discharge Date: [**2153-6-8**]
Date of Birth: [**2071-9-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Dyspnea and fatigue
Major Surgical or Invasive Procedure:
Shocked x1 when in VT
History of Present Illness:
Pt. is an 81 yo female with pmh of diastolic HF, HTN, afib, and
tchy/brday syndrome s/p pacer placement [**2-20**] recently admitted
this month for dyspnea who comes in complaining of one week of
increasing fatigue, dyspnea, and productive cough. She reports
that she was improved upon last discharge last week, but since
has noted worsening SOB at rest and upon exertion, fatigue, and
productive cough. She reports that she has been taking her
medications as directed. She denies other upper respiratory
symptoms, PND, LE edema, CP, palpitations, abd pain, f/c, n/v,
other focal signs of infection. She chronically unable to lay
flat because of dizziness. She reports constipation with no BM
for the past week. Because of this her appetitie has been
decreased, though she is still taking PO fluid.
.
In the ED her CXR was unchanged. First set of CEs were flat. EKG
revealed baseline LBBB. She was seen by cardiology who requested
admission to check pacer.
.
ROS: Negative for fevers, chills, chest pain, shortness of
breath, cough, abdominal pain, nausea, vomiting, diarrhea,
dysuria. Otherwise negative in detail.
Past Medical History:
1. Chronic diastolic heart failure
2. Hypertension
3. Paroxysmal atrial fibrillation - on amiodarone treatment
between [**1-/2153**] and [**2-/2153**], then discontinued due to her
history of lung interstitial disease
4. Tachy-brady syndrome s/p dual chamber pacemaker placement
[**2-20**]
3. TIA 17 years ago
4. Hypercholesterolemia
5. Osteoporosis
6. Hypothyroidism (recently diagnosed)
7. Left cataract surgery in [**2149**]
8. Left ankle surgery status post fracture 20 years ago
9. S/p appendectomy
Social History:
Social history is significant for the absence of current tobacco
use. The patient had smoked previously and quit 24 years ago.
There is no history of alcohol abuse. The patient is retired and
lives in an independent living community. Had worked as a
bookkeeper.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her mother passed away at 88 years of age from
Alzheimer's disease. Father passed away at 88 years of age from
Parkinson's disease. Brother passed away at 60 years of age from
myocardial infarction. Brother passed away at 87 years of age
from a stroke.
Physical Exam:
VS: 98.3 104/48 65 18 93%RA
GEN: Well-appearing, NAD
HEENT: Sclera anicteric, PERRL, EOMI, OP clear, MMM
NECK: Supple, no LAD, no increased jvd
CV: RRR, distant, no M/G/R
PULM: CTAB, no W/R/R
ABD: Soft, distended, NT, ND, +BS
EXT: No C/C/E
NEURO: AAOx3, CN II-XII grossly intact, moving all extremities
well
Pertinent Results:
STUDIES:
CXR [**2153-6-5**]: (dictation). pacemaker with unchanged leads. minor
linear atelectasis. No acute cardiopulmonary abnormality
.
CXR [**2153-6-7**]:
FINDINGS: In comparison with the study of [**6-7**], there is a
somewhat better
inspiration but otherwise little change. Again there is evidence
of elevated pulmonary venous pressure with bilateral pleural
effusions and bibasilar atelectasis. The cardiac silhouette is
at the upper limits of normal in size and the pacemaker device
remains in place. Endotracheal tube and nasogastric tube are in
similar position.
.
Abdominal film [**2153-6-7**]:
IMPRESSION: Progressive distention of small and large bowel,
most likely
representing worsening ileus. However, given this interval
progression, close interval follow up is recommended, as a
mechanical bowel obstruction cannot be entirely excluded.
.
Cardiac cath [**2153-6-7**]:
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Reduced left ventricular function with apical hypokinesis.
3. Cardiogenic shock with cardiac index from 1.8-2.0 l/min/m2.
4. Slight improvement in pulmonary artery saturation and cardiac
index
with reduction of alpha pressor agents.
.
Echo [**2153-6-7**]:
IMPRESSION: Hyperdynamic biventricular systolic function with
moderate LVOT obstruction and moderate mitral regurgitation at
the pacing rate of 100 bpm. Lessened LVOT obstruction and mitral
regurgitation with pacing rate of 80 bpm.
Compared with the prior study (images reviewed) of [**2153-1-26**], LV
function is more hyperdynamic and LVOT obstruction is
identified. Mitral regurgitation is now more severe.
.
Labs
[**2153-6-5**] 06:00PM BLOOD CK-MB-6 proBNP-371
[**2153-6-5**] 06:10PM BLOOD cTropnT-<0.01
[**2153-6-6**] 01:15AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2153-6-6**] 10:25AM BLOOD CK-MB-5 cTropnT-<0.01
[**2153-6-5**] 06:00PM BLOOD CK(CPK)-138
[**2153-6-6**] 01:15AM BLOOD CK(CPK)-67
[**2153-6-6**] 10:25AM BLOOD CK(CPK)-65
.
[**2153-6-5**] 06:00PM BLOOD WBC-9.8# RBC-4.41 Hgb-13.0 Hct-39.1
MCV-89 MCH-29.4 MCHC-33.2 RDW-13.6 Plt Ct-279
[**2153-6-5**] 06:00PM BLOOD Glucose-69* UreaN-31* Creat-1.2* Na-129*
K-6.6* Cl-92* HCO3-22 AnGap-22*
[**2153-6-5**] 06:00PM BLOOD PT-38.0* PTT-44.9* INR(PT)-4.1*
.
[**2153-6-8**] 03:22AM BLOOD WBC-5.1# RBC-2.99*# Hgb-9.0* Hct-28.6*
MCV-96 MCH-30.1 MCHC-31.4 RDW-14.0 Plt Ct-94*#
[**2153-6-8**] 03:22AM BLOOD Glucose-266* UreaN-42* Creat-2.6* Na-140
K-4.4 Cl-102 HCO3-13* AnGap-29*
[**2153-6-8**] 03:22AM BLOOD Calcium-6.0* Phos-5.0* Mg-1.8
[**2153-6-8**] 03:22AM BLOOD PT-97.6* PTT-91.4* INR(PT)-12.9*
[**2153-6-8**] 03:22AM BLOOD ALT-[**Numeric Identifier 95461**]* AST-8452* LD(LDH)-9135*
AlkPhos-54 TotBili-0.7 DirBili-0.3 IndBili-0.4
[**2153-6-8**] 04:01AM BLOOD Lactate-13.3*
[**2153-6-8**] 04:01AM BLOOD Type-ART pO2-62* pCO2-25* pH-7.19*
calTCO2-10* Base XS--16
Brief Hospital Course:
The patient was an 81 yo female with h/o diastolic HF(EF 70%),
HTN, afib, and tachy/brady syndrome s/p pacer placement [**2-20**] who
was admitted for lethargy and SOB with plans to interrogate her
pacemaker to look for an arrhythmia. Her pacemaker was
interrogated and no abnormalities were found. She was ruled out
for an MI with 3 sets of negative cardiac enzymes. Her CXR was
negative for PNA. Her cough and SOB was thought to be secondary
to bronchitis. She complained of urinary frequency and
suprapubic tenderness and had a UTI with no signs of an upper
tract infection. Her UTI was treated with ciprofloxacin.
.
During her hospitalization she was constipated with abdominal
distention and a KUB revealed dilated loops of small bowel. She
had not had a bowel movement for one week prior to admission and
was started on colace, senna, miralax, and a bisacodyl
suppository. On the evening of the [**2153-6-6**] she complained of
nausea and on the morning of [**2153-6-7**] she had an episode of
straining in the bathroom and was found down in her room. Code
blue was called and she was coded for PEA arrest. She received
3mg epinephrine, 1 mg atropine, 3 amps of bicarb, dextrose,
insulin, calcium for a potassium of 5.7 which was 3.8 upon
rechecking. During her PEA arrest, she had an episode of VT
which was shocked x 1 to sinus rhythm. EP was called to bedside
and paced her at 110. After aproximately 15 minutes of CPR, she
regained her pulse. She was started on dopamine, levophed on the
floor. BP stabilized in the systolic 80-90s, she was intubated
on AC and requiring high levels of PEEP. She was transferred to
the CCU.
.
While in the CCU she was in NSR in the 80s and captured at 60.
Her abdomen was distended and she required multiple pressors.
The event precipitating the PEA arrest was unclear. [**Name2 (NI) **] shock
was treated with pressors and IVF. She was emprirically covered
with vancomycin, cipro, and flagyl. She also received a bicarb
drip for mixed acidosis. Her CXR showed fluid overload but she
continued to be given IVF aggresively due to her hypotension.
The patient was also in ARF in the setting of her shock. A KUB
showed dilated loops of small bowel with no clear evidence of
obstruction but it could not be excluded. Surgery was consulted
but the patient was not stable enough for any surgical
intervention. A CT scan of her abdomen was necessary to
evaluate her adominal process however despite frequent
re-evaluations the patient was never stable enough to tolerate
going for a CT scan.
.
We communicated with her daughter, [**Name (NI) **] [**Name (NI) **], throughout her
stay in the CCU and initially the patient was full code. During
the course of the evening and early morning the patient required
blood transfusions for a dropping HCT. In the early morning of
[**2153-6-8**] when the patient was requiring blood transfusions and
continuing to require pressors, the daughter told the team over
the phone that her mother would not want this and that she
wanted to change her mother's code status to CMO and DNR. The
daughter came into the hospital accompanied by other family
members. At that point the family requested we stop her
pressors and the blood transfusions. The patient remained
intubated. The patient expired shortly afterwords and the
family decided not to have an autopsy.
Medications on Admission:
1. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
5. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Calcium Oral
9. Vitamin D Oral
10. Disopyramide 100 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
11. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
12. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
Completed by:[**2153-8-6**]
ICD9 Codes: 5990, 4271, 2762, 5849, 4280, 4019, 2724, 2449, 496, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4109
} | Medical Text: Admission Date: [**2178-12-17**] Discharge Date: [**2179-1-9**]
Date of Birth: [**2111-4-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2178-12-17**]:
1. Exploratory laparotomy.
2. Reduction of internal volvulus of the small bowel.
3. Small-bowel resection with primary anastomosis.
History of Present Illness:
67 year old man with [**Hospital 100256**] medical problems including DM
type 2, [**Hospital3 9642**] mechanical [**Hospital3 1291**], Ascending aorta repair with
graft CAD s/p CABG,hx of VF arrest s/p AICD [**2175**] who presents
with acute onset severe abdominal pain at 10am yesterday AM.
States was previosly feeling well, tolerating POs and having
regular BMs when this started. Never had pain like this before,
[**10-3**] diffuse, crampy. + nausea, no vomiting. Last BM
yesterday, normal, no blood. Denies Diarrhea. No fevers or
chills. In the Emergency Department, he was noted to be
hypotensive, started on vasopressors, received 3L IVF with
labored breathing and thus intubated in ED. He was admitted to
to the SICU.
Past Medical History:
CAD s/p CABGx3 [**2168**]
- h/o VF arrest [**6-30**] s/p ICD placement; required explantation
for MRSA pocket infection with reimplantation [**10-31**], s/p lead
removal [**4-2**]
- mechanical [**Last Name (LF) 1291**], [**First Name3 (LF) **]. [**Male First Name (un) 1525**], [**2168**]
- ascending aorta repair c graft [**4-/2169**]
- CHF (EF 20% per TTE [**2178-8-19**])
- high grade CoNS bacteremia in [**2-2**] c/b high grade CoNS, VRE
bactermia while on vancomycin [**3-2**], s/p 4 weeks daptomycin and
explantation of ICD leads
- pseudomonas UTI [**6-2**] s/p cefepime x 14 days, now pseudomonas
UTI [**8-2**] s/p meropenem x 14 days
- R lateral foot ulcer s/p debridement s/p zosyn x 14 days
- DM2 c/b neuropathy
- Hep C (dx [**4-2**], 2.38 million IU/ml. Seen by Hepatology, [**2178-7-30**]
note emphasizes deferring IFN/ribavirin tx for now given
infections, etc.)
- HTN
- HLP
- PVD s/p L BKA [**7-27**]
- hypothyroidism
- h/o opiate dependence, ?benzo dependence
- acute on chronic SDH, [**8-30**]
- h/o R scapula fx
- h/o MRSA elbow bursitis, [**5-1**]
- h/o closed bimalleolar fx s/p repair, removal of hardware [**6-26**]
Social History:
Lives in [**Location (un) **], though has been in rehab for much of the
past few months. Former cab driver. Social history is
significant for the current tobacco use of 40 pack years. There
is no history of alcohol abuse or recreational drug use. Lives
with common-law wife of 35 years who is a home health aid.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
VS: T96.0 66 80/50 24 100% facemask
GEN: ill appearing man, sleepy, answering questions with
difficulty
HEENT: Sclera anicteric. MMdry
CV: irregular irregular
LUNGS: Labored breathing. Diffuse bilateral rales
ABDOMEN: distended, diffusely tender with rebound and guarding
RECTAL: trace guaiac pos
.
At Discharge:
AVSS/afebrile.
GEN: Well in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B)
COR: Irregularly irregular
ABD: Midline incision with steri-strips c/d/i. Lower aspect
incisional wound 5cm x 3cm x 2cm granulating, clean. Wet-to-dry
packing [**Hospital1 **]. BSX4. Appopriately tender to palpation along wound,
otherwise soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3.
Pertinent Results:
On Admission:
[**2178-12-17**] 12:15AM PT-48.6* PTT-61.5* INR(PT)-5.2*
[**2178-12-17**] 12:15AM PLT COUNT-158#
[**2178-12-17**] 12:15AM NEUTS-90.2* LYMPHS-5.2* MONOS-4.0 EOS-0.4
BASOS-0.2
[**2178-12-17**] 12:15AM WBC-8.2 RBC-3.68* HGB-8.5* HCT-28.7* MCV-78*
MCH-23.1* MCHC-29.7* RDW-19.7*
[**2178-12-17**] 12:15AM URINE GR HOLD-HOLD
[**2178-12-17**] 12:15AM CALCIUM-6.7* PHOSPHATE-2.6* MAGNESIUM-1.7
[**2178-12-17**] 12:15AM LIPASE-15
[**2178-12-17**] 12:15AM ALT(SGPT)-25 AST(SGOT)-33 LD(LDH)-196 ALK
PHOS-59 TOT BILI-0.4
[**2178-12-17**] 12:15AM GLUCOSE-228* UREA N-40* CREAT-1.2 SODIUM-139
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
[**2178-12-17**] 12:44AM LACTATE-2.2*
[**2178-12-17**] 04:30AM PT-21.6* PTT-41.8* INR(PT)-2.0*
[**2178-12-17**] 04:38AM LACTATE-2.9*
[**2178-12-17**] 04:45AM PT-24.2* PTT-43.7* INR(PT)-2.3*
[**2178-12-17**] 06:11AM freeCa-1.04*
[**2178-12-17**] 06:11AM HGB-9.2* calcHCT-28
[**2178-12-17**] 06:11AM GLUCOSE-223* LACTATE-3.9* NA+-137 K+-4.2
CL--103
[**2178-12-17**] 07:58AM PT-19.1* PTT-42.3* INR(PT)-1.7*
[**2178-12-17**] 07:58AM PLT COUNT-212
[**2178-12-17**] 07:58AM WBC-14.8*# RBC-3.85* HGB-9.3* HCT-30.6*
MCV-80* MCH-24.1* MCHC-30.4* RDW-19.2*
[**2178-12-17**] 07:58AM CALCIUM-7.6* PHOSPHATE-2.4* MAGNESIUM-2.2
[**2178-12-17**] 07:58AM CK-MB-NotDone cTropnT-0.03*
[**2178-12-17**] 07:58AM GLUCOSE-230* UREA N-43* CREAT-1.6* SODIUM-140
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-21* ANION GAP-17
.
Prior to Discharge:
[**2179-1-7**] 06:29AM BLOOD WBC-4.4 RBC-3.21* Hgb-9.0* Hct-27.7*
MCV-86 MCH-28.0 MCHC-32.5 RDW-22.5* Plt Ct-119*
[**2179-1-7**] 06:29AM BLOOD Plt Ct-119*
[**2179-1-7**] 06:29AM BLOOD Glucose-157* UreaN-16 Creat-0.8 Na-132*
K-4.3 Cl-91* HCO3-34* AnGap-11
[**2179-1-7**] 06:29AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.8
[**2179-1-8**] 04:20AM BLOOD PT-26.4* PTT-48.8* INR(PT)-2.6*
.
IMAGING:
[**12-17**] CXR Interval worsening of mild pulmonary edema. Moderate
bibasilar atelectasis in the setting of low lung volumes.
[**12-17**] CT abd: Findings concerning for mesenteric ischemia with
portal venous air, with focus of air seen in mesentery centered
about loops of small bowel in the right mid abdomen with air
circumferentially surrounding the lumen suggestive of
pneumatosis and associated mesenteric stranding (301B:18-27).
Vascular event may represent etiology, though swirling
configuration suggests internal hernia.
[**12-18**] CXR improved basilar aeration. CVl well placed
[**12-20**] CXR New b/l poorly defined pulmonary opacities, some w/
nodular configuration.
[**12-20**] CXR Interval increase in diffuse widespread airspace
consolidation, ?ARDS.
[**12-21**] multifocal pneumonia. Co-existing ARDS is also possible.
[**12-21**] lung CT
[**12-21**] Head CT
[**12-28**]: Echo: EF 20-25%, PCWP>18, [**12-26**]+ MR, dilated LV, global
hypokinesis
[**1-2**] CXR: Worsening pulmonary edema. Evidence for bilateral
pleural
effusions, which may have increased as well.
[**1-4**] CXR:Mild-to-moderate pulmonary edema has improved since
[**1-2**]
[**1-5**] CXR: Cardiomegaly, bilateral pleural effusions and
atelectasis,
overall appearing minimally changed.
.
MICROBIOLOGY:
[**12-17**] Sputum MRSA Mod growth.
[**12-18**] Bcx: Staph coag neg 1/2 bottles
[**12-19**] BAL MRSA
[**12-20**] Sputum: MRSA, sparse GNR
[**12-23**] BAL: MRSA
[**12-24**] BAL: Negative
[**12-26**] C diff neg
[**12-30**] Catheter tip neg
.
PATHOLOGY:
[**2178-12-17**] SPECIMEN SUBMITTED: ILEUM.
DIAGNOSIS:
Ileum, Segmental resection:
1. Ischemic enteritis with focally transmural necrosis and
associated serositis.
2. One unremarkable resection margin; opposite resection margin
with mucosal ischemic changes and acute inflammation of the
superficial submucosa.
Clinical: Ischemic bowel, acute abdomen.
Gross:
The specimen is received fresh labeled with the patient's name,
"[**Known lastname **], [**Known firstname **]", the medical record number and "ileum." It
consists of a segment of small bowel measuring 92 cm in length
and 3 cm in average diameter. A portion of mesentery is
attached to the small bowel that measures 2 x 4 x 3 cm. The
specimen is not oriented. The mesentery is unremarkable. The
serosa of the bowel is focally erythematous and dusky looking.
There are two staples measuring 3.7 and 5.2 cm. The specimen is
opened along the antimesenteric surface to reveal fecal material
and blood within the lumen. The mucosa in the central portion of
the bowel measuring 34 cm in length is erythematous, brown and
dusky looking. No masses or polyps are identified. No
perforation site is identified. The bowel wall within the
affected area measures up to 0.2 cm in thickness. Normal
looking bowel measures up to 0.4 cm in thickness. The specimen
is represented in cassettes as follows: A = 5.2 cm stapled
margin, B = 3.7 cm staple margin, C = section of affected bowel,
D = transition between effected and normal bowel, E-G = fat.
Brief Hospital Course:
The patient with multiple medical problems was admitted to the
General Surgical Service on [**2178-12-17**] for evaluation of an acute
abdomen likely from ischemic bowel. He was admitted to the
SICU. He was made NPO, started on IV fluids, a foley catheter
and CVL were placed, empiric IV Vancomycin and Zosyn were
started, and he was given Fentanyl IV PRN for pain and Valium
for sedation. He was emergently brought to the Operating Room,
where he underwent exploratory laparotomy, reduction of internal
volvulus of the small bowel, and small-bowel resection with
primary anastomosis(reader referred to the Operative Note for
details). He was found to have ischemic bowel with obstruction,
peritonitis, and an internal volvulus of the small bowel.
He was returned to the SICU for post-operative care.
.
SICU/TICU EVENTS [**2178-1-17**] - [**2178-12-29**]:
[**12-17**] 1 u PRBC, 750 LR intraop, to ICU post op. On neo and epi.
Transfused 1 u for hct 28. Febrile to 101.
[**12-17**] pm - spike to 101.2, decreasing pressor requirements and
lactate. Pan-Cxs sent.
[**12-18**] Left subclavian placed. Bloody guiac + BM overnight. HCT
drifting down. GPC on blood culture 1/2 bottles [**12-18**] .
[**12-19**]: Bronch and BAL.Abx started after BAL
[**12-20**]: Low uop. Large heparin requirement given FFP 2 untis for
? atIII def. PS trial failed changed back to rate. TPN started.
[**12-21**]: Concern for depressed mental status in AM. Concern for
septic emboli to brain/eyes/lungs. Mental status improved in PM
w/o intervention except for holding of propofol. Also concern
for pt's high need of heparin to stay in therapeutic level.
Peripheral smear sent.LENI negative.
[**2178-12-22**]: Bedside TTE w/ hyperdynamic LV, FeNa 0.2%, given 3
Unit of Blood,He Had melanotic stool, but HD stable, started on
D5W at 30cc/h, Creatine improving. acutely became diaphoretic
sat down to 88% pt labored and desynchronous with ventilator,
tachycadic high BP w/ Map 110, tachycardic 120, CVP 26. Patient
had flush PE lasix bolus given, patient sedated, ABG improved
[**12-27**] - Extubated [**12-26**] PM, started on BiPAP. Back on Lasix gtt,
started Carvedilol, started bridge to Coumadin. Re-intubated due
to fluid reaccumulation
[**12-29**]: Extubated. Doing well.
[**12-30**] PICC placed
[**1-2**]: to TICU for resp distress, Bipap responsive, cardiac diet
now, restarted carvedilol, ace, aldactone, required bipap o/n
after brief desat
[**1-3**] Bipap during the day and extra Lasix 20mg IV x1, negative
for the day, Bipap overnight, held coumadin x 1 for INR 5.8
[**1-4**]: Opening of abdominal wound. Held coumadin for INR 5.7.
[**1-5**]: started glargine, removed foley, restarted coumadin 3mg.
[**1-6**]: Coumadin reduced to 2mg.
.
[**Hospital Ward Name **] 9 EVENTS:
On [**2179-1-6**], the patient was transfered to the inpatient floor.
He arrived on a Diabetic/low sodium regular diet, oral
medications, voiding without assitance, with IV Linezolid and
Meropenem continued. Coumadin was continued, and monitored
closely to maintain a therapeutic goal range of 2.5-3.5. The INR
on [**2179-1-8**] was 2.6.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient's blood sugar was monitored regularly throughout the
stay; Lantus and sliding scale insulin was administered as
indicated. Labwork was routinely followed; electrolytes were
repleted when indicated.
.
At the time of discharge on, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
diabetic/low sodium regular diet, ambulating with assistance,
voiding without assistance, and pain was well controlled. He
was discharged to an extended care facility for rehabilitation
and nursing care. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
.
Services Consulted during admission: Infectious Disease,
Otolaryngology, Cardiology, Pulmonary, Social Work, Physical
Therapy, and Occupational Therapy.
Medications on Admission:
Amiodarone 200 mg DAILY
Atorvastatin 40 mg DAILY
Polyethylene Glycol 3350 17 gram/dose [**Hospital1 **]
Amitriptyline 10 mg HS
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Captopril 25 mg TID
Lactulose 30 Q8H (every 8 hours) as needed for constipation.
Aspirin 81 mg Daily
Lorazepam 0.5 mg Q4H as needed for anxiety
Levetiracetam 500 mg QHS
Gabapentin 400 mg Q8H (
Warfarin 5 mg Daily
Oxycodone 5 mg Q4H as needed for pain.
Acetaminophen 500 mg q8 hours as needed for pain
Bisacodyl 10 mg [**Hospital1 **] prn
Albuterol Sulfate 90 mcg 2 Puffs IH Q6H prn
Ipratropium Bromide 17 mcg/Actuation QID (
Meropenem 500 mg q6
Spironolactone 25 mg DAILY
Torsemide 20 mg [**Hospital1 **]
Metolazone 5 mg [**Hospital1 **]
Metoprolol 12.5 mg [**Hospital1 **]
Potassium Chloride 20 mEq once a day
Insulin Glargine 40 units Subcutaneous at bedtime
Insulin Lispro per sliding scale
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for constipation.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY at 16:00:
St. [**Male First Name (un) 1525**] mechanical [**Male First Name (un) 1291**]; INR goal 2.5-3.5.
9. Ondansetron 4 mg IV Q8H:PRN nausea
10. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q6H (every 6
hours) as needed for pain.
11. Ativan 0.5 mg Tablet Sig: [**12-26**] Tablet(s) (give SL) PO every
6-8 hours as needed for Anxiety.
12. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Torsemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Metolazone 5 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
16. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day.
17. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO at
bedtime.
18. Neurontin 400 mg Capsule Sig: One (1) Capsule PO three times
a day.
19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
20. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO at
bedtime.
21. Captopril 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
22. Insulin Lispro 100 unit/mL Solution Sig: 4-22 units
Subcutaneous As directed per Humalog Insulin Sliding Scale.
23. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
24. Medication:
Morphine Sulfate 2-4 mg IV Q6H:PRN Breakthrough Pain Only
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Ischemic bowel.
2. Bowel obstruction.
3. Peritonitis.
4. Internal volvulus of small bowel.
5. Multifocal pneumonia
.
Secondary:
1. CAD
2. History of VF arrest [**6-30**] s/p ICD placement
3. Mechanical St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] on Coumadin prophylaxis INR Goal
2.5-3.5)
4. CHF (EF 20%)
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:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
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 [**5-3**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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 steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
*The lower incision wound will be cared for by your nurse. Car
is a wet-to-dry dressing changed twice daily.
.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Please call ([**Telephone/Fax (1) 2828**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) **] (Surgery) in 2 weeks.
.
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2179-1-27**] 1:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. (PCP) Date/Time:[**2179-1-29**] 11:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2179-2-23**] 10:15
Completed by:[**2179-1-8**]
ICD9 Codes: 5849, 2762, 4271, 2760, 4280, 5859, 3572, 2724, 412, 4241, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4110
} | Medical Text: Admission Date: [**2190-5-10**] Discharge Date: [**2190-5-24**]
Date of Birth: [**2118-10-1**] Sex: M
Service: Medical Oncology
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old man
with a history of non-small cell lung cancer complicated by
brain metastases that were resected on [**2190-3-16**]. He was
presented to our mergency department with shortness of breath. He
was in his usual state of health until 2-3 days prior to
admission when he began experiencing shortness of breath and
fatigue. He went to an outside hospital, where he was noted to
have a temperature of 99.2 F, heart rate of 106, oxygen
saturation of 89% on 2 liters of oxygen by nasal cannula and
subsequently 92% on 6 liters of oxygen by nasal cannula, and a
blood pressure of 53/31. He had a head CT scan that was
negative. He was given dexamethasone 4 mg IV x 1, 2 liters of IV
fluids, and then transferred to the [**Hospital1 188**].
Upon arrival at the [**Hospital1 69**], the
patient was found to be markedly hypoxic with an oxygen
saturation of 92% on 100% nonrebreather face mask. A subsequent
arterial blood gas demonstrated a pH of 7.44, pCO2 of 34, and pO2
of 57. He was given ceftriaxone and metronidazole, as well as
100 mg of hydrocortisone intravenously. The patient was started
on low dose dopamine for his hypotension and was transferred to
the MICU.
Of note, the patient reportedly had a CT angiogram done at the
outside hospital that demonstrated a persistent left upper lobe
mass, small bilateral pleural effusions, and small segmental
pulmonary emboli on the right. Although, the initial of
anticoagulation was considered due to this finding, it was held
initially because the patient reported bright red blood per
rectum for several days prior to admission, and also because of
his history of brain metastases.
Because of the brain metastases, a neurosurgery consult was
requested prior to the initiation of Heparin drip.
PAST MEDICAL HISTORY:
1. Non-small cell lung cancer complicated by left frontal
brain metastases status post resection on [**2190-3-16**].
2. Severe emphysema with a diffusion capacity of 52% of
predicted on pulmonary function tests done on [**2190-4-15**].
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Dexamethasone 2 mg po q day.
2. Phenytoin 100 mg po tid.
3. Lansoprazole 30 mg po q day.
SOCIAL HISTORY: The patient lives in [**Location 2624**], [**State 350**] with
his family. He has a 75 pack year smoking history and was still
actively smoking at the of his admission to the hospital. He
occasionally drinks alcohol. He formally worked in the Navy.
FAMILY HISTORY: The patient's mother died at age [**Age over 90 **] of old age.
The patient's father died at age 53 and may have had a history of
pulmonary disease of unclear etiology. The patient's brother
died of an ischemic stroke.
PHYSICAL EXAMINATION: On initial physical examination, the
patient's temperature was 102.7 F, heart rate 104, blood pressure
97/53, respiratory rate 24, and oxygen saturation was 90% on 100%
non-rebreather face mask. Patient was found to be a pleasant man
in mild respiratory distress. His sclerae were anicteric and he
had no jugular venous distention. His heart rate was tachycardic
and there were normal S1, S2 heart sounds. He had diffuse
rhonchi on pulmonary auscultation with expiratory wheezes. His
abdomen was soft, non-tender, non-distended, and there were
normoactive bowel sounds. He had no peripheral edema, no calf
tenderness, and warm extremities throughout. He was alert and
oriented x 3 and was mentating well. He was reportedly trace
guaiac positive on rectal examination.
Chest X-ray done on the day of admission demonstrated no evidence
of congestive heart failure or pneumonia. Also seen was interval
increase in the size of a previously evident left lung nodule
with development of a probable satellite lesion; these findings
were highly suggestive of malignancy. There was also a small
left sided pleural effusion.
The patient then had a CT scan of the chest done on the day of
admission that was initially read as demonstrating a right
posterior segmental pulmonary embolus, as well as interval
increase in the size of the left lower lobe lung mass. He then
had a head CT scan that demonstrated no evidence for a new
appreciable intracranial hemorrhage. Bilateral lower extremity
non-invasive studies also done on the day of admission
demonstrated no evidence of DVT.
Patient's initial laboratory evaluations demonstrated a white
blood cell count of 20.1 (differential 86% neutrophils, 2% bands,
9% lymphocytes, 3% monocytes). Hematocrit 41.4, platelet count
of 197,000. His serum sodium was 133, potassium 4.4, chloride
99, bicarb 24, BUN 31, creatinine 1.3, glucose 77, potassium 7.7,
magnesium 1.8, and phosphate 4.8. His ALT was 100, AST 59, and
amylase 74. His urinalysis demonstrated a specific gravity of
1.007, small blood, trace protein, trace ketones, and was
otherwise negative for any infectious process.
His electrocardiogram demonstrated a sinus tachycardia at 100
beats per minute, rightward axis, and incomplete right bundle
branch block, and had no significant change compared with an
electrocardiogram dated [**2190-3-15**].
HOSPITAL COURSE BY PROBLEMS:
1. Shortness of breath and hypoxemia: The patient's dyspnea and
hypoxemia were initially attributed to a pulmonary embolus as
noted above. However, after consultation with multiple
pulmonologists and radiologists, it was concluded that there was
no definitive evidence of a pulmonary embolus on the admission CT
scan. Because of this determination, the patient was not
anticoagulated on admission.
Also as noted above, there was no evidence of either pneumonia or
congestive heart failure on the admission imaging studies.
However, the patient remained persistently hypoxemic and dyspneic
on the first several days of hospitalization. An empiric trial
of diuresis was therefore attempted; while the patient had
increased urine output with this attempt, his dyspnea and
hypoxemia did not improve.
He was also covered with broad-spectrum antibiotics including
levofloxacin and metronidazole on admission for empiric coverage
of a possible infectious process given his admission with fever
and hypotension. At no point during his hospitalization,
however, did the patient have any evidence of a clear infectious
process.
In the absence of any definitive explanation of the patient's
dyspnea and hypoxemia, the etiology of his admission dyspnea and
hypoxemia was attributed to a congestive obstructive pulmonary
disease exacerbation superimposed on the patient's poor
underlying pulmonary function. He was initially treated with
stress dosed steroids. These steroids were rapidly tapered down
his admission dose of dexamethasone; he was subsequently
restarted on stress-dosed steroids when he later developed an
episode of adrenal insufficiency as noted below.
The patient was discharged with plans for a very gradual steroid
taper, as well as continued use of oxygen initially at
rehabilitation and subsequently at home.
2. Hypotension: As noted above, the patient was hypotensive on
admission to the hospital. Low dose dopamine was utilized to
maintain normotension during the first two days of his admission
in the Intensive Care Unit. The patient's blood pressure
subsequently normalized, and he did not require further
administration of pressors during this hospitalization. He did
subsequently develop a second episode of hypotension as noted
above; however, this episode was attributed to adrenal
insufficiency, and his hypotension resolved with administration
of stress dosed steroids.
3. Adrenal insufficiency: The patient was transferred from
the Intensive Care Unit to the Medicine Oncology Service on [**2190-5-15**]. On arrival to the Medicine floor, the patient was
febrile to 102 F. He was arousable only to vigorous stimulation.
His antibiotic coverage was at that time broaden to include
Vancomycin, ceftriaxone, and metronidazole in order to provide
empiric coverage for a possible Intensive Care Unit acquired
pneumonia.
Despite this broaden coverage, the patient remained febrile and
minimally responsive for the next 36 hours. On [**2190-5-17**], the
patient's systolic blood pressure dropped into the 80's; his
blood pressure normalized with the administration of an IV fluid
bolus.
On the following day, however, the patient was again febrile to
103.6 F, and his systolic blood pressure dropped to the 70's. A
repeat head CT scan done at that time was negative for any new
findings and there were no infectious sources that could explain
the patient's fever and hypotension. Because of his deteriorating
clinical status, the patient was again transferred to the
Intensive Care Unit.
Upon arrival in the Intensive Care Unit, the patient's random
morning cortisol level from the morning of transfer came back at
3. Because of this finding, the patient was initiated again on
stress dose steroids with subsequent relatively rapid improvement
in his clinical status.
Of note, the patient may have been taking 8 mg of dexamethasone
daily prior to his admission to the hospital, not 2 mg daily, as
was initially thought to his admission to the hospital. He
therefore may not been receiving adequate steroid supplementation
following his first transfer out of the Intensive Care Unit.
Following treatment with high dose steroids, the patient's
clinical status improved dramatically. He remained afebrile and
normotensive throughout the remainder of his hospitalization. His
mental status also improved dramatically. The patient was
therefore discharged home with plans for a very gradual steroid
taper as noted below.
4. Lung cancer: Once the patient's clinical status stabilized
following his second trip to the Intensive Care Unit, the
Thoracic [**Hospital **] Medical Oncology, and Radiation Oncology
services were consulted for input regarding the appropriate
management of the patient's non-small cell lung cancer. The
consensus opinion as that, given the patient's significant
underlying emphysema and his generally poor overall functional
capacity, that the patient was not an ideal candidate for
surgical resection of his lung mass. Any further decisions
regarding the appropriate management of his lung tumor, including
possible radiation therapy or chemotherapy, will be made once the
patient's clinical status stabilizes. He will follow up with Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 3274**] in the Medical [**Hospital **] Clinic in the future for
further management of this issue.
5. Right upper quadrant deep venous thrombosis: On [**2190-5-14**],
prior to the patient's first transfer out of the Intensive Care
Unit, he was noted to have a right upper extremity deep venous
thrombosis around a central venous catheter that had been
inserted in the Intensive Care Unit. This catheter was removed,
and the patient was started on a heparin drip. Following his
second transfer out of the Intensive Care Unit, he was initiated
on warfarin. His INR was still somewhat labile by the time of
his discharge from the hospital; his INR on the day of discharge
was 2.7.
He therefore, will be discharged on a warfarin regimen as noted
below, but will need careful monitoring including initial daily
monitoring of his INR following discharge from the hospital.
6. Infectious Diseases: As noted above, at no point during
hospitalization, was there any radiographic or microbiological
evidence to support an infectious process. The patient did
receive a total of 11 days of antibiotics for empiric coverage
and fever and hypotension given his intermittently for clear
appearance. His antibiotics were discontinued on [**5-21**], and
he remained afebrile without any clinically apparent source of
infection throughout the remainder of his hospitalization.
DISCHARGE CONDITION: Stable.
DISCHARGE PLACEMENT: [**Hospital1 49166**].
DISCHARGE DIAGNOSES:
1. Congestive obstructive pulmonary disease exacerbation.
2. Adrenal insufficiency.
3. Right upper extremity deep venous thrombosis.
4. Nonsmall cell lung cancer.
5. Hypotension.
DISCHARGE MEDICATIONS:
1. Prednisone taper as follows: 60 mg po q day through [**2190-5-25**], 50 mg po q day from [**2190-5-26**] through [**2190-6-1**],
40 mg po q day from [**2190-6-2**] through [**2190-6-8**], 30 mg po q
day from [**2190-6-9**] through [**2190-6-15**], 20 mg po q day from
[**2190-6-16**] through [**2190-6-22**], 10 mg po q day from [**2190-6-23**] through [**2190-6-29**], then 5 mg po q day from [**2190-6-30**] through [**2190-7-6**].
2. Warfarin 3 mg po q hs with a goal INR ranging between 2
and 3.
3. Lansoprazole 30 mg po q day.
4. Bactrim double strength one tablet po on Monday, Wednesday,
and Friday.
5. Docusate 100 mg po bid.
6. Senna one tablet po bid.
7. Nicotine 14 mg transdermal q day.
8. Acetaminophen 325-650 mg po q4-6h prn pain.
9. Phenytoin 200 mg po q day.
10. Ipratropium metered-dose inhaler two puffs qid.
11. Albuterol 1-2 puffs inhaler q6h prn wheezing.
FOLLOW-UP INSTRUCTIONS: The patient should have a follow-up
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in [**Hospital 746**] Clinic as
instructed by Dr. [**Last Name (STitle) 724**] in the future. Arrangements will also be
made prior to the patient's discharge for him to have a follow-up
appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3274**] in Medical [**Hospital **] Clinic 2-3
weeks following his discharge from the hospital. At that time,
Dr. [**Last Name (STitle) 3274**] will discuss making arrangements for the patient to
again be seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Radiation [**Hospital **] Clinic.
[**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**MD Number(1) 748**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2190-5-24**] 11:42
T: [**2190-5-24**] 11:46
JOB#: [**Job Number 49167**]
ICD9 Codes: 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4111
} | Medical Text: Admission Date: [**2172-1-24**] Discharge Date: [**2172-2-4**]
Date of Birth: [**2099-5-25**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / Lisinopril / Atenolol / Carac
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
low back pain, bilateral leg pain
Major Surgical or Invasive Procedure:
[**2172-1-24**] ALIF L3-4 and L4-5, revision posterior decompression
and fusion L2-5; repair of incidental durotomy
History of Present Illness:
She has had a significant decrease in her function. I last saw
her
for primarily gluteal pain that was back in [**2170**] as well as
right
hip pain. This primarily resolved. Her current symptoms are
left leg pain that goes down in an L5 distribution mostly in
line. Her right leg has primarily L3-L4 distribution and worse
with walking. She has had physical therapy done on her back,
but
now only does stretching. She was evaluated by Dr. [**Last Name (STitle) 25111**]
on
[**2170-7-30**], for injections. She is using a cane. She has
trouble getting up on a stepstool and has trouble going up and
down stairs secondary to weakness. She walks in a forward
flexed
posture.
Past Medical History:
Hypertension, Hyperlipidemia, Hypothyroidism
Social History:
see admit H&P
Family History:
see admit H&P
Physical Exam:
On physical examination, this is a healthy-appearing female.
Affect is within normal limits. She has a scoliosis with a
well-balanced spine. Her gait is forward flexed. She takes
short strides. Examination of lower extremities, she has 4/5
strength globally, no hyperreflexia. She has loss of reflexes.
She is unable get up on a stepstool on either side without
significant help. Previous incision is clean, dry, and intact.
No pain with internal rotation. Negative straight leg raise.
Pertinent Results:
[**2172-1-24**] 03:50PM GLUCOSE-182* UREA N-14 CREAT-0.5 SODIUM-142
POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-22 ANION GAP-13
[**2172-1-24**] 03:50PM estGFR-Using this
[**2172-1-24**] 03:50PM CALCIUM-7.8* PHOSPHATE-4.2 MAGNESIUM-1.7
[**2172-1-24**] 03:50PM HCT-28.6*#
[**2172-1-24**] 01:35PM TYPE-ART PO2-289* PCO2-42 PH-7.33* TOTAL
CO2-23 BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED
[**2172-1-24**] 01:35PM GLUCOSE-149* LACTATE-1.2 NA+-143 K+-3.3*
CL--109
[**2172-1-24**] 01:35PM HGB-11.9* calcHCT-36
[**2172-1-24**] 01:35PM freeCa-1.08*
[**2172-2-2**] 05:15AM BLOOD WBC-7.0 RBC-3.04* Hgb-9.4* Hct-28.3*
MCV-93 MCH-31.1 MCHC-33.4 RDW-13.3 Plt Ct-236
[**2172-2-3**] 06:00AM BLOOD PT-20.6* PTT-133.2* INR(PT)-1.9*
[**2172-2-2**] 05:15AM BLOOD PT-16.3* PTT-91.8* INR(PT)-1.4*
[**2172-2-1**] 04:00AM BLOOD PT-14.6* PTT-91.4* INR(PT)-1.3*
[**2172-1-30**] 11:48PM BLOOD Glucose-126* UreaN-11 Creat-0.6 Na-141
K-3.8 Cl-109* HCO3-23 AnGap-13
[**2172-1-30**] 11:48PM BLOOD Calcium-8.4 Phos-3.7 Mg-1.9
Brief Hospital Course:
The patient underwent the above procedure. For full details
please see the separately dictated operative note. The patient
progressed well post-operatively. She was kept on bedrest with
the head of bed flat for 48 hours postoperatively due to dural
tear that was repaired. A drain was utilized and was d/c'ed
when output had tapered down. Peri-operative antibiotics were
utilized for 24 hrs. Post-operative pain was controlled with IV
followed by PO medications. Diet was advanced without
complication. Physical therapy was consulted for assistance
with mobilization.
During PT, patient had syncopal episode. Complete workup
revealed no evidence of cardiac compromise (normal enzymes,
EKG). CT chest revealed subsegmental PE. Medicine was
consulted and recommended treatment with 3 months of
anticoagulation.
Patient was begun on coumadin bridged by heparain gtt. Once she
was therapeutic, heparin was discontinued and patient was
maintained on coumadin with goal INR [**3-20**]. Given her complicated
post-operative course, she was deemed most appropriate for
transfer to an extended care facility. INR should be closely
monitored and coumadin adjusted to the target range, and PT
should be continued at the facility.
Medications on Admission:
acetaminophen-codeine, alendronate, amlodipine 5, ergocalciferol
, estradiol, fexofenadine , ibuprofen, levothyroxine 112 mcg,
metronidazole 0.75 % Cream, omeprazole 20, simvastatin 20
Discharge Medications:
1. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: for severe pain; do not drink alcohol,
drive, or operate machinery while taking this medication.
Disp:*80 Tablet(s)* Refills:*0*
7. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm: do not drink alcohol, drive, or
operate machinery while taking this medication.
Disp:*30 Tablet(s)* Refills:*0*
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: for mild pain.
Disp:*80 Tablet(s)* Refills:*0*
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: target INR is [**3-20**], please draw daily INRs until stable for 3
days, adjust dosing PRN.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 25112**] in [**Location (un) 5087**]
Discharge Diagnosis:
lumbar spinal stenosis, spondylolisthesis, scoliosis
incidental durotomy
subsegmental pulmonary embolism
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 have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You may have been given a brace. This brace is to be
worn when you are walking. You may take it off when sitting in a
chair or while lying in bed.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Physical Therapy:
Continue to advance mobility. no bending, twisting, lifting
Treatments Frequency:
keep incision clean and dry. [**Month (only) 116**] shower, change dressing
afterwards. [**Month (only) 116**] leave open to air when dressing dry for 24
hours, no baths. Steri-strips will fall off on their own in
[**11-28**] days.
Followup Instructions:
-Follow up:
Provider: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3736**]
Date/Time:[**2172-2-11**] 10:40
oPlease Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
oAt the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
oWe will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Completed by:[**2172-2-3**]
ICD9 Codes: 4275, 4019, 2724, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4112
} | Medical Text: Admission Date: [**2114-12-10**] Discharge Date: [**2115-1-9**]
Date of Birth: [**2114-12-10**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 38669**] is a 29-week gestational age birth
weight 868 gram baby boy [**Name2 (NI) **] by C section on [**2114-12-10**] to a 30-year-old G2 P0 mother. Mother's maternal
history is notable for class D diabetes mellitus, type 1
diagnosed at age 5 for which she has excellent control. Last
hemoglobin A1C of 5 during pregnancy. Pregnancy concerns
prior to delivery included: decreasing AFI of 8, an absent end
diastolic flow accompanied by IUGR. Estimated fetal weight
of 774 grams at time of delivery. For these multiple
reasons, infant was delivered via C section at 29 weeks.
Infant delivered via C section initially with cyanosis,
decreased tone, little spontaneous respiratory rate. Patient
was given positive pressure ventilation times several minutes
with prompt increase in heart rate and spontaneous
respirations. At five minutes with still irregular
respirations, the patient was intubated in the DR. [**Last Name (STitle) **]
was transferred to the NICU for further management.
PHYSICAL EXAMINATION ON PRESENTATION: Birth weight is 868
grams. Vital signs: Temperature 98.6, respiratory rate 32,
pulse 150, blood pressure 38/19 with a mean of 32, SAO2 98
percent on 21 percent oxygen. In general: Preterm male in
radiant warmer in no apparent distress. HEENT: AFOF, red
reflex, present bilaterally. ET tube in place. Nasogastric
tube in place. Palate intact. Neck is supple, no crepitus.
Respiratory: Mechanical breath sounds equal bilaterally,
mild intercostal retractions noted. Cardiac: S1, S2 normal,
regular rate and rhythm, no murmur. Abdomen is soft,
nondistended, no bowel sounds, and no hepatosplenomegaly.
Extremities: Well perfused, no cyanosis or edema. Femoral
pulses are 2 plus bilaterally. No Ortolani or Barlow sign
present. Neurologic: Appropriate tone on exam. Spontaneous
MAEW. Suck, moro, palmar-plantar reflex intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Patient
was initially intubated in the delivery room and given two
doses of Surfactant. Patient was weaned off of mechanical
ventilation to CPAP plus six on day of life two. Remained on
CPAP until day of life eight at which point he was
transitioned to room and remained stable on room air until
day of life 14. Was placed back on CPAP for two days
secondary to increased apnea and bradycardia. Subsequently
weaned off back to room air on day of life 16. Patient
remained on room air and stable until time of discharge on
[**2115-1-9**].
Patient has exhibited apnea of prematurity
throughout his hospital course. At time of discharge,
patient routinely has two or three spells per 24 hours
treated with caffeine at 7 mg/kg/day by mouth every day.
Cardiovascular: Patient has remained cardiovascularly stable
throughout his hospital course. On day of life three, a
systolic murmur was noted on physical exam. Subsequent
cardiac echocardiogram revealed an open PFO with intermittent
left to right shunting. No PDA was detected.
Fluid, electrolytes, and nutrition: Patient was placed on
parenteral nutrition until day of life seven at which time
enteral feeds were introduced and increased steadily through
his hospital course. Patient obtained full enteral feeds on
day of life 14.
At time of discharge on [**2115-1-9**], the patient was receiving
breast milk 32 kilocalories/ounce by mouth per gavage.
Patient does attempt to breast feed several times a day with
some success. Discharge weight on [**2115-1-9**] is 1285
grams.(incresaed by 5 grams since yesterday)
Hematology: Patient's initial CBC was normal with a white
count of 5.6, platelets of 207, hematocrit of 60 with a
normal differential. Mom's blood type is O positive. Baby
is Coombs' negative. Patient's bilirubin was 10.0 mg/dl on
day of life two. The patient did receive phototherapy from
day of life two through day of life 17 at which time
phototherapy was stopped with an acceptable rebound bilirubin
level. On day of life nine, it was revealed that the patient
did have an increased direct hyperbilirubinemia for which we
followed closely with serial bilirubin levels. At time of
discharge, direct bilirubin was 1.1 mg/dl. Suggest
rechecking bilirubin prior to discharge.
Infectious disease: Patient received ampicillin and
gentamicin for the first 48 hours of life for rule out
sepsis. On day of life 14 secondary to increased apnea and
bradycardia as well as temperature instability, the patient
received a septic workup consisting of a CBC and blood
culture. Blood culture did subsequently grow out gram-
positive cocci in clusters, isolated by Staph epidermis.
Patient was started on an empiric course of Vancomycin, which
she completed a two week course.
Neurologic: Patient did receive a routine head ultrasound on
day of life two, which was reported as normal. On day of
life 11, patient received a followup ultrasound, which was
also reported as normal. On day of life 17 on [**2114-12-27**], head
ultrasound was reported as mild echogenicity in the germinal
matrix bilaterally interpreted as mild germinal matrix
hemorrhage. On [**2115-1-2**], head ultrasound revealed resolution
of the suspect germinal matrix hemorrhage. Suggested
followup head ultrasound on [**2115-1-10**].
Sensory: Audiology: No hearing screen was performed prior
to discharge.
Ophthalmology: Last eye exam on [**2115-1-9**] revealed an
immature zone II retinae bilaterally. Suggest followup in
two weeks.
CONDITION AT DISCHARGE: Stable.
DISPOSITION: Discharged to [**Hospital **] Hospital in [**Location (un) 50909**], [**Doctor Last Name 26532**].
CARE AND RECOMMENDATIONS AT TIME OF DISCHARGE: Feeds of
breast milk at 32 kilocalories per ounce. Total fluids of
150 cc/kg/day by mouth per gavage.
Medications include caffeine citrate 7 mg by mouth every day,
vitamin E 5 units by mouth every day, iron 0.1 cc by mouth
every day.
State newborn screening sent times two prior to transfer.
No immunizations administered prior to discharge.
DISCHARGE DIAGNOSES: Prematurity 29 weeks gestational age.
Rule out sepsis resolved.
Hyperbilirubinemia resolved.
Direct hyperbilirubinemia.
Respiratory distress resolved.
Bacteremia resolved.
Interventricular hemorrhage, germinal matrix hemorrhage
resolved.
Apnea of prematurity.
Immature feeding pattern.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) 56794**]
MEDQUIST36
D: [**2115-1-9**] 11:10:35
T: [**2115-1-9**] 11:39:56
Job#: [**Job Number 56795**]
ICD9 Codes: 7742, 7907, V290, 769 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4113
} | Medical Text: Admission Date: [**2103-12-31**] Discharge Date: [**2104-1-7**]
Service:
ADMISSION DIAGNOSIS: Severe coronary artery disease,
ejection fraction of approximately 25%.
DISCHARGE DIAGNOSIS: Severe coronary artery disease,
ejection fraction of approximately 25%, status post coronary
artery bypass graft x3.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old man
with a known history of three vessel coronary artery disease.
He had a cardiac catheterization in [**2100**] which showed three
vessel disease. His ejection fraction at that time was
approximately 50%. Recent echocardiogram demonstrates
current ejection fraction of between 20-25%, 80% intermediate
as well as diffuse disease in the proximal.
The patient has had a cardiac catheterization performed on
[**2103-12-12**] which showed a right dominant system and left main
and three vessel coronary artery disease, mild left
ventricular diastolic dysfunction, severe global left
ventricular systolic dysfunction, normal right ventricular
diastolic function. The patient had a right lower lobe
pneumonia in early [**2103-12-5**] and was started and
treated on levofloxacin. The patient also had congestive
heart failure at that time and was diuresed accordingly. The
patient did have placed of an AICD pacer on [**2103-12-9**]. The
patient now comes to [**Hospital1 69**] for
revascularization of his heart.
PAST MEDICAL HISTORY:
1. Insulin dependent-diabetes mellitus.
2. Coronary artery disease, three vessel with an ejection
fraction of 20-25%.
3. Prostate cancer status post resection in [**2096**], no
chemotherapy and no XRT.
4. Paget's disease.
5. Ulcerative colitis.
6. Peripheral vascular disease.
7. Status post left first toe amputation in [**4-3**].
8. Right inguinal hernia repair.
9. Status post left carpal tunnel release in [**2088**].
10. Right carpal tunnel release in [**2100**].
11. Status post appendectomy in [**2053**].
12. Cerebrovascular accident of the thalamus 6-8 years ago
with no deficit.
ALLERGIES: Penicillin causes anaphylactic shock.
MEDICATIONS:
1. Carvedilol 3.125 mg [**Hospital1 **].
2. Accupril 10 mg q day.
3. Aspirin 81 mg q day.
4. Protonix 40 mg q day.
5. NPH insulin 40 units q am/3 units q pm.
6. Regular insulin 4 units q am/18 units q pm.
7. Asacol 800 mg tid.
8. Actonel 35 mg q day.
PHYSICAL EXAMINATION: The patient is an elderly male in no
acute distress. Vital signs are stable. His height is 5
foot 9.5 inches, weight 182 pounds. HEENT: Atraumatic,
normocephalic. Extraocular movements are intact. Pupils are
equal, round, and reactive to light, anicteric. Throat is
clear. Neck is supple, midline. No masses, no
lymphadenopathy. Chest was clear to auscultation
bilaterally. Cardiovascular is regular, rate, and rhythm
without murmurs, rubs, or gallops. Abdomen is soft,
nontender, nondistended with obesity. Extremity examination
is significant for left first toe amputation, otherwise
nonedematous. There is some hyperkeratosis and cyanosis of
the lower extremities.
PREOPERATIVE LABORATORIES: Complete blood count:
12.1/15.4/46.6/169. PT 13.9, INR 1.3, PTT 35.3.
Chemistries: 141/4.6/100/25/21/1.1/97. Type and screen was
performed on [**2103-12-26**].
The patient had a preoperative chest x-ray performed on
[**2103-12-26**] which showed no evidence of congestive heart failure
or acute infiltrates. As mentioned above, mild widening and
elongation of the thoracic aorta. AICD in appropriate
position.
The patient was admitted for coronary artery bypass grafting
x3. The patient had a LIMA to the left anterior descending
artery and a right saphenous vein graft to OM and right
coronary artery. The patient tolerated the procedure well
without complication. In the postoperative period, the
patient was eventually admitted to the Intensive Care Unit
and remained on a Neo and milrinone drip for blood pressure
support and a paced for an underlying heart rate in the low
100s.
The patient remained on the ventilator secondary to acidosis
and appropriate changes were made. EP service did come by to
interrogate the AICD twice. Resect the parameters back to
preoperative settings. Patient was extubated on midnight on
postoperative day 0, and subsequently did well saturating on
99% on 3 liters of nasal cannula. From cardiac perspective,
the pacer rate was turn down, and patient was briefly in
sinus rhythm with approximately 20% paced rhythm, but
returned to 100% A-paced. The patient was continued on Neo,
milrinone, and insulin drips.
Patient was sent down to the floor on postoperative day #1
after weaning drips as appropriate. Unfortunately, the
patient was readmitted back down to the Intensive Care Unit
on the evening of postoperative day one for an episode of
hypotensive, dizziness, nausea, and diaphoresis. It was
noted that the patient had received Lasix and Lopressor prior
to the decrease in heart rate and blood pressure. The
patient was bolused with normal saline and A-paced.
Patient was closely monitored in Intensive Care Unit setting
and transfused 1 unit of packed red blood cells for a
hematocrit of 26.1 on postoperative day #2. The patient had
no other remarkable events on the remainder of his Intensive
Care Unit course and was transferred back down to the floor
on postoperative day #4.
Physical Therapy had been seeing the patient, but the patient
had not made much progress. On postoperative day four, the
patient's chest tubes and pacing wires were discontinued. He
had a mild O2 requirement at 97% on 2 liters and had some
significant sputum production, otherwise is doing well and
improving. The patient was subsequently discharged on
postoperative day six to rehabilitation facility tolerating a
regular diet, and adequate pain control on Morphine SR and
having no anginal symptoms or ectopic events.
It was noted that 48 hours prior to his discharge, the
patient did have some mild serous drainage from his old chest
tube sites. These sites appeared nonerythematous and without
evidence of gross infection. No erythema or exudate.
Physical examination on discharge: No acute distress. The
patient is limited to the chair, and not ambulating well or
often. Vital signs past 24 hours of 99.1, 99 in sinus,
110/50, respirations 20, and 93% on 2 liters. Blood sugars
are well controlled, a little low subsequent to evening
insulin dose ranging 52 to 152 over the past 24 hours. Chest
remains clear to auscultation with some fine crackles at the
base. Cardiovascular: Regular, rate, and rhythm without
murmurs, rubs, or gallops. Sternal incision is clean and dry
without drainage. There is some serous drainage from the
chest tube sites. Abdomen is soft, nontender, nondistended
and obese. Extremities: Significant for 1+ edema in both
lower extremities. Otherwise warm and well perfused.
Neurologically intact without focal motor or sensory
deficits.
LABORATORIES ON DISCHARGE: Complete blood count:
9.7/31.1/192. Chemistry: 136/4.9/97/31/22/0.9/120,
magnesium 2.0.
DISCHARGE MEDICATIONS:
1. Colace 100 mg [**Hospital1 **].
2. Aspirin 325 mg q day.
3. Tylenol 325-650 mg q4h prn.
4. Ibuprofen 400 mg po q6h prn.
5. Methalamine 800 mg tid.
6. Lopressor 12.5 mg [**Hospital1 **].
7. Morphine SR 30 mg po q12h.
8. Morphine immediate release 15 mg po q14h prn.
9. Milk of magnesia 15-30 mL q hs prn constipation.
10. Dulcolax 10 mg q day prn constipation.
11. Benadryl 25 mg q hs prn for insomnia.
12. NPH insulin 40 units q am and 3 units q pm.
13. Regular insulin 4 units q am and 18 units q pm.
14. Regular insulin-sliding scale as directed.
INSTRUCTIONS: The patient is to be discharged to
rehabilitation facility and continue aggressive physical
rehabilitation. He should receive fingersticks qid and
appropriate sliding scale. He should also have wound care
for both sternal incision as well as chest tube sites which
seem to be draining some serous fluid. The patient is also
to have cardiopulmonary checks. Diet should be cardiac and
diabetic.
DISPOSITION: Rehab facility.
CONDITION ON DISCHARGE: Good.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2104-1-7**] 10:27
T: [**2104-1-7**] 11:01
JOB#: [**Job Number 34276**]
ICD9 Codes: 4280, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4114
} | Medical Text: Admission Date: [**2198-6-14**] Discharge Date: [**2198-6-18**]
Date of Birth: [**2141-5-2**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 57 year-old
male with no known heart disease in the past who presented
with burning sensation substernally Thursday prior to
admission, which was relieved at rest. Consequently the
patient had a stress test on the following Saturday, which
showed lateral ST depressions with corresponding burning
chest pain, which caused the patient to stop at 8 minutes
before reaching target heart rate. The patient was then
referred for cardiac catheterization, which showed 80% left
anterior descending coronary artery stenosis with an ejection
fraction 60%.
PAST MEDICAL HISTORY: Renal calculi times two.
PAST SURGICAL HISTORY: Removal of renal calculi.
SOCIAL HISTORY: The patient is currently married and works
as an industrial machinery inspector. The patient also
admits to smoking one pack per day and states ethanol use is
rare.
FAMILY HISTORY: Positive for mother who had rheumatic fever
and required a valve replacement.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: Aspirin 325 mg po q.d.
PHYSICAL EXAMINATION: Vital signs temperature 99. Pulse 76
sinus. Blood pressure 130/80. Respirations 20. 93%
saturation on room air. The patient is a well developed,
well nourished male in no acute distress. HEENT sclera
anicteric. No evidence of oral ulcers. Mucous membranes are
moist. No cervical lymphadenopathy. Cranial nerves II
through XII intact. Chest is clear to auscultation
bilaterally. Sternotomy site no evidence of serosanguinous
drainage. No evidence of erythema and no click with very
stable to palpation. Cardiac regular rate and rhythm. No
evidence of murmur. Abdomen is soft, nontender, nondistended
with positive bowel sounds. No evidence of inguinal
lymphadenopathy and no hepatosplenomegaly. Extremities no
evidence of rash. No edema noted.
LABORATORIES: [**2198-6-18**], white blood cell count 11.7,
hematocrit 37.3, platelets 270, sodium 137, potassium 4.3,
chloride 97, bicarb 27, BUN 15, creatinine .8, glucose 103,
magnesium 2.1, calcium 9.3, phos 2.4.
HOSPITAL COURSE: The patient is a previously healthy 57
year-old male who presented with substernal burning
sensation, which was later defined by cardiac catheterization
to show 80% left anterior descending coronary artery stenosis
with an ejection fraction of 50%. Given these findings the
patient underwent an uncomplicated coronary artery bypass
graft times one (left internal mammary coronary artery to the
left anterior descending coronary artery) on [**2198-6-14**].
Postoperatively the patient was taken to CSRU for close
observation. The patient was immediately extubated without
any events. The patient maintained sinus rhythm and
maintained spontaneous respirations with good oxygen
saturation with minimal supplemental oxygen. This patient
was doing very well. The patient was transferred to the
floor on postoperative day number two where the patient's
pacing wires were discontinued after initiation of
Metoprolol. No episode of bradycardia occurred prior to
discontinuation of the pacing wires. By postoperative day
number three the patient was completely weaned off of
supplemental oxygen and was evaluated by physical therapy who
determined that with one additional day the patient would be
able to achieve level five physical therapy status for
discharge. By the following day discharge criteria was met
and the decision was made to discharge the patient to home in
good condition.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
Status post coronary artery bypass graft times one vessel
(left internal mammary coronary artery to left anterior
descending coronary artery).
MEDICATIONS:
1. Colace 100 mg po b.i.d.
2. Aspirin 325 mg po q.d.
3. Percocet prn.
4. Plavix 75 mg po q.d.
5. Metoprolol 50 mg po b.i.d.
FOLLOW UP PLANS: The patient was instructed to follow up
with Dr. [**Last Name (STitle) 70**] in six weeks. Dr. [**Last Name (STitle) 1437**] in seven to
ten days. Dr. [**Last Name (STitle) **] in seven to ten days.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 47727**]
MEDQUIST36
D: [**2198-6-18**] 11:26
T: [**2198-6-18**] 11:51
JOB#: [**Job Number 47728**]
cc:[**Last Name (un) 47729**]
ICD9 Codes: 4111 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4115
} | Medical Text: Admission Date: [**2151-12-2**] Discharge Date: [**2151-12-9**]
Date of Birth: [**2151-12-2**] Sex: M
Service: NEONATOLOGY
HISTORY: This is a 32-6/7 weeks gestational age triplet
admitted with prematurity.
MATERNAL HISTORY: This is a 35-year-old gravida 1, para 0
now three woman with past medical history notable for chronic
hypertension on atenolol and nifedipine, asthma on albuterol,
and depression (not on medications).
PRENATAL SCREENS: Blood type A positive, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
rubella immune, and group B Strep status unknown.
ANTEPARTUM HISTORY: Estimated date of delivery of [**2152-1-21**] for estimated gestational age of 32-6/7 weeks.
These are IVF triplets with pregnancy complicated by
hypertension.Ultrasound normal and consistent with dates. No
labor.Elective cesarean section for hypertension. No fever or
other clinical evidence of chorioamnionitis. Membranes were
ruptured at delivery yielding clear amniotic fluid. The
infant was vigorous at delivery. He was orally and nasally
bulb suctioned and dried. Apgar scores were 9 at 1 minute
and 9 at 5 minutes of age.
PHYSICAL EXAMINATION ON ADMISSION: Weight 1600 grams (25th
percentile). Length 42.5 cm (25th-50th percentile). Head
circumference 29 cm (25th percentile). Vital signs:
Temperature 98.1, heart rate 157, respiratory rate 45, and
oxygen saturation in room air 94 percent. Blood pressure of
49/25 with a mean arterial pressure of 39. Anterior fontanel
is soft and flat, nondysmorphic infant. Lips, gums, and
palate intact. Neck and mouth normal, no nasal flaring.
Chest: No retractions. Good breath sounds bilaterally.
Mild grunting respirations, no crackles. Cardiovascular:
Infant well perfused, regular rate and rhythm, femoral pulses
normal, S1, S2 normal, no murmur. Abdomen is soft,
nondistended, no organomegaly, no masses. Bowel sounds are
active. Patent anus. GU: Normal male genitalia. Testes
palpable bilaterally. CNS: Infant active and alert,
responds to stimulation. Tone average for gestational age
and symmetrical, moving all extremities symmetrically, gag
intact. Grasp and morrow symmetrical. Skin: Normal. No
rashes, birthmarks, abrasions. Musculoskeletal: Normal
spine, limbs, hips, and clavicles.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
infant demonstrated symptoms of mild respiratory distress
shortly after admission to the NICU with mild grunting and
tachypnea. A chest x-ray was done at that time, which was
normal. Symptoms resolved by 24 hours of age and respiratory
rates have been in the 40s to 60s. No episodes of apnea
noted. No methylxanthine have been initiated.
Cardiovascular: The infant received one normal saline bolus
shortly after admission to the NICU for marginally borderline
blood pressure. Blood pressures have subsequently been
normal throughout his hospitalization. Of note, he has had
at times a low resting heart rate sometimes running in the
110 to 120 range. No murmurs have been auscultated.
Fluid, electrolytes, and nutrition: IV fluids of D10W were
initiated upon admission to the NICU. Blood sugars have been
stable from the 70 to 100 range. Enteral feeds were
initiated on day of life one and advanced without incident to
full volume of 150 cc/kg/day by day of life five. His feeds are
given over 90 minutes due to mild episodes of spitting up.
Weight at time of transfer is 1605g. Head circumference 28.5cm.
GI: Peak bilirubin on day of life three was 9.0/0.3.
Single phototherapy was initiated at that time. A followup
bilirubin on day of life five was 5.5/0.2 mg/dL.
Hematology: A hematocrit was drawn upon admission to the
NICU. It was 58.6. Plt count 247. He has not received any
blood products during his hospitalization.
Infectious disease: A white blood cell count upon admission
to the NICU was 5,800. There were no maternal risk factors
for infection in this clinically well infant. No antibiotics
have been given.
Neurology: Head ultrasound not indicated for this 32-6/7
weeker.
Sensory: A hearing screen has not yet been performed.
Ophthalmology: Eye exam not indicated for this 32-6/7
weeker.
Psychosocial: [**Hospital1 69**] Social
Work has been involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **].
CONDITION AT TIME OF TRANSFER: Infant comfortable in room
air, tolerating full volume enteral feeds with stable
temperature in isolette.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 10377**]
Hospital via ambulance.
NAME OF PRIMARY PEDIATRICIAN: To be determined.
CARE RECOMMENDATIONS: Feeds at discharge: Feeds of Special
Care 20 calorie at 150 cc/kg/day. Hearing screen is recommended
prior to discharge home.
MEDICATIONS: None.
CAR SEAT POSITION SCREENING: Not done.
STATE NEWBORN SCREEN STATUS: First state newborn screen was
sent on [**12-6**], no abnormal results have been reported.
IMMUNIZATIONS RECEIVED: None.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the three criteria: 1. Born at less than 32 weeks, 2.
Born between 32 and 35 weeks with two of the following:
daycare during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school-age
siblings, or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity at 32-6/7 weeks.
2. Transitional respiratory distress.
3. Hyperbilirubinemia.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2151-12-7**] 01:58:50
T: [**2151-12-7**] 04:28:32
Job#: [**Job Number 56704**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4116
} | Medical Text: Admission Date: [**2122-1-6**] Discharge Date: [**2122-1-14**]
Date of Birth: [**2055-10-31**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
dyspnea and cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 66 y/o male with a history of CAD (VF arrest post
CABG with ICD/PPM inserted), systolic CHF (EF 20%), PVD s/p
bilat fem-[**Doctor Last Name **] bypasses, AF s/p DC cardioversion [**2120**], DM2 on
insulin and gout post recent admission with gout flare and
prednisone course in [**2121-10-15**] presents with one week of
shortness of breath with associated cough. He notes subjective
fevers and chills with associated night sweats. Over the past
day he has developed confusion and difficulty with concentration
which was noticed by his daughter. [**Name (NI) **] has been having associated
headaches and chest pain. The chest pain was described as
squeezing in nature and without radiation. He also notes some
increased lower exteremity swelling which has been increasing
over the past week.
.
Of note, recently saw his rheumatologist who started him on
methylprednisone as well as increased his allopurinol due to an
elevated uric acid. He was also admitted in [**Month (only) 1096**] for about a
week for a significant gout flare.
.
In the ED, initial vs were: T 102.9 P 100 BP 131/69 R 20 O2 sat
100% RA. Labs were noteable for a WBC of 26.8 and a glucose of
45. Patient was given an amp of D50, levofloxacin, ceftriaxone
and vancomycin. Vitals upon transfer were Temp 100.3, HR 100,
100% 2L.
.
On the floor, he appeared comfortable but in no acute distress.
He was oriented to self, place and time however he appeared to
have difficulty answering questions. He was complaining of left
sided chest pain which his wife noted had been occurring over
the past 2 weeks. The pain was nonradiating and was relieved
with nitro tab x1.
.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies sinus tenderness,
rhinorrhea or congestion. Denies palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. Severe CAD s/p 4vCABG [**2107**]
2. V-Fib arrest 4-days post-CABG s/p pacemaker/ICD [**2107**]
- Generator change and pocket revision in [**2120-1-14**] to right
side of chest secondary to pain
3. Ischemic cardiomypoathy / systolic CHF, EF 25%
4. Peripheral vascular disease s/p bilateral femoral-popliteal
bypass
5. multiple lower extremity catheterizations
6. Diabetes Type II - followed at [**Last Name (un) **]
7. Obstructive sleep apnea
8. Gout
9. Asthma
10. Mild sigmoid colonic thickening on recent CT-Abd/Plv,
colonoscopy showing sessile polyps, biopsy will have to happen
off plavix
11. Esophagitis, gastritis, peptic ulcer disease
12. Afib s/p TTE cardioversion [**1-/2121**]
Social History:
Married, lives at home with wife. Former 70 pack years tobacco
use but quit in [**2107**]. Denies alcohol or IVDA.
Family History:
Mother with kidney problems. Father died of unknown causes. One
sister died of stomach cancer, another sister also with stomach
cancer. Diabetes is prevalent throughout the family. There is no
family history of premature coronary artery disease or sudden
death.
Physical Exam:
General: patient appeared uncomfortable but in NAD AAOx3
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP unable to be appreciated, no LAD
Lungs: bibasilar crackles noted bilaterally, no wheezing or
rhonchi
CV: Irregular, SEM in the LUSB no rubs or gallops
Abdomen: distended abdomen
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2122-1-6**] 07:30PM WBC-26.8*# RBC-3.93* HGB-8.8* HCT-28.3*
MCV-72* MCH-22.5*# MCHC-31.2 RDW-17.5*
[**2122-1-6**] 07:30PM NEUTS-90* BANDS-5 LYMPHS-0 MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2122-1-6**] 07:30PM PLT COUNT-358
[**2122-1-6**] 07:30PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ OVALOCYT-OCCASIONAL
STIPPLED-OCCASIONAL ACANTHOCY-OCCASIONAL
[**2122-1-6**] 07:30PM PT-15.5* PTT-24.6 INR(PT)-1.4*
[**2122-1-6**] 07:30PM GLUCOSE-45* UREA N-44* CREAT-1.3* SODIUM-139
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
[**2122-1-6**] 07:30PM CALCIUM-8.1* PHOSPHATE-2.6*# MAGNESIUM-1.7
[**2122-1-6**] 07:30PM cTropnT-0.17*
[**2122-1-6**] 07:30PM CK-MB-4
[**2122-1-6**] 07:30PM CK(CPK)-85
[**2122-1-6**] 07:34PM GLUCOSE-44* LACTATE-1.9 K+-3.6
[**2122-1-6**] 08:00PM URINE HOURS-RANDOM
[**2122-1-6**] 08:00PM URINE GR HOLD-HOLD
[**2122-1-6**] 08:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2122-1-6**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
DISCHARGE LABS:
[**2122-1-14**] 06:15AM BLOOD WBC-7.6 RBC-4.12* Hgb-8.9* Hct-30.6*
MCV-74* MCH-21.6* MCHC-29.1* RDW-18.2* Plt Ct-301
[**2122-1-14**] 06:15AM BLOOD PT-28.9* INR(PT)-2.9*
[**2122-1-14**] 06:15AM BLOOD Glucose-221* UreaN-40* Creat-1.4* Na-133
K-4.6 Cl-97 HCO3-27 AnGap-14
[**2122-1-14**] 06:15AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
MICRO:
[**2122-1-9**] URINE URINE CULTURE-FINAL {YEAST}
INPATIENT
[**2122-1-7**] Influenza A/B by DFA DIRECT INFLUENZA A
ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL
INPATIENT
[**2122-1-7**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2122-1-7**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2122-1-6**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2122-1-6**] BLOOD CULTURE Blood Culture,
Routine-FINAL EMERGENCY [**Hospital1 **]
[**2122-1-6**] BLOOD CULTURE Blood Culture,
Routine-FINAL EMERGENCY [**Hospital1 **]
STUDIES:
[**2122-1-8**] CXR: Study is limited due to patient's respiratory
motion and the superior aspect of the lung apices excluded from
the field of view. The patient is status post median sternotomy
and CABG. Right-sided AICD/pacemaker device is noted with lead
terminating in the right ventricle. Abandoned pacer leads are
also noted within the left chest wall, with the tip from one of
these abandoned leads terminating in the region of the right
ventricle. The cardiac silhouette remains moderately enlarged.
There are low inspiratory lung volumes. This likely causes
accentuation and crowding of the pulmonary vascular markings,
but mild pulmonary vascular congestion is likely present. No
focal consolidation is seen. There are no large pleural
effusions. Assessment for pneumothorax is limited. Abdominal
clips are seen in the right upper quadrant of the abdomen. There
are no acute osseous findings.
[**2122-1-8**] ECHO:
Conclusions
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF= 20-25 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] A left ventricular
mass/thrombus cannot be excluded. Diastolic function could not
be assessed. Right ventricular chamber size is normal with
borderline normal free wall function. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. [In the
setting of at least moderate to severe tricuspid regurgitation,
the estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is no pericardial effusion.
IMPRESSION: Dilated left ventricle with severely depressed
systolic function secondary to septal and anterior akinesis and
hypokinesis of the remaining segments. Depressed RV systolic
function. Mild mitral and moderate tricuspid regurgitation. At
least moderate pulmonary artery systolic hypertension.
Compared with the prior study (TEE - images reviewed) of
[**2121-4-8**], regional LV wall motion abnormalities can be better
appreciated on the current study. Valvular abnormalities are
similar.
IMPRESSION: Limited exam. Probable mild pulmonary vascular
congestion. Low
lung volumes.
[**2122-1-8**]: LENI
IMPRESSION:
Negative Doppler ultrasound of both lower extremities, no
evidence for DVT.
Incidental left popliteal fossa [**Hospital Ward Name 4675**] cyst with internal
hemorrhage.
[**2122-1-11**]: CT LE (left)
IMPRESSION:
1. No fracture detected.
2. Moderately severe diffuse soft tissue swelling. Small joint
effusion and
[**Hospital Ward Name 4675**] cyst.
3. Mild tricompartmental degenerative change.
4. Atherosclerotic vascular calcification.
5. Unusual cystic change in the superolateral aspect of the
[**Last Name (LF) 15219**], [**First Name3 (LF) **] be
degenerative, but could also be seen in the setting of gout.
Clinical
correlation requested.
6. Faint calcification along popliteus tendon - ?
chondrocalcinosis.
[**2122-1-11**]: US Extremity Nonvascular Left
INDICATION: Fell on to left arm with painful fluid pouch.
COMPARISON: None.
FINDINGS: Grayscale, and color ultrasound imaging was performed
over the area
of tenderness in the left elbow. Within the superficial soft
tissues, there
is a 3.0 x 1.2 x 2.0 cm ovoid heterogeneously hypoechoic
collection with
enhanced through transmission and multiple internal septations,
but no
internal vascularity. Additionally, there is mild internal
echogenicity noted
in this collection.
IMPRESSION: Multiseptated fluid collection overlying the left
elbow within
the subcutaneous tissues, likely representing a hematoma.
Brief Hospital Course:
Mr. [**Known lastname **] is a 66-year-old male with a history of CAD (VF arrest
post CABG with ICD/PPM inserted), systolic CHF (EF 20%), PVD s/p
bilateral fem-[**Doctor Last Name **] bypasses, AF s/p DC cardioversion [**2120**], DM2 on
insulin and gout post recent admission with gout flare and
prednisone course in [**2121-10-15**] who presented with one week of
shortness of breath with associated cough with primary diagnoses
of acute on chronic systolic heart failure with demand ischemia
and health-care acquired pneumonia. Secondary issues during
hospitalization were gout flare and hyperglycemia.
# Acute on chronic systolic heart failure (EF 20 %)
The patient's admission weight was 202 lbs, which is above his
last dry weight in clinic in [**2121-10-15**] (181.6 lbs).
Decompensation is likely secondary to infectious process with
possible contribution of medication non-adherence. He had
predominantly had right-sided heart failure pathophysiology
given relatively clear lung exam and preponderance of lower
extremity edema. He underwent diuresis with IV furosemide with
discharge weight of 200.2 lbs. His creatinine fluctuated
throughout hospitalization from 1.3 to 1.6 notably with diuresis
with baseline Cr of 1.3. He was converted to his home
furosemide 120 mg PO BID. He was continued on metoprolol
succinate 50 mg PO qD. His spironolactone was discontinued, and
his lisinopril was decreased from 10 mg to 5 mg given past
issues with hyperkalemia and concurrent usage of digoxin. He was
also continued on statin for CAD. He has a pacemaker for primary
prevention. His diuretic regimen should continued to be
optimized on an outpatient basis. If the patient does not
maintain a stable weight on oral furosemide, torsemide could be
considered. He will follow-up with Dr. [**Last Name (STitle) **], his primary
cardiologist.
In addition, the patient likely had demand ischemia given
troponin elevation from 0.17 to 0.24 (baseline troponin T
appears to be 0.03 based on measurement on [**2121-4-5**]) with
negative CK-MB fraction and troponin downtrend to 0.14. He was
treated for NSTEMI briefly with a heparin gtt, which was
discontinued given low clinical suspicion. ECG showed only
non-specific ST-T changes. ECHO did not show any new regional or
global wall motion abnormalities.
# Health-care acquired pneumonia
Patient was noted to have an elevated WBC with a left shift,
fever up to 102.9 and a RR >20 fulfilling SIRS criteria in
addition to new cough. CURB-65 score was 3 based on confusion,
BUN > 19, and Age > 65 with brief MICU course. Chest radiography
did not show a definitive infiltrate. The patient was initially
started on treatment for health-care acquired pneumonia with
cefepime, vancomycin, and azithromycin. Influenza test was
negative. Blood cultures did not suggest bacteremia. He was
transitioned to room air with adequate oxygen saturation and
completed an 8-day course of vancomycin, cefepime, and
azithromycin for presumed pneumonia ([**2122-1-7**] to [**2122-1-14**]).
.
# Altered Mental Status:
According to his family he developed confusion prior to
admission, which has now resolved. Etiology was likely
encephalopathy / delerium in the setting of acute infection.
His sensorium cleared within a day. His insulin regimen was
optimized by [**Last Name (un) **] as discussed below.
.
#. Type 2 Diabetes (A1c 9.8), controlled with complications:
Home regimen on admission was Lantus 88 units qAM and lispro
SSI. [**Last Name (un) **] was consulted secondary to hypoglycemia on admission
(glucose 45) with secondary issue of persistent hyperglycemia
after regimen was changed to glargine 10 units. There was some
question about the etiology of hypoglycemia on admission as
steroid usage and counter-regulatory hormones from infection
would cause hyperglycemia. Consideration of adrenal axis testing
should be considered based on pattern of steroid usage. [**Last Name (un) **]
followed closely and his later hospital course was complicated
by persistant hyperglycemia. His insulin regimen at discharge
with insulin glargine 40 units SC qAM and insulin lispro 10
units SC AC. He will keep a log of blood glucose measurements at
home and call [**Last Name (un) **] if his blood glucose is greater than 400.
He will require ongoing close follow up for this.
.
#. Atrial Fibrillation:
He remained in normal sinus rhythm during hospitalization. He
was continued on metoprolol. His INR (1.4) was sub-therapeutic
on admission consistent with known non-adherence to regimen. He
was treated with warfarin during hospitalization, which was
discontinued after supra-therapeutic INR with discharge INR of
2.9. Per his primary cardiologist, he was recently changed to
pradaxa. He will have an INR check on [**2122-1-16**], which Dr. [**Last Name (STitle) **]
will follow-up. When his INR is below 2, he will start pradaxa.
.
#. Gout with fall
He was recently seen by rheumatology, and his allopurinol was
increased to 600mg daily given hyperuricemia. During his
hospitalization, he experienced a fall with trauma to his left
elbow and knee. US of left elbow suggested a hematoma given
supratherapeutic INR at time of fall. Imaging of left knee
showed known [**Hospital Ward Name 4675**] cyst, degenerative changes, faint
calcification suggestive of chondrocalcinosis, and effusion.
Arthrocentesis of the left knee was considered but was deferred
in setting of his INR. Septic joint was a consideration but
unlikely given concurrent therapy with broad spectrum
antimicrobials. Clinically, he had a convincing story for gout
flare given trauma and recent withdrawal of corticosteroids. He
was treated with colchicine 1.2 mg PO x 1, naproxen x 1, and
colchicine 0.6 mg PO BID from [**1-12**] to [**1-16**] with return to home
dosage on [**1-17**]. He improved rapidly on this regimen with
resolution of flare by discharge. Prednisone and standing
NSAIDs were not utilized given comorbid conditions including
diabetes and congestive heart failure. He will follow-up with
rheumatology.
# Chronic kidney disease, Stage 3
His creatinine experienced fluctuations during hospitalization
as mentioned above. His renal function should be assessed within
one week of discharge.
# Microcytic Anemia
Admission Hgb was 9.5 with discharge Hgb of 8.5. Iron studies
should be performed on outpatient basis. Some component may be
from CKD.
# Nutrition
His albumin was 2.8 with normal synthetic function given liver
function tests. He should be assessed for nutritional status.
# Communication: HCP [**Name (NI) 17380**],[**Name (NI) **] (HCP) [**Telephone/Fax (1) 17381**]
# Code: Full
# Transitions of care
1. For his acute on chronic systolic heart failure, assess
maintenance of discharge weight (200.2 lbs) and volume status.
Further optimization of cardiovascular regimen such as diuretic
conversion from furosemide to torsemide if not maintaining
weight on oral furosemide and conversion of metoprolol to
carvedilol given depressed ejection fraction.
2. Although he did not have a discrete infiltrate on chest
radiography, repeat PA and Lateral CXR in [**2-18**] weeks may be
judicious given likely pulmonary process.
3. His outpatient insulin regimen needs continual optimization
from [**Last Name (un) **] given changes made during hospitalization. His blood
glucose measurement log should be reviewed. He will call [**Last Name (un) **]
for blood glucose > 400 or low glucose readings.
4. Given hypoglycemia on admission in the setting of infection
and steroid usage, consider testing for relative or absolute
adrenal insufficiency.
5. Patient will have INR check followed by Dr. [**Last Name (STitle) **] on [**2122-1-16**]
and will need to start Pradaxa once INR < 2.
6. For gout, he will follow-up with rheumatology for further
assessment and optimization of gout therapy. NSAIDs and
corticosteroids should be used sparingly in a patient with heart
failure and diabetes given fluid retention, aforementioned
labile blood glucose measurements, and confusion.
7. Patient will need chemistry panel including creatinine to
assess for stability of renal function on home furosemide
regimen within one week of discharge.
8. He should be assessed for nutrition given albumin.
9. He should have iron studies to work-up his microcytic anemia.
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*5 Tablet(s)* Refills:*0*
10. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. Lantus 88 units at morning
12. Lispro sliding scale
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain/Fever.
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
6. Lasix 80 mg Tablet Sig: 1.5 Tablets PO twice a day.
Disp:*90 Tablet(s)* Refills:*0*
7. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
8. allopurinol 300 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 days: Take on [**1-15**] and [**1-16**]. On [**1-17**], return to your
normal home dose.
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day:
start your normal colchicine dose on [**1-17**].
12. Pradaxa 75 mg Capsule Sig: One (1) Capsule PO twice a day:
You will get an INR test. Do NOT start this medication now. Dr.
[**Last Name (STitle) **] will call by next Tuesday to tell you when to start this
medication.
Disp:*60 Capsule(s)* Refills:*2*
13. Outpatient Lab Work
Check INR on [**2122-1-16**] (FRIDAY) at [**Hospital6 **]
laboratory. LAB: Please fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office
(cardiology), fax # [**Telephone/Fax (1) 17382**]
14. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous qAM.
Disp:*[**2110**] units* Refills:*2*
15. insulin lispro 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous AC.
Disp:*1000 units* Refills:*0*
16. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: pneumonia, acute on chronic heart failure exacerbation,
gout
Secondary: Diabetes, chronic kidney disease
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 in the hospital. You were
admitted with cough and shortness of breath. We were concerned
that you had a pneumonia and treated you with antibiotics for
which you have completed a course. You also were given lasix to
remove some excess fluid from your body. It is very important to
follow a LOW SALT diet, or you will develop more fluid and have
heart problems. Your gout worsened during hospitalization, and
you were started on a higher dosage of colchicine for the next
few days for your gout.
Medication changes:
-STOP coumadin
-STOP spironolactone
-START pradaxa when Dr. [**Last Name (STitle) **] instructs you to start this
medication. You will need to have your *INR* checked on
[**2122-1-16**]. This result will be faxed to Dr.[**Name (NI) 5452**] office. If you
do not hear from Dr. [**Last Name (STitle) **] by [**2122-1-19**], please call his office and
ask when to start the pradaxa.
- START Colchicine 0.6 mg by mouth TWICE daily for 2(two) days
on [**1-15**] and [**1-16**] for your gout flare.
- THEN on [**1-17**], START your regular home dose (colchicine 0.6 mg
by mouth ONCE daily)
- CHANGE lisinopril from 10 mg to 5 mg
- CHANGE your insulin regimen:
Take lantus 40 units in the morning
Take humalog 10 units before meals
*** Your blood sugar was high during hospitalization. Please
continue to check your blood sugars three times per day and
bring a record of them to your [**Last Name (un) **] visit. If your glucose
level is > 400, please call [**Hospital **] clinic.
Please go to the followup appointment scheduled below.
***Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
INR check at [**Hospital6 **] lab on [**2122-1-16**].
Department: [**Hospital3 249**]
When: THURSDAY [**2122-1-22**] at 9:10 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This is a follow up of your hospitalization. You will become
established with your primary care physician after this visit.
Department: [**Hospital3 249**]
When: MONDAY [**2122-2-2**] at 3:25 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13530**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This will be your new primary care physician within [**Name9 (PRE) 191**].
Department: RHEUMATOLOGY
When: THURSDAY [**2122-1-29**] at 12:30 PM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) 11712**], [**First Name3 (LF) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
When: Monday, [**2-2**], 11AM
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**]
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 7960**]
When: Wednesday, [**2-4**], 1:30PM
ICD9 Codes: 486, 4280, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4117
} | Medical Text: Admission Date: [**2180-3-28**] Discharge Date: [**2180-3-31**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
male retired physician with [**Name Initial (PRE) **] history of critical aortic
stenosis, hypertension, hypercholesterolemia who presents
today with chest pain. The patient usually only has minimal
baseline exertion, also gets nonexertional chest pain, about
10 times in the past one to two months lasting 5 to 15
minutes at a time. He denies other symptoms. On day of
admission, he presented to the Emergency Room with acute
chest pain with radiation to his left arm which occurred at
rest 7 out of 10 in intensity. No shortness of breath,
diaphoresis, nausea, vomiting or palpitations.
REVIEW OF SYSTEMS: The patient denies orthopnea, dyspnea on
exertion, lower extremity edema, no change in bowel
movements, occasionally has bloody urine secondary to his
bladder cancer. Good energy, denies cough, fevers, chills.
No syncope or claudication. The patient is hard of hearing.
The patient refused surgery for his aortic stenosis when
offered one to two years ago. In the Emergency Department,
the patient's electrocardiogram showed ST elevations in the
anterior leads. He was taken directly to cardiac
catheterization. Vital signs in the Emergency Department:
pulse 90, blood pressure 170/80, respirations 18, saturating
95% on room air. The patient's chest pain resolved about 30
minutes into his Emergency Department visit. Cardiac
catheterization showed a right dominant system with three
vessel disease, left main 80% distally, LAD 80% at ostium, as
well as diffuse disease. Distal LAD with ulcerated 90%
stenosis, however with TIMI-3 beyond lesion. Left circumflex
with focal 70% stenosis at origin of OM. RCA had focal 70%
stenosis at mid segments. Hemodynamics revealed elevated
right and left sided filling pressures. Mean RA pressure 11.
PA systolic pressure 54. RVEDP at 12. Mean wedge 28. LVEDP
30. Cardiac output 3.3, cardiac index 1.7. Systemic and
pulmonary vascular resistance is elevated at 2150 and 250.
Aortic valve area 0.43 with a gradient of 51. Left V-gram
revealed fair anterolateral hypokinesis with apical and
inferior hypokinesis and an ejection fraction of 38%. No
mitral regurgitation was seen.
PAST MEDICAL HISTORY:
1. Colon cancer, status post right hemicolectomy greater
than 10 years ago
2. Bladder cancer status post left ureteral stent
3. Prostate cancer, status post prostatectomy greater than
10 years ago
4. Polycythemia [**Doctor First Name **] for the past 10 to 15 years, oncologist
Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**]
5. Hypertension, LDL cholesterol was 115 in [**8-29**].
6. Critical aortic stenosis
MEDICATIONS:
1. Metoprolol 50 mg po bid
2. Allopurinol 300 mg po q day
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a retired general physician,
[**Name10 (NameIs) **] alcohol. Quit smoking 50 years ago. He uses a cane to
walk. Lives alone with family assistance.
FAMILY HISTORY: Negative for coronary artery disease.
PHYSICAL EXAM:
VITAL SIGNS: Temperature 95.6??????, pulse 67, blood pressure
174/78, respirations 21, saturating 98% on 4 liters by nasal
cannula
GENERAL: The patient is in no acute distress with a groin
sheath in place.
HEAD, EARS, EYES, NOSE AND THROAT: Moist mucous membranes.
Jugular venous distention to jaw while lying in bed.
Extraocular movements full.
NECK: Carotids 2+ without bruits.
LUNGS: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm, grade [**2-2**] high
pitched systolic ejection murmur at the left upper sternal
border.
ABDOMEN: Soft, nontender, nondistended with normoactive
bowel sounds.
EXTREMITIES: No edema. DPs 1+ bilaterally.
GENITOURINARY: Foley bag with grossly bloody urine.
LABS AND RADIOGRAPHIC STUDIES: Initial CK 69, troponin 2.4.
Arterial blood gases 7.25, 42, 106. Chem-7: Sodium 140,
potassium 4.5, chloride 101, bicarbonate 27, BUN 38,
creatinine 1.6, glucose 126. Initial electrocardiogram
showed sinus rhythm of 93 with normal axis, 3 to [**Street Address(2) 37683**]
elevations in leads V2 through V4 with good R-wave
progression. No Q wave. T-wave inversions in 1 and L and
biphasic in V6. Subsequent electrocardiogram showed sinus
rhythm of 64 with normal axis, Q in V2, [**Street Address(2) 1766**] elevations in
V2 through V3, T-wave inversions in lead 2 through V6, 1 and
L. Diffuse T-wave changes.
HOSPITAL COURSE: The patient refused any surgical therapy
for his coronary artery disease. He refused coronary artery
bypass graft as well as percutaneous transluminal coronary
angioplasty. The patient was medically managed by starting
aspirin, Plavix and Lipitor. The patient received 48 hours
intravenous heparin. The patient remained symptom free on
heparin. The patient's beta blocker was also increased to
metoprolol 100 mg po bid. Nitrates were avoided secondary to
patient's critical aortic stenosis to avoid preload
reduction. The patient was evaluated by physical therapy and
was deemed unsafe to go home and short rehabilitation was
recommended.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: Discharge patient to rehabilitation.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg po q day
2. Metoprolol 100 mg po bid
3. Plavix 75 mg po q day
4. Lipitor 10 mg po q day
5. Allopurinol 200 mg po q day
6. Protonix 40 mg po q day
7. Colace 100 mg po bid
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post anterior myocardial
infarction
2. Critical aortic stenosis
3. Hypertension
4. Hypercholesterolemia
5. Polycythemia [**Doctor First Name **]
6. Prostate cancer
7. Bladder cancer
8. Colon cancer
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Doctor Last Name 10735**]
MEDQUIST36
D: [**2180-3-31**] 08:22
T: [**2180-3-31**] 08:34
JOB#: [**Job Number 13654**]
ICD9 Codes: 4241, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4118
} | Medical Text: Admission Date: [**2174-5-3**] Discharge Date: [**2174-5-6**]
Date of Birth: [**2147-8-13**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 26 year old
female with a past medical history significant for systemic
lupus erythematosus, end stage renal disease on hemodialysis,
idiopathic thrombocytopenic purpura, hypertension who
presented to the primary care physician on the day of
admission with a one month history of shortness of breath,
patient reports shortness of breath after walking one flight
of stairs. She also reports paroxysmal nocturnal dyspnea and
orthopnea. She denies any chest pain or palpitations. No
bright red blood per rectum, melena, or rashes. She was sent
to the Emergency Department, also for further evaluation.
The patient was also noted to have cervical lymphadenopathy
and hepatomegaly in the primary care physician's office as
well. In the Emergency Department, she was found to have a
blood pressure of 210/180. She was placed on a Labetalol
drip and her blood pressure decreased to 180/140. However,
when the Labetalol drip was discontinued, her blood pressure
went back up to 200/160. The patient does report having
headaches, in the last couple of weeks. She, however, denies
any visual changes or any focal neurological complaints. She
is not complaining of any abdominal pain either, in the
setting of this new hepatomegaly. She denies any
appreciation of scleral icterus, no fevers at home. The
patient had hemodialysis on [**5-2**] without complaint. The
patient also reports being compliant with all her
medications.
PAST MEDICAL HISTORY: Systemic lupus erythematosus.
End stage renal disease on hemodialysis.
Methicillin-sensitive Staphylococcus aureus endocarditis in
[**2173-5-9**]. She has 3+ mitral regurgitation.
Hypertension. Medication adjustment recently with
discontinuation of Minoxidil three weeks prior to admission.
History of osteoporosis secondary to steroids.
Ventricular septal defect repair at the age of 13.
Pulmonary hypertension.
History of methicillin-resistant Staphylococcus aureus
urinary tract infection.
Gastroesophageal reflux disease.
Sickle trait.
Idiopathic thrombocytopenic purpura with baseline platelets
between 50 and 100,000.
History of restrictive lung disease.
MEDICATIONS ON ADMISSION:
1. Labetalol 1000 mg p.o. b.i.d.
2. Prednisone 5 mg p.o. q. day.
3. Nephrocaps.
4. Procardia XL 90 mg p.o. q. day.
5. Protonix 40 mg p.o. q. day.
6. Moexipril 15 mg p.o. b.i.d.
7. Clonidine 0.6 mg p.o. b.i.d.
ALLERGIES: The patient has an allergy to Demerol which
causes anaphylaxis. She also has a questionable history to
cephalosporins which cause a rash and a history of allergy to
Unasyn which causes a rash.
SOCIAL HISTORY: No tobacco, no alcohol and no intravenous
drug use. She lives with her mother. She is a Jamaican
immigrant who came to this country in [**2163**].
PHYSICAL EXAMINATION: On physical examination she was
afebrile, 96.8, blood pressure was initially 211/179 which
responded to intravenous Labetalol drip, to 188/148, pulse
69, respiratory rate 99 percent on room air. Head, eyes,
ears, nose and throat, the fundi are normal bilaterally. Her
extraocular movements are intact. She has bilateral
preauricular and anterior, submandibular and axillary
lymphadenopathy. Chest is clear bilaterally. Cardiac
examination is regular, no murmurs. Abdomen, she had good
bowel sounds. She has a liver edge 4 fingerbreadths below
the costal margin. She has mild tenderness in the right
upper quadrant. The extremities showed no edema and no
rashes.
LABORATORY DATA: For laboratory data she had a white count
of 8.3, hematocrit of 37, she had platelets of 56. She had a
chem-7 notable for a creatinine of 7.1. She had normal
coags. She had normal liver function tests and an ALT of 34
and AST of 27, amylase of 68, and alkaline phosphatase of
118, total bilirubin was 0.7. Chest x-ray showed stable
cardiomegaly, interstitial and alveolar edema and a small
left pleural effusion. Electrocardiogram showed a normal
sinus rhythm at 65. She has positive LDH. She has no
significant ischemic changes compared to an old
electrocardiogram.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for further management of her
hypertensive urgency. The patient was continued on a
Labetalol drip in the Intensive Care Unit, however, this was
discontinued on [**2174-5-4**], and she was started on her home
medications which include her Moexipril 15 b.i.d., her
Labetalol 1000 b.i.d., her Clonidine 0.6 b.i.d. The patient
was also started on her Nifedipine initially at 90 mg q. day
which was her home dose. This was increased to 120 q. day.
The patient had adequate control of her blood pressure on
this home regimen and was transferred out of the Intensive
Care Unit. The patient also did initially receive some
Hydralazine in the Intensive Care Unit for prn control of
blood pressure. This was run by the Rheumatology Consultants
and was deemed okay in light of her history. The patient was
transferred out to the floor. Once her blood pressure was
stabilized, she was continued on her home regimen with the
noted increase in her calcium channel blocker from 90 to 120
q. day. She did not need any Hydralazine over night. She
went to hemodialysis on the day of discharge where her blood
pressures were adequately maintained in the 120s to 130s.
Over night, on the night prior to discharge, her blood
pressures remained adequately controlled with systolic blood
pressures in the 130s to 150s. The patient did not have any
further symptoms of headache or shortness of breath on the
floor. She was continued on her 5 mg of Prednisone for her
history of lupus. The patient also received a right upper
quadrant ultrasound on the day of discharge for further
evaluation of her hepatomegaly in the setting of normal liver
function tests. The result of this right upper quadrant
ultrasound is still pending. The patient did receive
hemodialysis on the day of discharge. Her platelets remained
stable during the course of her hospital stay. She does have
a history of idiopathic thrombocytopenic purpura. The
patient was consented for a human immunodeficiency virus
test, the result of this is still pending. The patient will
be discharged on the following blood pressure regimen,
Labetalol 1000 mg p.o. b.i.d., Moexipril 50 mg p.o. b.i.d.,
Clonidine 0.6 mg p.o. b.i.d. and Nifedipine sustained release
120 mg p.o. q. day. The patient has been scheduled for an
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Hospital 191**] Clinic on [**2174-5-10**] for follow up of her blood pressure. At that time if
her blood pressure remains elevated, increasing her Labetalol
should be considered.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Hypertensive urgency.
Lupus.
Congestive heart failure.
Hepatomegaly of unclear etiology.
Lymphadenopathy of unclear etiology.
MEDICATIONS ON DISCHARGE:
1. Prednisone 5 mg p.o. q. day.
2. Vitamin B complex.
3. Vitamin C
4. Folate capsule, one tablet p.o. q. day.
5. Protonix 40 mg p.o. q. day.
6. Clonidine 0.6 mg p.o. b.i.d.
7. Moexipril 15 mg p.o. b.i.d.
8. Sevelamer 800 mg p.o. q.i.d.
9. Labetalol 1000 mg p.o. b.i.d.
10. Nifedipine sustained release 120 mg p.o. q. day.
FOLLOW UP: The patient, again, will follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2174-5-10**] for a blood pressure check. The
patient also has a follow up appointment with Dr. [**First Name (STitle) **]
[**MD Number(4) 9138**] on [**2174-5-24**]. At that time the results of her
right upper quadrant ultrasound and her human
immunodeficiency virus test should be discussed with the
patient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 18612**]
Dictated By:[**Last Name (NamePattern1) 18613**]
MEDQUIST36
D: [**2174-5-6**] 15:33:19
T: [**2174-5-6**] 17:10:24
Job#: [**Job Number 18614**]
ICD9 Codes: 4019, 4280, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4119
} | Medical Text: Admission Date: [**2122-3-18**] Discharge Date: [**2122-3-23**]
Date of Birth: [**2071-10-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
non-small cell lung carcinoma
Major Surgical or Invasive Procedure:
1. left thoracotomy and left pneumonectomy
2. buttressing of bronchial staple line with intercostal muscle
3. mediastinal lymphadenectomy
History of Present Illness:
50yo female with left lower lobe lung mass that was biopsy
confirmed adenocarcinoma and FDG avidity on PET scan.
Past Medical History:
rhinoplasty, tonsillectomy, cervical dysplasia
Social History:
patient is single and lives with family
occupation: nursing supervisor
tobacco: former smoker, quit 3.5 yrs ago
EtOH: patient denies
Exposure: patient denies
Family History:
Mother: healthy
Father: HTN, CAD
Siblings: sister has HTN, brother died of alcoholism
Offspring: son healthy
[**Name2 (NI) **]: uncle died of melanoma
Physical Exam:
upon admission:
Gen: NAD, AOx3
Chest: CTAB
CV: RRR, S1/S2 appreciated
Abd: soft, NT/ND
Ext: no C/C/E
Pertinent Results:
[**2122-3-18**] 04:12PM GLUCOSE-137* UREA N-11 CREAT-0.6 SODIUM-139
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
[**2122-3-18**] 04:12PM estGFR-Using this
[**2122-3-18**] 04:12PM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-1.6
[**2122-3-18**] 04:12PM WBC-13.5*# RBC-3.76* HGB-10.1* HCT-30.9*
MCV-82 MCH-26.8* MCHC-32.7 RDW-13.0
[**2122-3-18**] 04:12PM PLT COUNT-412
Brief Hospital Course:
The patient was admitted to the Thoracic Surgery Service on
[**2122-3-18**], and the patient underwent a left thoracotomy and left
pneumonectomy, buttressing of bronchial staple line with
intercostal muscle, and mediastinal lymphadenectomy on the same
day which went well without complication (please refer to the
Operative Note for details). Post-operatively the patient was
transferred to the TSICU for monitoring.
Neuro: The patient initially received an epidural with good
effect and adequate pain control. When tolerating oral intake,
the patient was transitioned to oral pain medications.
CV: The patient did develop atrial fibrillation postoperatively
however, she was converted with lopressor and diltiazem and her
blood pressure remained stable on the floor. She was given
lopressor 12.5 mg PO BID and diltiazem 30 mg PO QID. She was
then later changed over to Diltiazem 60 QID and did well. She
ambulated without further A-fib events. It was noted that she
had some PACs on her telemetry strip while ambulating, however
the patient was not symptomatic at the time.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization. Serial CXRs show normal
pos-operative changes as expected for a pneumonectomy.
GI/GU/FEN: Post-operatively, the patient had an NG tube and was
NPO with IV fluids. Diet was advanced when appropriate, which
was well tolerated. Patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. No antibiotics were
started.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required. Near the end of her
hospital day, she did develop superficial thrombophlebitis of
her right antecubital fossa which was treated with warm
compresses and arm elevation. No further imaging was done.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
calcium/vitamin D, multivitamin, ativan, vicodin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
6. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*1*
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety. Tablet(s)
8. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every eight (8) hours as needed for
shortness of breath or wheezing.
Disp:*1 vial* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
non-small cell lung carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101, chills, or shakes
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops significant drainage
-You may shower. No tub bathing or swimming for 4 weeks
-Keep bandaid over chest tube site and change daily until healed
-keep right arm elevated with warm compress over antecubital
area four times a day, if arm becomes more red and painful,
please give us a call.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2122-4-2**] 11:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) 24**]
Chest X-Ray: [**Location (un) **] radiology 30 minutes before your
appointment
Completed by:[**2122-3-23**]
ICD9 Codes: 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4120
} | Medical Text: Admission Date: [**2188-11-25**] Discharge Date: [**2188-12-2**]
Date of Birth: [**2153-10-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**2188-11-28**] mitral valve repair (28mm [**Company 1543**] CG Future Ring)
History of Present Illness:
This 35 year old pediatrician is visiting from [**Country 6607**] and
developed severe dyspnea on exertion, orthopnea, dry cough, and
questionable fever and chills. He presented to the ER and a CXR
showed RUL pulmonary edema. A loud systolic murmur was noted.
Echocardiography showed wide open mitral regurgitation and he
was referred for surgical evalualtion.
Blood culture from the ER were notable for one culture which
grew a gram negative rod and infectious disease was consulted.
Past Medical History:
asthma ( mild and intermittent)
OSA (wears mouthguard, no CPAP)
inguinal herniorrhaphy
Social History:
works as a pediatrician
lives with wife in [**Name (NI) 6607**]
no tobacco use
no ETOH
Family History:
father with MI in early 50's, died of CVA in late 70's
Physical Exam:
Admission
VS T 98.7 HR 110-120ST BP 107/54 RR 20 O2sat 97%-RA
Gen NAD
HEENT PERRL/EOMI, anicteric, MMM. neck supple, no JVD
Chest RUL diminished BS
CV RRR, 5/6 SEM
Abdm soft, NT
Ext no edema, palpable pulses
Discharge
VS T 98.9 HR 86SR BP 114/64 RR 20 O2sat
Gen NAD
Neuro A&Ox3, nonfocal exam
Pulm CTA bilat
CV RRR< no murmur. Sternum stable, incision CDI
Abdm soft, NT/ND/+BS
Ext warm, + pedal edema bilat
Pertinent Results:
[**2188-11-25**] 04:30AM GLUCOSE-113* UREA N-18 CREAT-1.0 SODIUM-141
POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-24 ANION GAP-13
[**2188-11-25**] 04:30AM proBNP-1356*
[**2188-11-25**] 04:30AM WBC-11.1* RBC-4.45* HGB-14.0 HCT-39.0* MCV-88
MCH-31.5 MCHC-36.0* RDW-12.9
[**2188-11-25**] 04:30AM PLT COUNT-285
[**2188-11-30**] 06:40AM BLOOD WBC-9.1 RBC-3.24* Hgb-10.0* Hct-28.4*
MCV-88 MCH-30.8 MCHC-35.1* RDW-12.7 Plt Ct-200
[**2188-12-1**] 05:20AM BLOOD PT-12.8 INR(PT)-1.1
[**2188-11-30**] 06:40AM BLOOD Plt Ct-200
[**2188-12-1**] 05:20AM BLOOD UreaN-16 Creat-0.8 Na-139 K-4.1
[**2188-11-27**] 08:15PM BLOOD ALT-33 AST-22 LD(LDH)-200 AlkPhos-59
TotBili-0.4
[**2188-11-27**] 08:15PM BLOOD %HbA1c-5.7
PRE-BYPASS:
1. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler.
2. The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are three aortic valve leaflets. There is no aortic
valve stenosis. No aortic regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. The mitral
valve leaflets are myxomatous. There is partial mitral leaflet
flail of P2 scallop. An eccentric, posterior directed jet of The
effective regurgitant orifice is >=0.40cm2 The mitral
regurgitation vena contracta is >=0.7cm. Severe (4+) mitral
regurgitation is seen. Mitral Annulus is dilated.
6. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including Phenylephrine andf in
Sinus rhythm.
1. A well-seated mitral annuloplasty ring is seen with normal
leaflet motion and gradients (mean gradient = 5 mmHg). There is
no valvular systolic anterior motion ([**Male First Name (un) **]). No mitral
regurgitation is seen. A small echogenic structure is noted to
be in the left atrial wall, near where the native P1 and 2 would
have been, about 1 cm cephalad to the mitral annuloplasty ring.
Discussed with Dr. [**Last Name (STitle) **], most likely a pledgetted suture that
was placed as part of the valve repair.
2. LV function is Normal.
3. Aorta is intact post decannulation
4. Other findings are unchanged
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2188-11-28**] 10:45
[**Known lastname **],[**Known firstname 275**] [**Medical Record Number 79901**] M 35 [**2153-10-17**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-12-1**]
12:28 PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2188-12-1**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79902**]
Reason: folowup RT ptx on [**12-1**] film
[**Hospital 93**] MEDICAL CONDITION:
35 year old man with
REASON FOR THIS EXAMINATION:
folowup RT ptx on [**12-1**] film
Final Report
CHEST PORTABLE AP:
REASON FOR EXAM: 35-year-old man with follow up right
pneumothorax.
Since earlier today, sternotomy wires for MVR are unchanged.
Left pleural effusion with associated atelectasis is also
stable. Right
pneumothorax persists and may be slightly smaller. There is
overall no other change since earlier today.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: MON [**2188-12-1**] 5:46 PM
Brief Hospital Course:
He was admitted on [**11-25**]. Diuresis was begun and he did not
require intubation. Pre-op workup was completed and he underwent
surgery with Dr. [**Last Name (STitle) **] on [**11-28**]. Please see OR report for
details in summary. Patient had MV repair w/28MM [**Company 1543**] ring.
His bypass time was 61 minutes with a crossclamp of 45 minutes.
He tolerated the operation well and was transferred to the CVICU
in stable condition on phenylephrine and propofol drips. He
remained hemodynamically stable in the immediate post operative
period, was weaned from the pressors and was extubated without
difficulty.
ID was consulted on [**2188-11-28**] due to [**2-15**] blood cultures on
[**2188-11-25**] growing gram negative rods. He was started on IV Zosyn
and Vancomycin post-op day 0. Later that afternoon Zosyn was
discontinued and Meropenem was started. Vancomycin was continued
until [**2188-11-30**] after negative blood cultures. Final ID
recommendations were made on [**2188-12-2**]. Patient will take Flagyl
500MG PO three times daily for 6 weeks, follow up with ID in 4
weeks.
On POD1 he was begun on beta blockers and diuretics. He was
also transferred to the step down floor. On the floors he
developed atrial fibrillation transiently for which his beta
blocker dose was increased. Anticoagulation was begun, in the
event dysrhythmia persisted. He converted to sinus rhythm and
maintained this at discharge. Warfarin was discontinued on POD 4
due to normal sinus rhythm for greater than 24 hours. His
hospital course was otherwise uneventful. He was discharged home
on POD 4.
Medications on Admission:
bronchodilators (MDI) prn
Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*180 Tablet(s)* Refills:*0*
2. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain.
Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take as long as you take narcotics.
Disp:*60 Capsule(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 weeks.
Disp:*126 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
severe mitral regurgitation
s/p mitral valve repair
asthma
obsructive sleep apnea
s/p inguinal herniorraphy
Discharge Condition:
good
Discharge Instructions:
shower daily and pat incisions dry. No baths or swimming
no lotions, creams or powders on any incision
call for fever greater than 100.5
no driving for one month and off all narcotics
no lifting greater than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any weight gain greater than 2 pound a day or 5 pounds in
a week
Followup Instructions:
see your primary care physician [**Last Name (NamePattern4) **] [**2-13**] weeks
cardiologist follow up in [**3-16**] weeks
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] ( or get a referral for a
cardiac surgeon to follow you in Winnipeg for a postop visit in
4 weeks)
Follow up in [**Hospital **] clinic on 4 weeks with Dr [**Last Name (STitle) 438**] ([**Telephone/Fax (1) 6732**]
Completed by:[**2188-12-2**]
ICD9 Codes: 4240, 486, 9971, 7907, 5119, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4121
} | Medical Text: Admission Date: [**2172-10-15**] Discharge Date: [**2172-10-23**]
Date of Birth: [**2135-11-15**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
SOB, CP, n/v
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. [**Known lastname **] is a 36 year old female with history of recently
diagnosed ALL, who came to the oncology clinic to receive her
chemothrapy and complained of worsening shortness of breath and
chest pain for a few days, and was referred to ED for further
evaluation and treatment. Per patient, she has been experiencing
worsening dyspnea for the past week when she had to increase the
number of pillows from 2 to 4 due to shortness of breath when
she slept. States a [**6-14**] midsternal chest pain that radiates
circumferentialy around the ribs to the back that started a few
days ago. Pain is gradual and constant and worse with
inspiration, gets better when she is sits up. Has a productive
cough with white/clear phelegm. Denies any fevers/chills/night
sweats.
.
She has also been experiencing severe nausea and vomiting for
the past week where she has been unable to hold any food down.
Her weight has been fluctuating but no big weight loss recently.
She does endorse dizziness since yesterday when she stands up,
relieved when she sits or lies down.
.
With her hx of asthma, she only uses her inhalers. Has not been
to the ED for any exacerbations. States an increased frequency
of use of her inhalers in the past few weeks.
.
Of note, patient recently presented to ED on [**2172-8-11**] with some
RUE weaknesa and parethesia, and was found to have a WBC of
140K, and emergently leukopheresed, and was diagnosed with ALL.
She was discharged on [**2172-9-22**], and has been receiving
chemotherapy regularly. Today is her phase II day 25 therapy.
.
In the ED, patient's initial vitals were: Afebrile, T98.2 BP
154/120 HR 138 RR 18 SPO297% on R/A. Sat's: off oxygen 93%, 97%
on 4L (depends on position). She was slightly tachypneic, RR
25-30s, and it hurts for her to breath in. She underwent CTA to
rule out PE. Her scan demonstrated large bilateral pleural
effusions and a small pericardial effusion. bedside US showed no
tamponade, and small effusion. She was given 1 gram of Cefepime,
500-1000cc of normal saline, had 200cc urine (no foley). No
change in HR was seen after receiving morphine or IVF. The
oncology fellow was notified of the patient's planned admission
and course. per onc fellow, no urgent need to tap, but may need
to tap overnight if pt is very symptomatic from the pleural
effusion.
.
She was transferred to the [**Hospital Unit Name 153**] for further management.
.
On the floor, she continued to complain of shortness of breath
while lying down, and is sitting up while talking. She continued
to complain of nausea.
.
Review of sytems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied any palpitations. Denied diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria.
Past Medical History:
PAST MEDICAL HISTORY:
- ALL
- Asthma: uses inhalers
- HTN
- Cervical Intraepithelial neoplasia
Social History:
SOCIAL HISTORY: Lives at home with aunt and sister. [**Name (NI) **] 2
children (7, 17). Denies alcohol, tobacco, illicit drugs. Was
previously employed at [**Company 59330**], hasn't been working since being
diagnosed with ALL in [**Month (only) 205**]. She hopes to go back to work. Denies
any recent travel. Her son has been sick with a cold, but hasn't
been with her since he got sick.
Family History:
FAMILY HISTORY:
No family h/o leukemia and lymphoma
Physical Exam:
PHYSICAL EXAMINATION:
VS: T: 98.7 HR: 131 BP 158/122 RR 30 Sat 100% on 4L
Pulsus paradoxus was 5.
GENERAL: No acute distress. She is alert and oriented x3 in good
mood and affect.
HEENT: Pupils are equal and reactive to light. Conjunctivae are
pink. Oropharynx is dry. There are no specific lesions on lips,
teeth, or gums.
NECK: Supple, with no thyromegaly, and no palpable mass.
JVP=10cm
LYMPH NODES: There is no palpable lower cervical,
supraclavicular, axillary, or groin lymphadenopathy.
LUNGS: Decreased breath sounds bilaterally. Poor airway entry.
Diffuse crackles and wheezes
ABDOMEN: Soft, nontender, nondistended with no
hepatosplenomegaly and no masses.
EXTREMITIES: There is no lower extremity edema.
SKIN: There are no rashes and no palpable lesions.
Pertinent Results:
LABORATORIES:
WBC 0.5 Hgb 8.9 Hct 26.3, plt 16 MCV 85 N:23.0 L:74.7 M:1.4
E:0.7 Bas:0.2
Gran-Ct: 161 , repeat 80 --> by discharge the ANC was 1580
On discharge, the pt's WBC's were 4.9, h/h 8.2/24.7 and plts 9
142 105 10
-------------123
3.6 27 0.7
Chems were normal through admission, normal renal function,
except for phosphorous which had the tendency to run high, was
4.8 on d/c.
CK's normal through admission.
Tbili 1.7 (1.3 indirect and 0.4 direct) on admission, trended
down to 1.0 on d/c.
ALT/AST 44/27 on admit, 43/24 on d/c.
LDH 273 on admit and 265 on d/c.
AlkP normal through admission
Alb 3.7
CK MB was normal through admission [**7-12**]
TropT slightly elevated at 0.09-0.11 then trended slightly more
to 0.14-0.17, however not thought to be due to ACS
BNP 5007 on admission
PT: 14.1 PTT: 24.3 INR: 1.2
UA: neg
BCx negative x2
IMAGING:
- CXR ([**2172-10-15**])
IMPRESSION: New interstitial edema and moderate bilateral
pleural effusions with adjacent atelectasis.
.
- TTE [**2172-10-16**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis (LVEF = XX %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size is normal. with severe
global free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2172-8-12**],
global biventricular systolic dysfunction is new. The
pericardial effusion is new.
.
- CTA report [**2172-10-15**]: FINDINGS: There is no evidence of
pulmonary embolism, aortic dissection, or
pneumothorax. The thoracic aorta is normal in caliber.
There are bilateral moderate new pleural effusions with adjacent
atelectasis
in the lower lobes bilaterally. There are scattered noncalcified
pulmonary
nodules, which are new compared to the recent prior study of
[**9-19**]. Small-
to-moderate pericardial effusion is present. There is diffuse
interstitial
septal thickening, compatible with edema. The airways are patent
to the
subsegmental levels bilaterally. There is no hilar, mediastinal
or axillary adenopathy.
This study is not optimized for subdiaphragmatic evaluation.
Known liver mass in segment VI is not imaged on this study.
IMPRESSION:
1. New large bilateral pleural effusions, small-to-moderate
pericardial
effusion, and interstitial septal thickening, compatible with
edema.
2. Bilateral noncalcified pulmonary nodules. Short interval
development
since the prior study favors infectious/inflammatory etiology,
progression of
the disease less likely.
.
EKG on admission ([**2172-10-15**]):
rate 127, sinus rhythm. normal axis. pr, qrs and qt intervals
within normal range. low amplitude qrs in limb leads. t wave
flattening in limb leads. less than 0.5mm ST depression in V5,
V6.
.
ECHO [**2172-10-16**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis (LVEF = XX %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size is normal. with severe
global free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
.
Compared with the prior study (images reviewed) of [**2172-8-12**],
global biventricular systolic dysfunction is new. The
pericardial effusion is new.
.
EKG [**2172-10-16**]
Sinus tachycardia with slowing of the rate compared to the
previous tracing
of [**2172-10-15**]. The T waves are biphasic in leads I, II aVL, aVF and
V3-V6, similar
to that recorded on [**2172-9-19**] though not as prominent. Followup
and clinical
correlation are suggested.
.
CXR [**2172-10-16**]
FINDINGS: Cardiomediastinal silhouette appears unchanged from
previous study.
Bilateral pleural effusions are seen with bibasilar atelectasis
and mild
pulmonary edema. There is no pneumothorax.
.
ECHO [**2172-10-20**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate global
left ventricular hypokinesis (LVEF = 30%). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with focal hypokinesis of the apical free wall.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. There is mild
pulmonary artery systolic hypertension. There is a small
pericardial effusion. The effusion appears circumferential.
IMPRESSION: Moderate global left ventricular systolic
dysfunction. Mild regional right ventricular systolic
dysfunction. Mild mitral regurgitation. Mild pulmonary
hypertension. Small pericardial effusion.
Compared with the prior study (images reviewed) of [**2172-10-16**],
right ventricular cavity is slightly larger, although both RV
and LV overall systolic function has improved. Pericardial
effusion size and other findings are similar.
CXR [**2172-10-21**]
Lung volumes have improved, possibly because of deeper
inspiration. Moderate
bilateral pleural effusions persist. Bibasilar atelectasis is
improved.
Upper lungs clear. Moderate enlargement of the cardiac
silhouette is
unchanged. There is no distention of mediastinal veins to
suggest particular
elevation of central venous pressure.
Brief Hospital Course:
36yo newly Dx'd ALL in [**8-13**], currently getting E2993 Tx, phase
II day+26 admitted for SOB, orthopnea, n/v found to have heart
failure with EF 15-20% with bilateral pleural effusions and
small pericardial effusion, pancytopenic.
.
1. Heart [**Name (NI) 94059**] pt was admitted to the ICU and Dx'd with
acute heart failure, which was thought to be due to Daunorubicin
therapy in the past several months VS myocarditis/pericarditis.
She was tachycardic and HTN, had a CTA without PE or dissection
and had a TTE showing EF of 15-20%, global hypokinesis of LV,
hypokinesis of free wall of RV, and small pericardial effusion.
Given IV Lasix diuresis with good response, hemodynamically
stabilized and called out to the floor where she was continued
on IV Lasix diuresis, then switched to PO diuresis. Cards was
consulted and recommended a heart failure regimen of Lasix 40mg
PO qday, Metoprolol 25mg PO bid, Lisinopril 5mg POqd, and
Aldactone 25mg PO qday, which the pt was started on and
tolerated well. The pt then had a repeat echo the day after she
developed some acute CP (see below) which showed an improvement
in her EF to 30%, improvement in systolic fxn of both
ventricles, no increase in pericardial effusion. By the time of
discharge, the pt's vitals had stabilized and bp's were in the
low 100's-110's and pulse 80's-90's, and her weight had
decreased down to pre-admission weight. The pt will be d/c'd on
her current HF regimen and will need to be reassessed, including
her heart failure meds and repeat echo in the future.
.
2. Chest pain--Pt c/o substernal pleuritic type pain on
admission, and had one acute episode of SOB and substernal chest
pain on the floor, pleuritic in nature, for which an EKG was
obtained which was significant for small voltage QRS complexes
in V3-V6 (no ST changes), a CXR was obtained which showed
continued pleural effusions, and cardiac enzymes were drawn. The
pt received a dose of 40mg IV Lasix and had good UOP overnight,
and the CP/SOB resolved uneventfully. Pt was not given any ASA
during the admission due to low platelet count.
.
Several EKG's were recorded through her admission, all without
ST changes, and CE's were trended through admission. CKMB's
where flat, however there was a small increase in her Troponins
ranging from 0.09 to 0.17. This small increase was thought to be
due to either demand ischemia or to a possible myo/pericarditis
picture, for which Cards recommended doing an oupt cardiac MR in
the future is still clinically warranted.
.
3. [**Name (NI) 94060**] pt had crackles on PE, was requiring O2 via NC, and
had CXR showing pleural effusions. She was started on her home
asthma regimen and occasionally given prn Xopenx nebs, Alubterol
being avoided due to tachycardia at the time. She was weaned off
the O2 as her HF resolved and by time of d/c was satting well on
room air, not tachypneic, not having difficulty breathing.
.
4. [**Name (NI) 94061**] pt was neutropenic on admission and started
on empiric Cefipime, despite being afebrile. The pt never spiked
a fever through admission and Cefipime was discontinued. All
cultures were negative through admission. The pt was started on
Neupogen with appropriate response, which was then d/c'd. The pt
will be discharged on her home regimen of prophylactic ABx
including Atovaquone and Acyclovir.
.
5. [**Name (NI) 94062**] pt was anemic but felt to be at baseline. Did
receive 1U PRBC's through admission but Hct remained stable
through rest of admission.
.
6. [**Name (NI) 94063**] pt was thrombocytopenic with plts 21 on
admission and received 5U plts during admission, with minimal
response. It was felt that the pt had many platelet antibodies
as a result of a long platelet transfusion history and
considering that she was being followed for future
transplantation, that further platelet transfusions would
increase her antibodies and make transplantation more difficult.
Therefore, a lower platelet count was tolerated and aggressive
transfusion was not pursued. She had no clinical evidence of
bleeding, her Hct remained stable, and her tachycardia trended
down as her volume overload and heart failure resolved.
.
7. Pericardial effusion--There was some concern for a
hemorrhagic pericarditis, with a small pericardial effusion seen
on echo and her platelets being low and low voltage QRS
complexes seen on an EKG once. She did not have a rub or pulsus
paradoxus on PE. She received a follow up echo showing that the
pericardial effusion had not increased in size.
.
8. [**Name (NI) 94064**] pt was complaining of a headache on admission
that she said was consistent with what she described as a
history of migraines, however she did not have phonophobia,
photophobia, or an aura. She did however appear to be in pain.
She was started on her home dose of Ultram and she refused any
narcotic pain meds. She occasionally c/o this h/a during
admission but they spontaneously resolved without any
complications with conservative Ultram management.
Medications on Admission:
Medications: (confirmed by [**2172-10-15**] hem/onc note)
ACYCLOVIR - 200 mg Capsule - 2 Capsule(s) by mouth three times a
day
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily
ATOVAQUONE [MEPRON] - 750 mg/5 mL Suspension - 10 mL by mouth
once a day
CIPROFLOXACIN - 250 mg Tablet - 1 Tablet(s) by mouth twice a
daily
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
inhaled twice a day
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol -
2
puffs po four times a day as needed for prn
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth every 6 hours as
needed for Nausea
MERCAPTOPURINE - 50 mg Tablet - 2 Tablet(s) by mouth once daily.
Bring to appointment on Monday [**2172-9-21**].
METOCLOPRAMIDE - 5 mg Tablet - [**2-7**] Tablet(s) by mouth every 8
hours as needed for Nausea
OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - 1 Tablet(s) by mouth
twice
a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
ONDANSETRON HCL - 8 mg Tablet - one Tablet(s) by mouth every 8
hours as needed for Nausea
OXYCODONE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth every 6 hours as needed for Pain
TRAMADOL - 50 mg Tablet - [**2-7**] Tablet(s) by mouth every six (6)
hours as needed for headache
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*3*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO ONCE (Once).
Disp:*30 Tablet(s)* Refills:*3*
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
6. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO BID (2
times a day).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for nausea.
9. Olanzapine 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
12. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation twice a day as needed for shortness of breath
or wheezing.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
1. ALL
2. Heart failure
Discharge Condition:
By the time of discharge, the pt's volume overload was much
improved, heart function had slightly improved as seen by heart
ultrasound, had good oxygen saturation on room air and vital
signs were stable, had been stabilized on a medicine regimen,
and was medically clear for discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] and found to be in heart failure. You
were stabilized in the intensive care unit and given medicines
to draw off extra fluids from your body. Cardiology was
consulted and recommended a regimen to treat your heart failure.
You had a repeat ultrasound of your heart which showed some
improvement.
You were started on 4 new medicines which will be very important
to continue after discharge: Lasix, Metoprolol, Lisinopril, and
Aldactone. You will need to follow up with your physician to
assess your heart function and the necessity of continuing these
medicines. It is very important to take these medicines as
prescribed as your heart is still not up to its full strength.
Please return to the hospital or to a health care provider if
you experience fevers, chills, or night sweats, continued
shortness of breath, difficulty breathing, swelling of your
legs, chest pain, or any other concern.
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4613**] on Monday [**2172-10-26**] at 2pm on [**Hospital Ward Name 23**] [**Location (un) 436**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2172-10-27**]
ICD9 Codes: 4280, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4122
} | Medical Text: Admission Date: [**2179-8-31**] Discharge Date: [**2179-9-3**]
Date of Birth: [**2107-1-5**] Sex: F
Service: THORACIC SURGERY
ADMITTING DIAGNOSES:
1. Nonsmall cell lung cancer.
2. Congestive heart failure.
3. Moderate-to-severe mitral regurgitation.
4. Moderate tricuspid regurgitation.
5. Mild-to-moderate aortic regurgitation.
6. Atrial fibrillation.
7. Hypothyroidism.
8. History of rheumatic fever.
DISCHARGE DIAGNOSES:
1. Nonsmall cell lung cancer - status post right upper
lobectomy and mediastinal lymph node dissection.
2. Congestive heart failure.
3. Moderate-to-severe mitral regurgitation.
4. Moderate tricuspid regurgitation.
5. Mild-to-moderate aortic regurgitation.
6. Atrial fibrillation.
7. Hypothyroidism.
8. History of rheumatic fever.
ADMITTING HISTORY AND PHYSICAL: The patient is a 72-year-old
female, who was recently diagnosed with a right upper lobe
mass after being worked up for congestive heart failure.
This mass, which was initially noted on chest x-ray during
the congestive heart failure workup, was further evaluated by
CT scan which was followed by mediastinoscopy on [**2179-8-9**]. Lymph node biopsy initially did not demonstrate a new
lesions, but she presents for definitive evaluation. Her
lymph node biopsy initially did not give a definitive proof
of malignancy. The patient presents for definitive
evaluation of this mass. She has not had any recent cough,
or sputum, or chest pain, or weight loss.
ADMITTING PHYSICAL EXAMINATION: Patient's temperature is
98.9, pulse 72, respiratory rate 20, with an O2 saturation of
96% on room air, blood pressure was 138/54, and her admitting
weight was 66 kg. Otherwise, she was alert. Neck revealed
no adenopathy. Her lungs were both clear bilaterally. The
heart was regular, rate, and rhythm. Abdomen was soft and
the extremities had no edema.
ADMITTING LABORATORIES: Hematocrit was 36.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**8-31**] on which day she underwent a right upper lobe
lobectomy with a mediastinal lymph node dissection without
note of intraoperative complication. She had minimal blood
loss during the procedure.
Postoperatively, the patient was extubated without difficulty
and taken to the Post Anesthesia Care Unit. Pain control was
provided by an epidural catheter which was notably placed
intrathecally. Placement of this catheter intrathecally
required the patient to stay in the Post Anesthesia Care Unit
on postoperative day one, but otherwise she was doing well
with incentive spirometry and aggressive chest PT.
She was transferred to the floor on postoperative day two,
where she remained afebrile and continued with chest PT and
incentive spirometry, and had her chest tubes removed.
By postoperative day three, the patient had remained
afebrile. Otherwise, was not breathing well with good O2
saturations on room air and was ambulating without
difficulty. Pain control was not an issue, and the patient
successfully passed her voiding trial, and was therefore
discharged to home in good condition. Discharge hematocrit
was 32.1.
Patient was discharged to home in good condition and asked to
followup with Dr. [**Last Name (STitle) 175**] at his office in one week and also
to followup with Dr. [**Last Name (STitle) **] at his office in early next week.
DISCHARGE MEDICATIONS:
1. Digoxin 250 mcg po q day.
2. Levothyroxine 125 mcg po q day.
3. Lipitor 20 mg po q day.
4. Percocet 5/325 1-2 tablets every 4-6 hours as needed.
5. Ibuprofen one every eight hours as needed.
6. Bisacodyl rectal suppositories for constipation as needed.
7. Lopressor 12.5 mg twice a day.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Name8 (MD) 3363**]
MEDQUIST36
D: [**2179-9-3**] 09:19
T: [**2179-9-14**] 11:10
JOB#: [**Job Number 48161**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4123
} | Medical Text: Admission Date: [**2124-2-17**] Discharge Date: [**2124-3-24**]
Date of Birth: [**2073-1-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
PICC placement
HD tunneled line placement
central venous line placement
ultrasound guided percutaneous liver biopsy
History of Present Illness:
54F with schizophrenia, htn, dm, who was found unresponsive by
her son at approximately 3 am in the bathtub. He said he had
seen [**Last Name (un) **] the night before and she was okay, in no acute
distress, though he notes she has not been taking her meds for
many months. He said she was breathing shallowly and slapped her
several times in the face with no response and then called EMS.
Was given narcan in the field. In ED, hypotensive with sbp in
50s, hr 160s, was intubated and right subclav placed. Pt. was
hyperthermic to 106 and because patient was on antipsychotics at
home, there was a question of overdose and both dantrolene (for
nms) and physostigmine (for anticholinergic) were given. In
addition, pt. got head CT (neg) and chest CT which showed
bibasilar consolidation. Pt. received Vanc and Ceftriaxone for
coverage of pneumonia/meningitis. She was started on Levophed
and vasopressin for pressors. As they were attemtpting to LP
patient at 6AM, it was noted that she had a hematoma around
subclavian site and patient was oozing blood there. Coags were
checked and showed INR 146. Pt. transferred to [**Hospital1 18**] MICU. On
arrival, pt. was very hypotensive and oozing from every orifice.
Past Medical History:
1. DM on oral hypoglycemics: metformin and glyburide
2. HTN
3. schizophrenia
4. Asthma
Social History:
Lives with son, [**Name (NI) **]. [**Name2 (NI) **] extensive family. Is originally from
[**Male First Name (un) 1056**]. Per famiy, was drinking heavily several weeks ago
but not recently. No other drugs. ?tob.
Family History:
Non-contributory
Physical Exam:
VS: T 91.7 HR 56 BP 86/40
Vent: ac 15 x 550, fio2 100%, peep 5
GEN: not responsive to painful stimuli
HEENT: pupils constricted but reactive, og tube with brb
CV: rrr s1s2 no mrg
LUNG: coarse bs b/l
ABD: soft, nt, nd, with rectal bag with thin bloody liquid
EXT: no edema, ulcerations on legs
NEURO: not responding to painful stimulus
LINES: right subclavian oozing blood
Pertinent Results:
# At admission ([**2124-2-17**]):
-GLUCOSE-299* UREA N-19 CREAT-1.7* SODIUM-147* POTASSIUM-3.4
CHLORIDE-117* TOTAL CO2-10*
-CK(CPK)-2153*, CK-MB-147*, MB INDX-6.8*, cTropnT-6.86*
-CALCIUM-6.7* PHOSPHATE-3.8 MAGNESIUM-2.0
-WBC-14.7 w/34 PMNs, 8 bands.
-Hct 31->17 after IVF
-Plt 91->26
-INR(PT) >66 at admission -> -> 3.5
-Fibrin <45, FDP >1280, D-dimer >10,000
-LACTATE-10.3*
-ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
-ECG: Sinus rhythm. Wandering baseline. Left axis deviation. Q-T
interval
prolongation. A repeat tracing of diagnostic quality is
suggested. There is low limb lead voltage. No previous tracing
available for comparison
-CXR: Satisfactory positioning of tubes and lines as described.
No pneumothorax detected. No definite consolidation.
# Other data:
-ALT peaked at 4377 on [**2124-2-19**] then stable in low 100s at
discharge
-AST peaked at 8458 on [**2124-2-19**] then stable in 60s at discharge
-creatinine 1.4 at admission -> peaked at 8.0 on [**2124-2-29**] (then on
dialysis)
-peak TropT 9.88 on [**2124-2-18**]
-peak CK 4104 on [**2124-2-20**] and CK-MB 149 on [**2124-2-18**]
-total bili peaked at 13 on [**2124-2-21**] then trended down
-alk phos peaked at 1436 on [**2124-3-14**] then trended down
# Imaging:
-[**2124-3-22**]: sinus CT: no acute process seen.
-[**2124-3-18**]: CT head: no evidence of intracranial hemorrhage or
shift of normally midline structures. Ventricles and cisterns
are normal. Hypodensities within both basal ganglia consistent
with old lacunar infarcts. The [**Doctor Last Name 352**]-white differentiation is
preserved. There are no abnormally enhancing regions within the
brain.
-[**2124-3-18**]: CT torso: no acute process; no evidence of abscess.
-[**2124-3-13**]: LE doppler U/S: no evidence of lower extremity DVT.
-[**2124-3-12**]: [**Month/Day/Year 60478**]: Normal appearance of the liver, pancreas,
pancreatic and common bile ducts.
-[**2124-3-7**]: Gallbladder scan: No evidence of cholecystitis.
Delayed gallbladder emptying following CCK administration with
EF of 12% after 30 minutes (normal range is more than 35%).
-[**2123-3-7**]: Left upper extrem doppler U/S: No evidence of deep
venous thrombosis in the left upper extremity.
-[**2124-3-1**]: Echocardiogram: EF >=65%. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. LV wall thickness,
cavity
size, and systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. RV chamber size and free wall
motion are normal. 1+ MR. Mild pulmonary artery systolic
hypertension. No pericardial effusion.
-[**2124-3-1**]: EEG: Abnormal EEG due to the slow and disorganized
background
and bursts of generalized slowing. These findings indicate a
widespread
encephalopathic condition affecting both cortical and
subcortical
structures. Medications, metabolic disturbances, and infection
are
among the most common causes. There were no focal abnormalities
although encephalopathies may obscure focal findings. There were
no
epileptiform features.
-[**2124-2-21**]: MRI head: areas of increased diffusion within the left
internal capsule and bilateral frontal cortex is suspicious for
a subacute infarct, as these are also seen as abnormal on T2 and
FLAIR. Please correlate with the length of the patient's
symptoms. Sinus disease as described above. Scalp hematoma.
-[**2124-2-17**]: Echocardiogram: EF 50%, no masses or thrombi seen in
the LV. No VSD. RV chamber size is normal. RV systolic function
appears depressed. LV inflow pattern suggests impaired
relaxation. No pericardial effusion.
Brief Hospital Course:
54F w/ DM/HTN/Schizophrenia, p/w septic shock and oligouric ARF,
now on HD and has slow to improve MS.
# Fevers: Patient initially admitted in presumed septic shock,
although no infectious source identified. Toxicology consult
was obtained and felt that her presentation was consistent with
septic shock. All cultures, including blood, urine, catheter
tip, c.diff, have been with NGTD. Urine cultures have grown out
>100,000 CFU of [**Female First Name (un) **] albicans. In unit, she was given 14d
course of ctx/vanc for empiric tx of pneumonia and meningitis
but LP was deferred due to DIC. This coverage was changed to
clinda+levaquin for empiric tx of aspiration pneumonia, and then
to levo + flagyl for cholangitis. Antibiotics discontinued
~[**3-14**] and patient defervesced although she has had intermittent
spikes and negative cultures. Caspofungin started for fungal
UTI on [**3-17**] but d/ced after 3 days. Pan-CT of head, chest,
abdomen, pelvis was negative for any source for fever. WBC scan
was performed on [**3-22**] and revealed possible uptake in the
left lower extremity, but Xrays in this area did not show an
acute process. Final read of WBC scan was read as normal.
# LFT Abnormalities: LFT??????s trended upwards in the MICU, thought
to be secondary to shock liver. Transaminases peaked, but alk
phos has been more or less persistently elevated and rising with
elevated GGT. RUQ ultrasounds shows no evidence of cholangitis
or cholecystitis. HIDA scan shows normal gb flow, but shows low
??????EF?????? ?????? the significance of this is unclear. [**Name2 (NI) 60478**] WNL. A liver
biopsy was performed on [**3-16**], but results are negative for
granulomatous hepatitis (i.e. fungal infx).
# Renal failure: The patinet had oliguric renal failure due to
her shock/hypotension. In the MICU, she was started on CVVH and
then was transitioned to hemodialysis Tue/[**Last Name (un) **]/Sat. A tunneled
line was placed on [**2-28**]. However, by [**3-16**], her renal fxn
improved off of dialysis so nephrology signed off.
# Mental status: MRI with subacute L internal capsule, b/l
frontal cortex infarct, scalp hematoma, sinus thickening. EEGx2
showed toxic metabolic slowing. She has had decreased but
waxing/[**Doctor Last Name 688**] MS; she has been following commands in Spanish,
and slowly increasing her vocab. Her expressie aphasia is
improving. She needs speech therapy as an outpt.
# Heme: Was found to have DIC on admission, this was most likely
secondary to sepsis. Pt has had episodes of bleeding around HD
cath site, she has responded to DDAVP for uremic bleeding. HCT
stable by time of discharge.
# Cardiovascular: on presentation, the patient was found to have
NSTEMI which can be attributed to demand ischemia in the setting
of tachycardia and hypotension. The patient was started on a
beta-blocker and this was titrated upwards.
# Endocrine: history of type II diabetes, continue sliding scale
insulin. Oral hypoglycemics were held given her acute
presentation.
# FEN: on tube feeds per NGT, nutrition input appreciated. PEG
to be placed [**3-20**]. On [**3-16**]-5 the patient developed
hypernatremia due to being NPO and having insufficient IV
fluids. This was corrected with free water repletion via IV and
NG. Her last speech and swallow evaluation was [**3-23**] which she
failed. Hopefully as her aphasia improves, so will her ability
to protect her airway. She needs further assessment of this
problem as an outpt.
# Access: tunneled HD cath placed [**2124-2-28**] for hemodialysis and
removed [**2124-3-23**] as pt no longer needed HD. PICC left arm ([**3-7**]),
NGT, foley.
# Psych: reinstitution of psychotropic meds was deferred given
the patient's acute presentation.
# Communication: with her daughter [**Name (NI) 440**] [**Name (NI) **] (healtcare proxy),
brother [**Name (NI) **]. [**Name2 (NI) **] contact information is: [**Name (NI) 440**] [**Telephone/Fax (3) 60479**]
Medications on Admission:
1. Geodon
2. Cogentin
3. Perphenazine
4. Metformin
5. Glyburide
6. Lisinopril
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Type II diabetes mellitus
Hypertension
Schizophrenia
Acute renal failure
Hepatitis
Discharge Condition:
Good
Discharge Instructions:
Please take your medications as directed.
If you have these symptoms, call your doctor:
fever/chills/shortness of breath/ chest pain/ bleeding/ fainting
She should start on a statin once her liver function stabilizes.
Followup Instructions:
Please see your primary care physcian within 3 weeks
Completed by:[**2124-3-24**]
ICD9 Codes: 0389, 2762, 5849, 5070, 2851, 2767, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4124
} | Medical Text: Admission Date: [**2173-4-11**] Discharge Date: [**2173-4-18**]
Date of Birth: [**2110-3-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base / Adult Low Dose Aspirin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
S/P AVR replacement (21 porcine)/aortotomy [**2173-4-14**]
History of Present Illness:
63 year old woman with known aortic stenosis pre-op for aortic
valve replacement with Dr. [**Last Name (STitle) **] on [**4-27**] presented to the
emergency department with dyspnea and fluid overload. Her
dyspnea greatly improved with diuresis. Cardiac surgery was
consulted for aortic valve replacement.
Past Medical History:
Aortic stenosis
Hyperlipidemia
Hypertension
Social History:
Ms. [**Known lastname 12163**] lives alone and works as a respiratory therapist.
She denies tobacco or alcohol use.
Family History:
Non-contributory
Physical Exam:
Physical Exam
Pulse: 95 Resp: 18 O2 sat:98%RA
B/P Right: 109/69
Height: 63" Weight: 51kg
General: Well-developed female 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 3/6 systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None
[X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 2801**] [**Hospital1 18**] [**Numeric Identifier 89445**]
(Complete) Done [**2173-4-14**] at 3:58:19 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2110-3-14**]
Age (years): 63 F Hgt (in): 62
BP (mm Hg): 134/78 Wgt (lb): 130
HR (bpm): 67 BSA (m2): 1.59 m2
Indication: Intraoperative TEE for aortic valve replacement.
Aortic valve disease. Left ventricular function. Mitral valve
disease. Preoperative assessment. Right ventricular function.
Valvular heart disease.
ICD-9 Codes: 786.05, 786.51, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2173-4-14**] at 15:58 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW4-: Machine: u/s 4
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 25% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Ascending: *4.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *4.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *76 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 53 mm Hg
Aortic Valve - Valve Area: *0.9 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Severely depressed
LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (area 0.8-1.0cm2). Trace AR.
MITRAL VALVE: Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. Overall left
ventricular systolic function is severely depressed (LVEF= 25
%). Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Trace aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**2173-4-14**]
at 1505
Post bypass
Patient is in sinus rhythm and receiving an infusion of
phenylephrine and milrinone. LVEF= 30%. RV function normal.
Bioprosthetic valve seen in the aortic position. It appears well
seated and the leaflets move well. The peak gradient across the
valve is 25 mm Hg. Mild mitral regurgitation persists. Aorta is
intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2173-4-15**] 08:58
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**4-14**] where she underwent an aortic valve
replacement with a 21mm porcine valve and an aortoplasty.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the surgical intensive care
unit in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on no inotropic or vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on post-operative day four the patient was ambulating freely,
the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home in good
condition with appropriate follow up instructions.
Medications on Admission:
Benazepril 40mg daily, Lipitor 5mg daily, Prempro 0.3/1.5mg
daily
Amoxicillin 2g prior to procedure
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. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. atorvastatin 10 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. Prempro 0.3-1.5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 10
days.
Disp:*20 Tablet(s)* Refills:*2*
8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day for 10 days.
Disp:*20 Tablet, ER Particles/Crystals(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Aortic stenosis, Hyperlipidemia, Hypertension,
S/P AVR replacement (21 porcine)/aortotomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
.Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
The following appointments have been scheduled for you.
Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2173-5-6**] 1:15
Cardiologist: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2173-5-11**] at 9:45am
Wound check in cardiac surgery office [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **] [**Telephone/Fax (1) 170**], our office will call you to make this
appointment.
Please call and schedule an appointment to be seen by your
primary care provider [**Last Name (NamePattern4) **]. [**First Name (STitle) 17859**] [**Telephone/Fax (1) 40171**] in [**3-9**] weeks
Completed by:[**2173-4-18**]
ICD9 Codes: 4241, 5119, 2724, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4125
} | Medical Text: Admission Date: [**2163-6-9**] Discharge Date: [**2163-6-17**]
Date of Birth: [**2119-4-22**] Sex: F
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Shortness of breath
HISTORY OF PRESENT ILLNESS: The patient is a 44 year old
woman with Type 1 diabetes, hypertension and chronic renal
insufficiency who presented with shortness of breath times
four days. The patient reports that she awoke from sleep
with shortness of breath, orthopnea which has been getting
progressively worse. At baseline she has some dyspnea on
exertion with mild to moderate exertion. It occurs with one
flight of stairs. She now is complaining of shortness of
breath at rest. She reports she also is having increasing
lower extremity edema for the last several weeks which had
responded to increasing doses of Lasix orally, initially 40
mg p.o. b.i.d., then 60 mg p.o. b.i.d., however, this was no
longer helping. She was also complaining of fatigue and
several weeks of difficulty sleeping secondary to orthopnea.
She denies chest pain, cough, fever and chills. She has had
no other change in medications recently, no change in her
diet, no history of coronary artery disease. The patient
reports decreasing urine output for over the last four days.
No hematuria or dysuria. No calf pain and no upper
respiratory symptoms. In the Emergency Department the
patient was noted to be hypoxic with an oxygen saturation in
the mid 80s on room air. She was 94% on 100% nonrebreather.
Her chest x-ray was consistent with congestive heart failure.
She was given Lasix 100 mg intravenously with clear urine
output around 280 cc and no change in symptoms. She was also
found to have a hematocrit of 22. Her baseline is about 28,
however, she had no recent evidence of bleeding. The patient
was admitted to the Medical Intensive Care Unit for treatment
of her congestive heart failure and acute renal failure.
PAST MEDICAL HISTORY: Type 1 diabetes times 40 years
complicated by retinopathy, neuropathy and nephropathy,
hypertension, depression, chronic renal insufficiency with
baseline creatinine around 4.8, history of diabetic
ketoacidosis as a child, however, no recent episodes. Denies
history of coronary artery disease, history of chronic anemia
with a baseline hematocrit of around 28 to 30, history of
carpal tunnel syndrome status post release in [**2155**], and
history of hospitalization in [**2159**] for hypotension and
hyperkalemia secondary to Atenolol and Capoten, history of
cervical polyp as well as a history of fibrocystic breast
disease.
MEDICATIONS ON ADMISSION: Her home medications include Lasix
60 mg p.o. b.i.d., Cardura 6 mg p.o. b.i.d., Niferex 150 mg
p.o. b.i.d., Norvasc 10 mg p.o. q. day, Insulin NPH 22 units
q. AM, 2 units q. PM and a regular insulin sliding scale.
ALLERGIES: The patient reports having had reaction to
Capoten, Atenolol, Cozaar, Labetalol and Verapamil which have
all caused hypotension in the past.
SOCIAL HISTORY: She is single and lives in the [**Location (un) 86**] area
alone. She does have a sister in the area. She denies
tobacco, alcohol and intravenous drug use.
FAMILY HISTORY: She has a mother with diabetes, hypertension
and myocardial infarction at age 65 and sister with
hypertension.
PHYSICAL EXAMINATION: Physical examination at the time of
admission revealed her temperature was 98.6, pulse 103, blood
pressure not noted on her initial note. Respirations are 25
and sating 92% on 100% nonrebreather. Generally, she was in
moderate respiratory distress, speaking in full sentences.
Head, eyes, ears, nose and throat examination, extraocular
movements were full. Pupils were equal, round and reactive
to light, anicteric sclera, moist mucous membranes. Neck was
supple with jugulovenous pressure of about 12 cm.
Cardiovascular examination, her heart was tachycardiac but
regular with no murmurs, rubs or gallops appreciated. Chest
examination showed she had diffuse inspiratory and expiratory
rales. No wheezing, no dullness to percussion. Abdomen was
soft, moderately distended, nontender with normoactive bowel
sounds. Rectal examination, she was guaiac negative in the
Emergency Department. Back, she had no cerebrovascular
accident tenderness. Extremities, she had 2+ bilateral pedal
edema to the mid calf with warm feet, 1+ posterior tibial
pulses bilaterally.
LABORATORY DATA: Laboratory data at the time of admission
revealed white count 7.1, hematocrit 22.8, platelets 288.
Coagulation screen was all within normal limits. Her sodium
was 138, potassium 4.7, chloride 105, bicarbonate 17, BUN 65,
creatinine 4.8 and glucose was over 400. Anion gap was 16.
Urinalysis, urine was clear, specific gravity of 1.010, small
blood, negative for leukocyte esterase and nitrites, 100
protein, 500 glucose and no ketones. Initial CK was 344 with
an MB of 14 and index of 4.2. Calcium was 6.6, potassium
4.7, phosphate 5.0, magnesium 2.3. Chest x-ray is consistent
with pulmonary edema, borderline cardiomegaly and small right
pleural effusion. Electrocardiogram showed sinus tachycardia
at a rate of 105 with normal axis and intervals, no acute ST
changes or T wave inversions.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit. She was ruled out for myocardial
infarction by enzymes. She was continued on 100%
nonrebreather. She was diuresed with intravenous Lasix. She
was transfused several units of blood for her anemia and iron
studies were sent. It was felt that her anemia was
consistent with chronic disease most likely due to her renal
insufficiency. She was seen by the Renal Service who
recommended starting Epogen as well as Calcium Carbonate.
She was continued on her home insulin regimen and covered by
a regular insulin sliding scale. She was also seen by the
Heart Failure Service throughout the course of her admission.
She was transferred to the [**Hospital Unit Name 196**] Service out on the floor on
[**2163-6-11**]. At that time she had significantly diuresed.
Her jugulovenous pressure was about 8 cm and her lung
examination was significant only for bibasilar rales.
However, her creatinine increased, eventually reaching a peak
of 7.0 at which time her Lasix was discontinued. She had an
echocardiogram which showed an ejection fraction of 65%, a
mildly dilated left atrium, normal valve. Her phosphate
continued to remain high and she was also started on RenaGel.
Several days prior to discharge it was decided that the
patient would benefit from stress echocardiogram to assess
for any ischemia. She exercised on a brisk protocol at 3.25
minutes. Her heartrate maximum is 59%. She stopped
secondary to inability to keep up with the treadmill. There
were no ischemic electrocardiogram changes. The
echocardiogram showed a small fixed anterior septal defect.
She had an ejection fraction of 44% and a moderate global
hypokinesis. Her Metoprolol was increased to 50 mg p.o.
b.i.d. and her creatinine continued to come down. On the day
of discharge she was seen by Dr. [**Last Name (STitle) **] and had an
arteriovenous fistula placed in her left upper extremity.
The procedure was uncomplicated and the patient was
discharged to home.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE MEDICATIONS:
1. Metoprolol 50 mg p.o. b.i.d.
2. RenaGel 800 mg p.o. t.i.d.
3. Calcium Carbonate 1000 mg p.o. t.i.d.
4. Amlodipine 10 mg p.o. q. day
5. Lasix 60 mg p.o. q. day
6. Epogen 10,000 units subcutaneously one time per week
7. Iron Sulfate 325 mg p.o. t.i.d.
8. NPH Insulin 23 units q. AM and 2 units q. PM
9. Percocet 1 to 2 tablets prn pain following arteriovenous
fistula placement for several days
FOLLOW UP: The patient is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
in one month as well as Dr. [**Last Name (STitle) **] in the Heart Failure Clinic.
She will also follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] from the Renal
Service.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] M.D.12-661
Dictated By:[**Last Name (NamePattern1) 1203**]
MEDQUIST36
D: [**2163-6-17**] 19:56
T: [**2163-6-18**] 08:18
JOB#: [**Job Number 25844**]
1
1
1
DR
ICD9 Codes: 4280, 5849, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4126
} | Medical Text: Admission Date: [**2140-2-2**] Discharge Date: [**2140-2-2**]
Date of Birth: [**2117-8-7**] Sex: F
Service: EMERGENCY
Allergies:
Penicillins / Morphine / Oxycodone Hcl/Acetaminophen
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 22F with a hx of lupus , ESRD on HD and malignant
hypertension who presents today "feeling out of sorts."
Following dialysis on Saturday the patient reports feeling weak.
Her BP was 147/60. She also states that the pain from the
uveitis in her L eye has gotten worse.
.
In the ED the patient's vitals were as follows: T 99, HR 71, BP
209/118, RR 16, O2 sat 98%RA. She was started on a labetolol gtt
with marginal improvement in her pressures. The patient was tx
to the ICU for further mgmt.
.
ROS is negative for any chest pain, SOB, and n/v. She reports
that since she's started the nicardipine she has been having
some urinary retention.
Past Medical History:
1. Lupus - [**2134**]. Diagnosed after she began to have swolen
fingers, a rash and painful joints.
2. ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose
every 3 months for 2 years until began dialysis 3 times a week
in [**2137**] (T, Th, Sat). Awaiting living donor transplant from
mother.
3. HTN - [**2137**]. Normal BPs run 180's/120's. Has had 1
hypertensive crisis that precipitated seizures in the past.
4. Uveitis secondary to SLE - [**4-15**]
5. HOCM - per Echo in [**2137**]
6. Vaginal bleeding [**2139-9-20**]
7. Mulitple episodes of dialysis reactions
8. Anemia
9. Coag neg. Staph bacteremia and HD line infection - [**6-15**]
10. H/O UE clot, was on coumadin, but no longer
Social History:
Lives in [**Location 669**] with mother and 16 year old brother. Graduated
[**Name2 (NI) **] School and then got sick so currently is not working or
attending school. Denies any T/E/D.
Family History:
-No family history of SLE.
-Grandfather has HTN.
-Distant history of DM.
-No history of clotting disorders
-No other history of other autoimmune diseases
Physical Exam:
T 98.2 HR 75 BP 190/115 R 14 O2 sat 100% RA
GEN: pleasant female in NAD, A & O X 3
HEENT: MMM, OP clear, no LAD
HEART: nl rate, S1S2, iii/vi HSM along LLSB
LUNGS: CTA b/l, no rrw
ABD: benign
EXT: dialysis line in L thigh, site c/d/i
Pertinent Results:
HEAD CT: no acute evidence of hemorrhage.
CHEST PA and L: no acute cardiopulmonary process.
Brief Hospital Course:
22F with hx of lupus and subsequent complications who presents
today with hypertensive emergency.
P:
# Hypertensive emergency - Precipitant is unclear. [**Name2 (NI) **]
reports that she is compliant with medications. Pain from
uveitis may have been a precipitant. This may also reflect a
progression of her disease.
- Placed on labetalol gtt for SBP as high as 220 with fair BP
control; transitioned back to po labetalol once BP was
reasonably well controlled. Pt refused additional
antihypertensives, saying, "You new doctors [**Name5 (PTitle) **] in here and
think you can make my blood pressure perfect, but I have high
blood pressure all the time and always have."
- Will continue home medications
- According to renal (Dr [**Last Name (STitle) 7143**], who follows pt), she insists
that no volume be removed at HD, saying that when volume is
removed, she feels "terrible." As a result, her volume status
complicates her blood pressure management
- After patient was informed that she would have to wait until
4pm for hemodialysis, she left against medical advice.
.
# ESRD - [**2-12**] to lupus nephritis. Patient will be receiving
transplant kidney from mother. Cont [**Name2 (NI) 44537**]. Renal offered
patient dialysis while in house
.
# Headache - Patient reported retro-orbital pain with uveitis.
Head CT was negative for intracranial hemorrhage.
.
# Uveitis - Followed by outpatient optho specialist. Patient
specifically refused evaulation by [**Hospital1 18**] ophtho consult despite
retro-orbital pain.
.
# Anemia - Hct has fallen from 35 to 27 within the past month.
Will repeat. Baseline anemia [**2-12**] renal disease. Receives EPO at
HD.
Medications on Admission:
Clonidine 0.3mg Q24H
Ativan 1mg q4-q6h
Sevalamer 800mg TID
Lisinopril 40mg [**Hospital1 **]
Valsartan 320mg daily
Labetalol 600mg TID
Prednisone 40mg daily
Moxifloxacin TID
Nicardipine 30mg q8h
Scopalamine
Discharge Medications:
same
Discharge Disposition:
Home
Discharge Diagnosis:
hypertensive urgency; end stage renal disease due to lupus
nephritis
Discharge Condition:
fair
Discharge Instructions:
Follow up with your PCP within the next week.
.
Continue hemodialysis on your regular schedule.
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4127
} | Medical Text: Admission Date: [**2103-7-9**] Discharge Date: [**2103-8-3**]
Date of Birth: [**2024-12-10**] Sex: M
Service: MEDICINE
Allergies:
Allopurinol / Ciprofloxacin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Severe Rash
Major Surgical or Invasive Procedure:
1. Debridement of scrotum under GETA.
2. Right Knee Arthrocentesis.
3. Suprapubic Catheter.
History of Present Illness:
78 yo M with ESRD, HTN, hyperlipidemia, MGUS who presents with
an approximately 7-day h/o desquamative rash that he states
began after taking an antibiotic prescribed in [**Country 3594**].
Mr. [**Known lastname **] presented to a [**Hospital 15762**] hospital [**6-29**] with complaint
of sore throat, 'heavy tongue' with difficulty talking, and
generalized weakness. He was reportedly diagnosed with a URI and
given an antibiotic (unsure of which) as well as tylenol. After
3 days of taking the antibiotic, he began to have a generalized,
desquamative rash, characterized by desquamation worst on the
scrotum and lips, with ulceration, oral bullae, and also
involving the trunk and to lesser extent on etremities. It was
pruritic. He discontinued taking the antibiotic approximately 1
week ago. At this point, he continues to experience some
pruritis, though states that is has improved somewhat, and does
not believe that he has had further ulcers appear over the past
few days. As a result of his oral involvement and some
dysphagia, he has had decreased PO intake over the past several
days. Of note, MR. [**Known lastname **] had diffuse skin flaking noted after
starting allopurinol [**2102**].
He denies any recent fevers or night sweats, shortness of
breath, chest pain, diarrhea or dysuria. He feels that the
'tongue-heaviness' and weakness have improved somewhat. He has
had frequent gouty flares in [**Country 3594**], typically involving his L
elbow and wrist.
ED course also notable for markedly elevated Cr of 6.7, which is
significanlty increased from prior measurement of 3.5 [**11-30**]. His
daughter reports a Cr of 5.6 last week in [**Country 3594**]. He was given
30cc of kayexalate for K=5.7, IV fluids for mild dehydration,
and a dermatology consultation was obtained.
Past Medical History:
-ESRD,followed by Dr. [**Last Name (STitle) 1860**]. Thought to be secondary to
nephrosclerosis. Cr 3.5 [**11-30**].
-anemia
-hypertension
-hyperlipidemia
-gout. Admitted [**8-30**] with polyarticular gout flare.
-MGUS
Social History:
Lives in [**Location 15763**] and United Sates
Former smoker
no drug use
occasional alchohol use
Family History:
non-contributory
Physical [**Location **]:
PE T102 HR 102 BP 134/76 RR 20 98% R/A
Gen: patient appears stated age, found lying flat in bed
surrounded by family, in mild discomfort
HEENT: Sclera anicteric, conjunctiva uninjected, +arcus senilis,
PERL (2mm -> 1mm with light), EOMI. Has significant ulceration
involving lips, with areas of crusting and hemorrhage. No oral
lesions appreciated currently (per family, had grayish bullae
earlier).
Neck: no JVD, no LAD, nl ROM
Cor: RRR nl S1 S2 no M/R/G
Chest: clear to percussion and asculation
Abd: soft, NT/ND, +BS. No HSM appreciated.
EXT: no calf tenderness. No edema
SKIN: crusting hemorrhagic perioral erosions, with superficial
desquamation involving primarily his trunk and to lesser extent
extremities, with both penile and more significnatly scrotal
ulceration, and ulcer involving lateral aspect of distal L lower
extremity.
Musculoskeletal: no synovitis currently.
Neuro: MS [**First Name (Titles) **] [**Last Name (Titles) **], CN II-XII in tact, UE/LE strength 5+
bilaterally ([**Last Name (Titles) **] limited by discomfort from rash)
Pertinent Results:
[**2103-7-8**] 11:15PM PLT COUNT-358#
[**2103-7-8**] 11:15PM NEUTS-70.0 LYMPHS-17.4* MONOS-5.0 EOS-7.5*
BASOS-0.1
[**2103-7-8**] 11:15PM WBC-8.7 RBC-3.98* HGB-11.8* HCT-35.8* MCV-90#
MCH-29.6 MCHC-33.0 RDW-17.3*
[**2103-7-8**] 11:15PM GLUCOSE-120* UREA N-64* CREAT-6.7*#
SODIUM-135 POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-21* ANION GAP-22
[**2103-7-8**] 11:20PM URINE [**Month/Day/Year 3143**]-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2103-7-8**] 11:20PM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0
[**2103-7-8**] 11:20PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-<=1.005
[**2103-7-8**] 11:27PM LACTATE-2.8*
[**2103-7-9**] 04:40AM WBC-6.7 RBC-3.53* HGB-10.5* HCT-31.6* MCV-90
MCH-29.7 MCHC-33.2 RDW-17.3*
[**2103-7-9**] 04:40AM calTIBC-246* FERRITIN-504* TRF-189*
[**2103-7-9**] 04:40AM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-5.1*
MAGNESIUM-2.1 IRON-18*
[**2103-7-9**] 04:40AM LIPASE-46
[**2103-7-9**] 04:40AM ALT(SGPT)-26 AST(SGOT)-26 ALK PHOS-75
AMYLASE-200* TOT BILI-0.5
.
Skin, left ankle, punch (A-B):
Subepidermal bullae with hyperkeratosis, parakeratosis,
scattered dyskeratotic keratinocytes, and a lichenoid
lymphohistiocytic inflammatory infiltrate (see note). Note: The
findings raise a differential diagnosis including erythema
multiforme/[**Doctor Last Name **]-[**Known lastname **] syndrome/toxic epidermal necrolysis
and bullous drug disorder. Clinical correlation is suggested.
.
Note: Sections show an epidermis with focal compact
hyperkeratosis, and an interface dermatitis characterized by
baso vacuolar degeneration, lymphocytes at the dermal-epidermal
junction and dyskeratotic keratinocytes. The lymphocytes do not
appear atypical. The differential diagnosis includes [**First Name8 (NamePattern2) **]
[**Known lastname **] syndrome/erythema multiforme spectrum of disorders or a
lichenoid/fixed drug eruption.
.
Negative Cultures:
[**2103-7-27**] JOINT FLUID
GRAM STAIN-FINAL; FLUID CULTURE-No Growth
[**2103-7-26**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2103-7-26**] URINE
URINE CULTURE-FINAL
[**2103-7-26**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2103-7-25**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2103-7-24**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2103-7-24**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2103-7-20**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-19**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-18**] DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS-FINAL; Direct
Antigen Test for Herpes Simplex Virus Types 1 & 2-FINAL
[**2103-7-19**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-18**] SWAB
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS-FINAL; VARICELLA-ZOSTER
CULTURE-PRELIMINARY
[**2103-7-16**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-15**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-15**] STOOL
FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; OVA +
PARASITES-FINAL; O&P MACROSCOPIC [**Month/Day/Year **] - WORM-FINAL; CLOSTRIDIUM
DIFFICILE TOXIN ASSAY-FINAL
[**2103-7-15**] SCOTCH TAPE PREP/PADDLE
SCOTCH TAPE PREP/PADDLE-FINAL
[**2103-7-14**] URINE
URINE CULTURE-FINAL
[**2103-7-14**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-14**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-13**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-13**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-12**] URINE
URINE CULTURE-FINAL
[**2103-7-12**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-12**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-9**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-8**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-8**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-8**] URINE
URINE CULTURE-FINAL
.
Cultures that grew bacteria:
[**2103-7-24**] CATHETER TIP-IV
WOUND CULTURE-FINAL {ACINETOBACTER BAUMANNII}
[**2103-7-15**] SWAB
GRAM STAIN-FINAL; WOUND CULTURE-FINAL {YEAST, PRESUMPTIVELY NOT
C. ALBICANS}; ANAEROBIC CULTURE-FINAL {PREVOTELLA SPECIES}
[**2103-7-16**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}
.
IV catheter tip cx: acinetobacter baumannii ([**Last Name (un) 36**] to cefepime,
gent, zosyn and tobra. Resistant or indeterm to others.)
.
Joint aspirate.
[**2103-7-27**] 4:59P (2) FEW NEEDLE I/E
Intra/ExtraCellular NEG c/w monosodium urate crystals
(2) Source: Knee
[**2099-3-18**] 9:18P FEW NEEDLE I/E
Intra/ExtraCellular NEG c/w monosodium urate crystals
.
CT Pelvis ([**7-29**]) IMPRESSION:
1. No abscess or fluid collection identified.
2. Tiny bilateral pleural effusions.
3. Uncomplicated large right inguinal hernia containing multiple
small bowel
.
1. Skin, left lower leg (A-C):
Multiple fragments of stratum corneum.
2. Skin, scrotum (D-E):
Skin with ulceration, marked acute and chronic inflammation,
focal necrosis and granulation tissue formation (see note).
Note: No microorganisms are seen in PAS and gram stained
sections.
.
CXR: The heart, mediastinal and hilar contours are within normal
limits. The lungs demonstrate no focal areas of consolidation or
effusion. The osseous structures are within normal limits.
IMPRESSION: No evidence of CHF or pneumonia.
Renal Ultrasound: The right kidney measures 7.2 cm. The left
kidney measures approximately 8.0 cm. The kidneys are echogenic
bilaterally, somewhat limiting evaluation. There is no
hydronephrosis or stones. Note is made of a tiny hypodense
lesion in the upper pole of the left kidney measuring
approximately 9 mm, consistent with a simple cyst. The bladder
is partially distended with an apparent fold in the mid-portion
on the sagittal view. This could be due to Note is made of
bilateral ureteral jets. IMPRESSION:
1) No hydronephrosis.
2) Small echogenic kidneys.
3) Partially distended bladder with a possible fold, although a
diverticulum cannot be entirely excluded. This could be
reassessed with better distension of the bladder if indicated.
Echocardiogram [**2103-7-10**]
Left Ventricle - Ejection Fraction: >= 70% (nl >=55%)
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D
or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
TRICUSPID VALVE: Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler (cannot exclude). Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
CT abd/pelvis [**2103-7-28**]:
IMPRESSION:
1. No abscess or fluid collection identified.
2. Tiny bilateral pleural effusions.
3. Uncomplicated large right inguinal hernia containing multiple
small bowel loops.
Brief Hospital Course:
Mr. [**Known lastname **] is a 78 year-old male with ESRD, HTN,
hyperlipidemia, MGUS who presented with Erythema
multiform/[**Doctor First Name **]-[**Known lastname **] syndrome after taking allopurinol
presumably. He had extensive desquamation of the skin with
recurrent fever. He was managed on the floor in a supportive
manner with fluids, empiric antibiotics, and wound care. He
developed PAF and was rate controlled. There was a question of
Fournier's gangrene of the scrotum which was debrided by urology
in the OR. He was transferred to the ICU during this time. He
was transferred back to the floor after 5 days in the MICU. On
the floor he had low grade feveres. His central line was pulled
and the tip grew out acinetobacter sensitive to cefepime. All
[**Known lastname **] cultures were negative. Patient was treated with 7 days of
cefepime for a line infection. Finally, he developed an acute
gouty flare treated with colchicine, oxycodone, and prednisone.
.
Hospital Course by Problem:
.
SJS: Derm was consulted for help with the diagnosis and
management of SJS. Two biopsies were taken. The 1st biopsy was
c/s SJS. 2nd biopsy from leg could also represent TEN or drug
reaction. Dermatology recommended constant skin hydration w/
multiple ointments and topical steroid. No IgG or steroids were
started as the patient presented past the window during which
time this is found to be a useful intervention. The inciting med
was allopurinol he recieved in [**Country **]. (NOTE: Cipro was also
started at the same time and should be suspected as well.) On
the floor insensible losses were tremendous and he recieved
aggressive IVF. Wound care was managed with xeroform and
bactroban. The ID service was consulted for persistent fevers
and a surveillance culture that showed GPC. ID service
recommended broad empiric antibiotics given travel hx and very
complicated patient. Pt was started on meropenem and
vancomycin. On [**7-15**], the urology service was consulted for
worsening pain and skin breakdown on the scrotum and penis.
Fournier's Gangrene was suspected and thus the patient was taken
to the OR for debridement. He was then tx to the SICU and then
the MICU for more aggressive management. He spent 5 days in the
ICU and was called out to the floors again. His rash continued
to improve. Skin care with bactroban and xeroform continued
throughout the hospitalization and the dry intact skin was
moistened with aquaphor.
Line infection: On callout from the MICU, patient was having low
grade fevers on the floor. Panculture including urine, [**Month/Year (2) **],
and CXR was negative. Patient's central line was d/c and tip
grew out cefepime sensitive acinetobacter. Subsequent [**Month/Year (2) **]
cultures remained negative. Thus, patient was treated with 7
days total of cefepime.
Scrotal lesion: It was minimally debrided for a concern of
Fournier's gangrene but it did not appear gangrenous and urology
OP note stated edematous but healthy tissue underneath. The
lesion did not appear gangrenous, and the patient remained
afebrile with normal WBC. Samples were also taken for HSV and
VXZ. These samples were negative.
.
A-fib: The patient was found to be in paroxysmal a-fib on [**7-10**].
He was well rate controlled with toprol XL 200. Echo showed no
clot. He converted to sinus on his own but has been in and out
of afib. Diltiazem 30 mg po qid was started [**2103-8-1**] for improved
rate control, as patient was running in the 90s. Since
initiation of this medication, patient is again back in sinus.
PR interval < 0.12 on BB + CCB. Coagulation was held initially
due to dysphagia and concern for mucosal involvement and bleed
risk. On [**7-24**], heparin and coumadin were intiated with a goal
of INR [**3-1**]. Currently, patient is supratherapeutic on coumadin.
His last INR was 4.2.
.
CRI: Pt has baseline renal failure with a Cr of 3.4 in [**2102-11-27**]
but presented w/ creatinine of 6. The renal svc was consulted
and he was volume repleted. His Cr trended down. He had eos in
his urine, so while hypovolemia was most likely the cause of
acute on chronic renal failure, could not rule out AIN.
Currently his creatinine is 2.1. He will follow-up with [**First Name8 (NamePattern2) 3122**]
[**Doctor Last Name 1860**] in 1 month. Continue IVFs prn to keep well hydrated.
Constipation: Patient w/ h/o hemorrhoids. No BM x 5 days but had
a good BM [**2103-8-2**] w/ assist of an enema. Plan to manage w/
colace, senna, and enema prn if no BM x 2 consecutive days.
Gout: Pt had a history of gout. On [**7-19**] he developed right knee
pain and a low grade fever. No ankle and wrist pain. On [**7-28**]
the pt's knee was tapped. This was notable for monosodium
nitrate, negative birefringent, needle-shaped crystals c/w gout.
Cx and gram stain were negative for any organisms. NSAIDs were
not an option given CRI. Thus, patient treated w/ renal dose of
colchicine. He continued to have pain, and thus po prednisone
and oxycontin/oxycodone were added. Currently, his pain is well
controlled.
Hyperglycemia: no h/o of [**Name (NI) 15764**] pt had high [**Name (NI) **] sugars early in
his hospitalization that resolved as his health improved. On
steroids, his sugars are again in the 200s. We are managing this
with a sliding scale of insulin.
Communication was with [**First Name8 (NamePattern2) **] [**Known lastname **] (daughter) cell
[**Telephone/Fax (1) 15765**], home [**Telephone/Fax (1) 15766**]; [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13662**] (daughter) cell
[**Telephone/Fax (1) 15767**]; [**Name (NI) **] [**Name (NI) **] (son) cell [**Telephone/Fax (1) 15768**]
.
The patient was discharged to [**Hospital3 672**] rehab in good
condition with improving skin lesions, rate controlled heart in
sinus rhythm, and well controlled pain.
Medications on Admission:
Meds on admission:
Atenolol 100
Amlodipine 10
Lipitor 20
Lasix 40
(was started on gout regimen including colchicine prior to going
to [**Country 3594**], which he discontinued shortly after leaving
[**Location (un) 86**]).
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: [**1-28**] gtt Ophthalmic QID (4
times a day).
Disp:*1 tube* Refills:*0*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl
Topical QD ().
Disp:*1 bottle* Refills:*0*
4. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*0*
5. 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:*0*
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical Q
6HRS () as needed for PRN pruritis.
Disp:*1 tube* Refills:*0*
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for knee pain.
9. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
10. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Epogen 10,000 unit/mL Solution Sig: One (1) injection
Injection qMon,Wed,Fri.
13. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day for 3
days: Taper as follows:
[**8-4**] = 20 mg po qd,
[**8-5**] = 10 mg po qd,
[**8-6**] = 10 mg po qd.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection four times a day: please follow attached
sliding scale.
16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Principal:
1. [**Doctor Last Name **]-[**Known lastname **] Syndrome.
2. Paroxysmal Atrial Fibrillation with rapid ventricular
response
3. Acute Gout Flare - Right Knee.
4. Dermal necrosis of the scrotum.
5. Acinetobacter catheter-related bloodstream infection.
6. Right Inguinal Hernia.
Secondary:
1. Gout.
2. MGUS.
3. Hypertension.
4. Hypercholesterolemia,.
5. ESRD - Hypertensive Nephrosclerosis.
6. Anemia of ESRD/Chronic Disease.
Discharge Condition:
afebrile (on steroids), skin healing, heart rate controlled,
gout pain controlled.
Discharge Instructions:
Monitor for fevers, chills, rashes, worsening knee pain, or
increased sedation (on narcotic).
NEVER TAKE ALLOPURINOL. Wear your new bracelet letting health
care professional know of this allergy. You should also NOT
take VANCOMYCIN or CIPROFLOXACIN, as these medications may also
have been involved in starting or worsening the rash.
You have been started on a medication called coumadin. Coumadin
thins your [**Last Name (LF) **], [**First Name3 (LF) **] it is important that you take precautions
to avoid bleeding. First, use an electric razor to shave.
Second, do not engage in activities in which you might fall and
bruise yourself. Finally, do not eat large amounts of leafy
green vegetables because this can interfere with your coumadin.
Followup Instructions:
Follow up with PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Call to set up an appointment
within 1-2 weeks of leaving rehab. [**Telephone/Fax (1) 7976**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D., PH.D.[**MD Number(3) **]: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2103-9-13**] 4:30
You will be contact[**Name (NI) **] regarding a follow-up appointment with an
ophthamologist. If you do not hear from anyone by Monday, please
call [**Telephone/Fax (1) 253**] to schedule an appointment within the next [**1-28**]
weeks.
Urology appointment: follow up with Dr. [**Last Name (STitle) 9125**], [**8-7**], 3:00pm,
[**Hospital1 **] [**Location (un) 453**]. If any questions, call [**Telephone/Fax (1) 6445**].
Follow up with Dermatology at [**Hospital1 **] in [**1-28**]
weeks. The department will call you to set up an appointment. If
you don't hear from them in one week, please call to set up an
appointment, [**Telephone/Fax (1) 1971**].
You should hear back regarding an appointment to follow-up with
a rheumatologist. If you do not hear about this by Monday,
please call [**Telephone/Fax (1) 2226**] to schedule this within 1-2 weeks.
ICD9 Codes: 5849, 7907, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4128
} | Medical Text: Admission Date: [**2140-5-31**] Discharge Date: [**2140-6-14**]
Date of Birth: [**2071-3-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
CABG
History of Present Illness:
69 y/o male with HTN, DM2, CAD, ESRD on HD presents as transfer
from [**Hospital3 417**] Hospital after presenting with sudden onset
of substernal chest pain, not pressure, begining at rest while
lying down, described as sharp, [**6-20**] in intensity, not
radiating, not relieved with nitroglycerin originally, lasting
one and a half hours, and finally resolving with a second
nitroglycerin and oxygen. It was associated with diaphoresis and
shortness of breath, but no nausea or vomiting. At [**Hospital 6451**] EKG with ST depresions in II, III, aVF, and V3-V6 and
CK 179 and trop I 0.67 (0045) CK 163 and Trop I 0.89 (0635). He
is on a nitro drip and heparin drip, and since then he has been
chest pain free and without shortness of breath.
He has 3 vessel CAD by cath in [**7-16**] at which time he had cypher
stent to ostial 90% LCX lesion. He has been on plavix since
then. He recently had a cardiac catheterization on [**2140-5-26**], for
abnormal ETT showing inferolateral ischemia, which showed focal
midsegment LAD 85% stenosis, 100% stenosis of D1, and severe
diffuse 95% instent restenosis of proximal stent segement of
LCX, and 100% stenosis of RPDA.
.
[**Last Name (NamePattern4) 33329**] here for consideration of CABG, as he was to be
evaluated in the coming days by Dr. [**Last Name (Prefixes) **].
Past Medical History:
1. Coronary artery disease, status post small myocardial
infarction in [**2119**], status post catheterization in [**2134**] for
congestive heart failure with no intervention,
status post Persantine MIBI in [**2131**] with a reversible defect
in the inferior wall. LCX stent placed. 3v disease on [**2140-5-26**]
catheterization.
2. Non-insulin-dependent diabetes mellitus.
3. Congestive heart failure.
4. End stage renal disease on hemodialysis T/H/Sat
5. Chronic anemia with a baseline HCT in the high 20s.
6. Multiple myeloma-in remission
7. Hypertension, difficult to control.
8. Hyperlipidemia.
9. Gout.
Social History:
Patient lives with his wife, has 3 sons and 1 daughter.
Quit smoking in [**2115**], 35-pack-year history.
Denies recent alcohol. No drug use.
Family History:
+DM, +HTN, no CAD, no stroke, MGM with stomach cancer
Mother died at 64 from renal cell carcinoma.
Father died in his 30s of unknown causes. Three siblings
with elevated cholesterol, diabetes, and hypertension.
Physical Exam:
EXAM: T 99.6 BP 101/40 HR 72 RR 12 SAT 97% 3L O2 by NC
General: well apearing male in no distress
HEENT: PERRL, EOMI, Sclera anicteric
NECK: No JVP elevation, no carotid bruitss, normal carotid
pulses
CHEST: Lungs clear with out rales
HEART: RRR. 2/6 systolic murmur over entire precordium
BACK: No sacral edema
ABD: Normal active bowel sounds, soft, NT, ND, no masses
EXT: Equal femoral pulses B/L, weak [**Doctor Last Name **] and DP pulses b/l with
hairless, wasted ext below the knees
NEURO: Non focal
Pertinent Results:
[**2140-6-14**] 06:20AM BLOOD WBC-7.3 RBC-2.84* Hgb-8.7* Hct-25.3*
MCV-89 MCH-30.6 MCHC-34.4 RDW-18.7* Plt Ct-168
[**2140-6-12**] 04:30AM BLOOD WBC-9.0 RBC-3.23* Hgb-9.8* Hct-28.4*
MCV-88 MCH-30.5 MCHC-34.7 RDW-19.6* Plt Ct-128*
[**2140-6-14**] 06:20AM BLOOD Plt Ct-168
[**2140-6-14**] 06:20AM BLOOD Glucose-100 UreaN-40* Creat-4.6* Na-135
K-4.4 Cl-101 HCO3-25 AnGap-13
Brief Hospital Course:
69 y/o male with HTN, DM2, ESRD on HD, 3V CAD s/p Stent to LCX,
with resolved chest pain, on heparin drip. He was taken to the
operating room on [**2140-6-9**] where he underwent a CABG x 3 and
MVRing. He was transferred to the SICU in critical but stable
condition. He was extubated and weaned from his vasoactive drips
by POD #1. He was followed by renal who continued his
hemodialysis.He was transferred to the step down unit by POD #3.
He did well postoperatively and was ready for discharge on POD
#5.
Medications on Admission:
Lasix 20 mg QD
Diovan 160mg QD
Imdur 15mg QD
SL nitro 0.4 mg prn
Hydralazine 20 mg [**Hospital1 **]
Minoxidil 10 mg QD
Toprol 200 mg QD
Lipitor 80 mg QHS
ASA 325 mg QD
Allopurinol 100 mg [**Hospital1 **]
Prandin 1 mg QD
Plavix 75 mg QD
Iron 325 mg QD
Renagel 800 mg [**Hospital1 **]
Epogen with Dialysis
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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. 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*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
Coronary Artery Disease
Mitral Valve Regurgitation
Hypertension
Diabetes mellitus
End stage renal disease on hemodialysis
Anemia of Chronic Disease
Epistaxis
Discharge Condition:
Good.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 33330**] Appointment should
be in [**6-20**] days
Completed by:[**2140-6-15**]
ICD9 Codes: 4240, 5856, 4280, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4129
} | Medical Text: Admission Date: [**2110-5-26**] Discharge Date: [**2110-6-18**]
Date of Birth: [**2040-4-7**] Sex: M
Service: MEDICINE
Allergies:
Augmentin / Heparin Agents / Azithromycin / Tape
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Hickman placement ([**2110-6-13**]) - right sublcavian; double tunneled
hickman line with c-arm.
History of Present Illness:
Patient is a 70 year-old male with striatonigral degeneration,
history of multiple admissions for hypoxia and respiratory
failure who presents with fever.
Patient was recently admitted in [**Month (only) **], ([**Date range (1) 16592**]) when he
was admitted with hypoxia/respiratory failure. He was found to
have a pseudomonal PNA and acute exacerbation of hypoxia at that
time was thought to be secondary to thick secretions. He was
treated with zosyn x 14 days, vancomycin x 10 days. Initially,
the patient required ventilatory support due to hypercarbia but
was able to be weaned to trach mask by the end of the second
week. Additionally, fluid overload played a component in this.
Other things complicating admission were hypernatremia and
metabolic alkalosis requiring diamox. Pt was d/cd home on
[**2110-5-19**].
Per wife, pt left on the day of discharge at 4 pm. He arrived
home and by 8 pm he was spiking a temperature. He has had fevers
since then, more noticable in the AM, with the highest morning
of admission to 102.5. Because of his continued fevers, and
culture sputum results (one of three colonies of pseudomonas
came back sensitive to tobra but not to zosyn), a PICC was
placed by IR on [**2110-5-22**] as an outpt and he was started on
tobramycin IV (360 mg IV q24 hr). He was also started on flagyl
PO for diarrhea that resolved.
+fatigue; + increased grey secretions this week per wife. Today,
PICC line was clogged, the patient was still febrile, and sent
to ED per PCP.
In the ED, VS on arrival were: T: 100.5; HR: 97; BP: 114/75; RR:
20: 98 on 3L trach mask. He was given flagyl 500 mg IV and
levaquin 500 mg IV
Past Medical History:
1. Striatonigral degeneration.
2. History of methicillin-resistant Staphylococcus aureus.
([**11-27**] stool)
3. History of vancomycin-resistant Enterococcus.
4. History of multiple aspiration pneumonias.
5. GERD.
6. Diverticulosis.
7. Prostate cancer status post prostatectomy.
8. Hypothyroidism.
9. Tracheostomy.
10. History of bullous pemphigus.
11. History of upper GI bleed.
12. Jejunostomy tube placement.
Hospitalizations:
[**2108-3-24**]: Pseudomas in sputum txt with zosyn then changed to
gent
[**2108-4-24**]: Bronch to adjust trach placement and sputum
[**2107-11-24**]: fever, hypoxia, inc. secretions txt with ceftaz
[**2108-9-24**]:pseudomonas pna, wound infection
[**2109-6-24**] fever, UTI, coag negative staph blood infection
Social History:
Lives with wife, bed bound; no EtOH/drugs/smoking. Has personal
care attendent.
Family History:
NC
Physical Exam:
VS: T: 96.7; BP: 96/56; HR: 69; RR: 16; O2 95 10L trach collar
Gen: Contracted, opens eye, NAD
HEENT: Sclera anicteric, OP clear, MMM
Neck: Chin to chest, difficult to assess
CV: RRR S1S2. Difficult to auscultate
Lungs: Prolonged I: E ratio. clear anteriorly with audible
wheezes
Abd: +BS. Soft, mildly distended. NT
Back: Unable to assess
Ext: Contracted upper extremities. BLE trace edema
Neuro: opens eyes, tracks sometimes. Otherwise cannot assess.
Pertinent Results:
INITIAL LABS
Chemistries ([**2110-5-26**] 08:20PM) GLUCOSE-94 UREA N-47* CREAT-0.9
SODIUM-146* POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-46* ANION GAP-7*
MAGNESIUM-2.6
Coags: ([**2110-5-26**] 08:20PM) PT-12.4 PTT-25.4 INR(PT)-1.1
CBC: ([**2110-5-26**] 08:20PM) WBC-9.4 RBC-3.09* HGB-9.2* HCT-28.8*
MCV-93 MCH-29.9 MCHC-32.0 RDW-14.5* NEUTS-76.4* BANDS-0
LYMPHS-12.1* MONOS-5.3 EOS-6.1* BASOS-0.2
Lactate: ([**2110-5-26**] 08:33PM) LACTATE-1.1
UA: ([**2110-5-26**] 09:10PM) COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG
BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG
RBC-[**1-26**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0
DISCHARGE LABS
Chemistries: ([**2110-6-15**] 03:10AM) BLOOD Glucose-127* UreaN-27*
Creat-0.5 Na-143 K-3.9 Cl-99 HCO3-41* AnGap-7*
Calcium-8.4 Phos-2.8 Mg-2.2
CBC: ([**2110-6-15**] 03:10AM) BLOOD WBC-5.9 RBC-2.86* Hgb-8.2*
Hct-26.8* MCV-94 MCH-28.8 MCHC-30.7* RDW-14.6 Plt Ct-295
VBG: ([**2110-6-15**] 05:40PM) BLOOD Type-MIX Temp-36.4 pO2-50*
pCO2-96* pH-7.27* calTCO2-46* Base XS-12
OTHER STUDIES:
Initial EKG: sinus in 80s. nl axis. nl intervals. +APCs. ?
bigeminy in part of strip vs. APCs. no acute ST changes.
Chest AP [**2110-5-26**]
IMPRESSION: 1. Right middle lung zone linear atelectasis. 2.
Mild cardiomegaly.
Brief Hospital Course:
Patient is a 70 year old male with striatonigral degeneration,
multiple hospital admission for hypoxia and respiratory failure
who was recently d/cd on [**2110-5-19**] with a pseudomonal pneumonia
who presented with fevers and sputum cultures that grew
pseudomonas and later MRSA and with stool positive for c. diff.
Required ventilatory support for much of hospital stay, but
currently on trach mask, afebrile for many days and improved.
1. Fever: [**Month (only) 116**] have been secondary to tracheobronchitis/PNA
(grew pseudomonas on sputum cultures from [**5-28**], [**5-29**], [**5-31**] and
[**6-4**]; grew MRSA on sputum cultures from [**5-28**], [**5-29**], [**5-31**], [**6-8**];
grew enterobacter on sputum from [**6-4**]). Was c. diff positive at
presentation. Both blood and urine cultures were negative
throughout stay. The pulmonary infection was treated with
tobramycin, meropenum and vancomycin; the c. diff was treated
with flagyl. The patient remained afebrile from [**6-10**] until
discharge.
2. Hypercarbic respiratory failure: Was placed on vent on [**5-28**] as
ABG showed 7.28/104/63. During this time, the patient produced
copious secretions. Initial attempts at weaning were
unsuccessfull as the patient would experience apneic episodes on
pressure support ventilation. Therefore, he emained on vent
until [**6-10**], at which time trials of trach mask were successfully
attempted during the day time. From [**6-13**] until discharge, did
well back on trach mask. A VBG done on [**6-16**] which showed:
7.40/70/40.
3. Seizure: Patient had seizure like activiy on [**5-28**] (leg
twitching, face twitching) which lasted for 15-30 seconds and
resolved spontaneously. There was no bladder or bowel
incontinence noted (pt. had foley in place). Ativan, 1 mg was
given just after event ended. The patient was seen by neurology
who thought it may have been due to toxic metabolic, structural,
or hypoxia. An EEG showed encephalopathy. No further seizure
activity was noted during hospital stay.
4. Anemia: Presented with a Hct of 28.8 from a highly variable
baseline (25-35). Was guiac (-) on [**5-31**]. Iron studies of 9/95
showed low iron and TIBC, c/w anemia of chronic disease. On
[**6-11**], Hct was 19.8 for which he recieved one unit of pRBCs. No
other blood products were needed and the patient's Hct at
discharge was 26.8.
5. Abdominal distention: Noted on [**6-2**]. NG was placed and
bilious secretions were noted. G-tube was noted to be clogged,
so this was re-opened using solution of pancrease and
bicarbonate. Over time, the disention diminished and the NG was
removed. At discharge, some distention remained, although less
than had been noted initially.
6. Right hip fracture: A KUB on [**6-3**] showed a chronic fracture
of the right femoral neck. Hip films confirmed this. The
patient's wife noted that this was an old fracture and she chose
to not work it up any further.
7. Striatonigral degneration: Stable during stay. We continued
outpatient medications (Sinemet and Ritalin)
8. Hypothyroid: Stable during stay. We continued outpatient
levoxyl.
9. GERD: Stable during stay. We continued outpatient PPI.
10. FEN:
Fluids: Initially treated with 1/2 NS, which was later
discontinued. For intial hypernatremia, recieved free water
boluses. Later in stay, patient was total body overloaded;
lasix (20 mg IV initially, then 40 mg IV) was used to take off
some of this fluid.
Electrolytes: Initially, was slightly hypernatremic. For this,
free water was given and sodium corrected. Other electrolytes
were repleted PRN.
Nutrition: Novasource pulmonary tube feeds were used.
11. PPx: No SC heparin as allergy; pneumoboots. Aggressive bowel
regimen. Kinair mattress. PPI.
12. Access: Hickman was placed by surgery on [**2110-6-13**]; a prior
PICC was then pulled.
13. Code: DNR but can be ventilate. Confirmed with wife.
14. Communication: Wife, [**Name (NI) **] [**Name (NI) 16593**] [**Telephone/Fax (1) 16594**].
Medications on Admission:
Mirapex 1.5 mg QID (8:30 am, 1:30 pm, 6:30 pm, midnight)
Sinemet 25/250 mg 1 q8am, .5 1 pm, .5 6 pm
Motilium 10 mg 8:30 am, 1:30 pm, 6:30 pm
Nexium 40 mg [**Hospital1 **]
Robinul 1 mg .5 8:30 am, .5 6:30 pm
Ritalin 10 mg 8:30 am, 1:30 pm, 6:30 pm
Levoxyl 150 mcg qam
Unafiber q8:30 am, q6:30 pm, qmidnight
Colace Liq 100mg 8:30am, 1pm, midnight
lactulose 10mg/15ml 2-4tablespoons at midnight.
Bisacodyl 1 q8am
Albuterol Sulfate (2.5mg) q8am, q1pm, q6pm qmidnight.
Ipratropium bromide (0.5mg) q8am, q1pm, q6pm qmidnight.
Pulmicort Respules (0.5mg/2ml) q8am, q6pm qmidnight
Tylenol PRN
MOM, fleets enema PRN
Ultravate (blisters) PRN
Comply (tube feed formula) 4.5 cans over 18 hours - rate of 60
ProMod (protein supplement) 1 scoop per can of comply.
Miconazole powder 2% tube site
DoubleGuard tube site
Furosemide 20mg PRN
Flagyl 500mg PRN
Duoderm gel chin
Mepilax dressing chin
NS flushes without heparin
Discharge Medications:
1. Pramipexole 0.25 mg Tablet Sig: 1-2 Tablets PO QID (4 times a
day).
Disp:*240 Tablet(s)* Refills:*2*
2. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
QAM (once a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
3. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
Q1PM AND Q6PM ().
Disp:*60 Tablet(s)* Refills:*2*
4. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*2*
7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Unifiber Oral
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*3*
10. Aquacel-Ag 1.2-2 X 2 %- Bandage Sig: One (1) Topical Q3
days ().
Disp:*10 Bandages* Refills:*3*
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Glycopyrrolate 1 mg Tablet Sig: .5 Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
Disp:*1 MDI* Refills:*3*
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb IH
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
Disp:*qsx1 month Neb IH* Refills:*3*
15. Normal Saline Flush 0.9 % Syringe Sig: One (1) 50 cc normal
saline flush Injection once a week.
Disp:*qs x 1month 50 cc* Refills:*3*
16. Protein Supplement Packet Sig: One (1) packet PO three
times a day: 1 pack three times a day with tube feeds.
Disp:*qsx1 month * Refills:*3*
17. Nutren 1.5 Liquid Sig: One (1) 60 cc PO q hour.
Disp:*1 month* Refills:*2*
18. Lactulose 10 g/15 mL Solution Sig: Twenty (20) mL PO four
times a day.
Disp:*3 months* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Fair, sats stable, afebrile
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Return to hospital if increasing shortness of breath,
significant change in mental status, or persistent fevers.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2110-7-3**] 11:40
Follow up within one week of discharge
ICD9 Codes: 2760, 4280, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4130
} | Medical Text: Admission Date: [**2103-9-19**] Discharge Date: [**2103-9-23**]
Date of Birth: [**2031-11-3**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
melena, recurrent
Major Surgical or Invasive Procedure:
EGD with endoclip placement
History of Present Illness:
Pt is a 71 y.o lady w/ severe AS (valve area 0.8 cm2, mean
gradient >60), w/ recent admit [**Date range (1) 45316**] for UGI bleed, presents
with melena x 5 days. On her last admission, patient presented
w/ similar presentation, dark stools over several weeks. At that
time, Hct was 22 and she was hemodynamically stable. EGD/c scope
identified brisk bleed in 2d or 3d part of duodenum on endoscope
but no lesion identified despite epi injection. Pt proceeded to
IR, but they were unable to identify any active bleed but
prophylactively embolized a gastroduodenal artery. Pt
transferred to the MICU for observation and management of acute
GIB. Pt remained hemodynamically stable, requiring 5 u of
prbc's over 4 days, her hct stabalized, and she was discharged
home on [**9-9**]. She reports initially feeling well after
discharge, had a stable hct at her PCP's follow up appt (35.8 on
[**9-13**]). She then developed melena again, a few stools a day,
"mahogany" in color, with no associated diarrhea or GI upset.
She began to feel progressively weak, pale, with dyspnea on
exertion. She contact[**Name (NI) **] her PCP, [**Name10 (NameIs) **] seen in the office, and was
sent to the ED for eval of recurrent GI bleed. Of note, pt is
not symptomatic of her AS and has never had syncope, chest pain,
or exertional dyspnea (up until her GI bleeds). Her ROS is
essentially negative except for the above.
Upon arrival to the [**Name (NI) **], pt's hct was 22.6 (from 35.8 on [**9-13**])
with grossly positive stool guaiac. She had mild hypotension to
100's/45's, HR 70. She was not hypoxic. It was thought that
patient had potential for severe hypotension, given her bleed
and AS, and thus she was admitted to the [**Hospital Unit Name 153**] for close
observation.
Past Medical History:
**UGI bleed as above
**severe AS, normal EF, valve area 0.8 cm2 on echo [**2097**], mean
gradient of >60 on echo last year
**hypothyroidism
**hypercholesterolemia
**hypertension
Denies h/o rheumatic fever, heart disease
Social History:
lives with husband; still works full time as office coordinator,
exercises regularly at curves; leads very active lifestyle, quit
tobacco at age 35 (has 20 pack year history), occasional etoh.
FULL CODE
Family History:
father with MI at age 61
brother w/ MI at age 53?
Mom w/ vaginal ca, 87 yo
Sister w/ breast ca, passed away at age 63
brother with gastric ca
Physical Exam:
PE T 98.4 BP 112/45 HR 70 R 18 sat 100%
Gen: healthy-appearing, middle-aged female, appears slightly
older than stated age, no distress, smiling
HEENT: MM dry, pale conjunctivae, good skin turgor, op clear, no
exudates
NECK: supple, no thyromegaly, no JVD
CHEST: cta
CV: RRR, [**2-24**] harsh, crescendo murmur heard everywhere, no
radiation to carotids or axilla, but some radiation to apex. not
late-peaking
ABD: soft, non tender, no rebound or guarding, NABS, no masses
RECTAL: guaiac positive, dark brown stool, no masses
EXTRM: benign
NEURO: totally intact, great historian, CN intact, moving all
extrm w/ good strenght and ease, finger to nose intact
Pertinent Results:
[**2103-9-19**] 09:49PM HCT-24.0*
[**2103-9-19**] 09:49PM RET AUT-5.3*
[**2103-9-19**] 03:57PM HGB-7.5* calcHCT-23
[**2103-9-19**] 03:20PM GLUCOSE-101 UREA N-19 CREAT-0.7 SODIUM-140
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12
[**2103-9-19**] 03:20PM WBC-8.8 RBC-2.30*# HGB-7.2*# HCT-22.6*#
MCV-98 MCH-31.5 MCHC-32.1 RDW-16.0*
[**2103-9-19**] 03:20PM NEUTS-70.4* LYMPHS-22.3 MONOS-3.9 EOS-2.6
BASOS-0.7
[**2103-9-19**] 03:20PM HYPOCHROM-2+ POIKILOCY-1+ MACROCYT-2+
[**2103-9-19**] 03:20PM PLT COUNT-268
[**2103-9-19**] 03:20PM PT-12.6 PTT-23.8 INR(PT)-1.0
Brief Hospital Course:
Patient was admitted to the [**Hospital Unit Name 153**] given her tight AS and
recurrent UGI bleed.
1. Upper GI bleed: Patient remained hemodynamically stable
throughout her admission. She received 3 units of packed red
blood cells over her first evening of admission with adequate
hct bump (22.6 to 30). She had 2 large bore IV's placed, had an
NG lavage in the ED which was negative, was started on IV
protonix, and was seen by GI consultation. She proceeded to EGD
the next morning which showed an active, pulsatile bleed from a
discrete spot in the duodenal sweep. No ulcers/erosions were
noted. 7 cc of epinephrine (1/10K) was injected for hemostasis
w/ partial success. Five endoclips were then placed over the
site of bleeding, and complete hemostasis was achieved. She
tolerated the procedure well and was transferred back to the
[**Hospital Unit Name 153**] for continued observation. Her hct remained stable (>30),
as well as her hemodynamics, and she will be discharged with
close PCP and GI follow up.
2. AS: remained stable. Worried initially for hypotension, given
decreased preload, then worried for pulm edema w/ IVF, blood
products. O2 sats never wavered, bp's stable, antihypertensive
med held during admission but should be restarted as soon as hct
fully stabalized.
3. hypothyroid: continued home dose.
4. FEN: NPO w/ slow advancement to regular diet.
5. hyperlipidemia: cont lipitor
6. osteopenia: held prempro. Can restart as outpatient.
7. full code
8. dispo: discharged to home in stable condition with gi/ pcp
follow up, hct check and hopeful re-initiation of nifedipine in
coming days.
Medications on Admission:
atorvastatin 10 qd
nifedipine 60 qd
synthroid 150 qd
prempro 0.625-5
prilosec
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. stop your nifedipine
until discussed with Dr [**Last Name (STitle) 838**]
5. Outpatient Lab Work
Hematocrit early next week
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
Discharge Condition:
stable
Discharge Instructions:
**Take all medications as prescribed. We had stopped your blood
pressure medication, nifedipine, during your bleed. We have not
restarted this, but you should discuss this w/ Dr [**Last Name (STitle) 838**] next
week.
**If you develop progressive weakness, dark or bloody stools,
dizziness, please return to the nearest emergency room.
**follow up with your physicians, as stated below.
Followup Instructions:
Dr [**Last Name (STitle) 838**] next week. Please call [**Telephone/Fax (1) 21516**] to schedule an
appt to have your blood counts checked.
Provider: [**Name10 (NameIs) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2788**] INTERNAL MEDICINE Where:
OFF CAMPUS [**Location (un) 2788**] INTERNAL MED. Phone:[**Telephone/Fax (1) 23790**]
Date/Time:[**2103-12-12**] 9:00
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 5799**]
Completed by:[**2103-9-23**]
ICD9 Codes: 5789, 4241, 4019, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4131
} | Medical Text: Admission Date: [**2121-2-27**] Discharge Date: [**2121-3-8**]
Date of Birth: [**2047-1-4**] Sex: F
Service: C MED
HISTORY OF PRESENT ILLNESS: This is a 74-year-old female who
has a known history of aortic stenosis and mitral
regurgitation, as well as hypercholesterolemia and
hypothyroidism who is admitted with a syncopal episode. The
patient syncopized at the dentist and was found to have a
heart rate in the 200s and a blood pressure of 80. She was
transferred to the [**Hospital1 **] [**First Name (Titles) 2142**] [**Last Name (Titles) **],
where she had a regular supraventricular tachycardia at
approximately 180 beats per minute, which broke briefly with
vagal maneuvers, and then recurred. She was given adenosine
and Lopressor without effect and then spontaneously converted
to normal sinus rhythm, had a stable pulse and blood
pressure. During these episodes she denied chest pain,
shortness of breath, abdominal pain, nausea, vomiting,
diarrhea, bright red blood per rectum, melena or dysuria.
PAST MEDICAL HISTORY:
1. Mitral stenosis and mitral regurgitation.
2. Aortic stenosis.
3. Hypercholesterolemia.
4. Hypothyroidism on replacement.
5. Macular degeneration.
ALLERGIES: None.
MEDICATIONS ON ADMISSION:
1. Synthroid 0.088 mg po q.d.
2. Lipitor 10 mg po q.d.
SOCIAL HISTORY: The patient lives with her husband in [**Name (NI) 26532**]. No tobacco history, no alcohol history.
PHYSICAL EXAMINATION: Temperature 95.0. Blood pressure
110/70. Pulse 70. Respirations 20. Oxygen saturation 96%
on room air. In general, this is an elderly woman in no
acute distress. Her head, eyes, ears, nose and throat are
unremarkable. Her neck shows no elevation and jugular venous
pulsation. Her lungs have crackles a third of the way up at
the bases bilaterally. Her heart is regular with a normal
S1, S2. A 3/6 systolic crescendo-decrescendo murmur is heard
at the right upper sternal border. A holosystolic [**3-26**] murmur
is audible at the apex with a diastolic component. Her
abdomen has normal bowel sounds, is soft, nontender,
nondistended. No masses are palpable. Her extremities
reveal no cyanosis, clubbing or edema. Neurologically, she
is alert and oriented times three. Her cranial nerves are
grossly intact. Her strength is [**5-25**] in the upper and lower
extremities. Her sensation is intact.
LABORATORY DATA: Admission laboratories are significant for
a white blood cell count of 9.1 (differential: 75% polys,
17% lymphocytes). Potassium 4.1, BUN 20, creatinine 1.0.
Chest x-ray showed congestive heart failure, no
consolidations and no effusions.
Electrocardiogram: Regular supraventricular tachycardia with
right axis deviation, diffuse ST depressions.
HOSPITAL COURSE: This is a 74-year-old woman with known
aortic stenosis and mitral regurgitation and mitral stenosis
who presented with syncope in the setting of a
supraventricular tachycardia and hypotension.
1. Cardiovascular: The patient was initially evaluated for
a myocardial infarction. She had an enzyme leak with a peak
troponin of 16.3, and a peak CK of 145 with an MB of 16 for
an index of 11%. She therefore was taken to the coronary
catheterization laboratory where she was found to have clean
coronary arteries. However, the patient was found to have
severe mitral regurgitation and moderate aortic stenosis
(aortic valve gradient 10 mmHg, aortic valve area 0.9 square
cm, mitral valve gradient 19 mmHg, mitral valve area not
calculated). During the catheterization, hemodynamic testing
revealed improved cardiac output with dobutamine. The
patient was transferred to the Cardiac Intensive Care Unit on
dobutamine and nitroglycerin. These medications were quickly
weaned off as the dobutamine was found to put the patient
back into supraventricular tachycardia. Once she was weaned
off these medications, she was transferred again to the
floor. The patient was evaluated by the Cardiac Surgery
Team. It was felt that double valve replacement surgery on
this frail 74-year-old woman would present an intraoperative
mortality risk of up to 30% given the extensive aortic
calcification seen during the cardiac catheterization. It
was therefore recommended that the patient be managed
medically and that surgery be reserved only as a last ditch
effort if medical management should fail.
The patient was started on amiodarone, Lopressor, and an ACE
inhibitor. She was taken for an electrophysiology study in
an attempt to possibly ablate a arrhythmia focus. On further
consideration, as the patient was known to not tolerate her
supraventricular tachycardia, it was felt that a better
approach would be to insert a pacemaker and then ablate the
patient's AV node, thereby, ablating any possible tachycardic
foci. The pacemaker was inserted, however, the procedure was
complicated by hemopericardium, secondary to a right
ventricular leak. The patient was transferred back to the
Coronary Care Unit, where she was found to have tamponade
physiology. A pericardial drain was placed. The following
day, the pericardial drain was withdrawn after a repeat
echocardiogram showed no re-accumulation of the
hemopericardium. On the following day, another repeat
echocardiogram was also clear. After further consultation
with the Electrophysiology Team, it was decided that the
patient would be discharged home on medical management to
follow-up in the Electrophysiology Device Clinic and AV
nodule ablation would be considered at a later time.
The patient was also started on oral Lasix q.d. for a gentle
diuresis. She is to follow-up in the Electrophysiology
Clinic the week after discharge. The patient was discharged
home on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Heart's monitor to monitor her QT interval
during the amiodarone load. The results of this monitor will
be interpreted by her electrophysiologist, Dr. [**Last Name (STitle) **].
2. Infectious Disease: The patient was noted to have an
elevated white blood cell count and hypothermia during her
admission. She also had diarrhea. The diarrhea was negative
for C. difficile. The white blood cell count normalized on
its own. There is no consolidation on chest x-ray and the
patient had no clinical symptoms of infection. Urinalysis
and culture were also negative.
3. Endocrine: The patient's hypothyroidism was maintained
on her usual dose of Synthroid. Her TSH and T4 were within
normal limits.
4. Communication: The patient lives at home with her
husband, who is demented, however, friends of the family are
extremely involved in the patient's care. The [**Location (un) 38550**]
can be reached at area code [**Telephone/Fax (1) 38551**], or area code
[**Telephone/Fax (1) 38552**].
5. Code status: Full.
CONDITION OF DISCHARGE: The patient is discharged in stable
condition.
FOLLOW-UP: She is to follow-up in the Electrophysiology
Clinic next week with Dr. [**Last Name (STitle) **]. AV nodule ablation will
be considered at a later date.
DISCHARGE DIAGNOSES:
1. Syncope.
2. Supraventricular tachycardia.
3. Mitral regurgitation.
4. Aortic stenosis.
5. Status post pacer placement.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg po q.d.
2. Amiodarone 400 mg po q.d.
3. Lisinopril 10 mg po q.d.
4. Synthroid 0.088 mg po q.d.
5. Atenolol 12.5 mg po q.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**MD Number(1) 5226**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2121-3-12**] 22:05
T: [**2121-3-12**] 22:05
JOB#: [**Job Number 38553**]
ICD9 Codes: 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4132
} | Medical Text: Admission Date: [**2148-5-1**] Discharge Date: [**2148-5-9**]
Date of Birth: [**2089-12-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
G tube clogged
Major Surgical or Invasive Procedure:
port-a-cath placed
G tube placed by IR
Suprapubic cath replaced
History of Present Illness:
58 M c quadriplegia [**2-23**] C4/C5 fracture [**2130**] and vent dependent c
PEG tube [**2-23**] massive thalamic bleed in [**2133**] who presents for
evaluation of clogged G tube. Noted on Saturday to have sluggish
passage of feeds through G tube. This morning, noted to have no
passage through G tube and sent to [**Hospital1 18**]. On discussion with RN
at rehab facility, pt c no obvious grimacing to abdominal
palpation, no aberrations of vital signs. Of note was recently
started on cefepime --> transitioned to zosyn for elevated WBC
and + sputum ctx. Also of note, recently had suprapubic catheter
replaced and has had intermittent leakage of urine via penis
over last several days.
.
In ED, VS - 98.0, 62, 108/64, 100% RA, rectal exam performed but
stool not felt and unable to be disimpacted. CT abdomen showed
multiple abdominal wall abscesses, no evidence for obstruction.
Recevied vancomycin, ceftazidime, and blood cultures drawn. Had
episode of bradycardia to 30 in ED for which pt. received
atropine once with rise in HR to 90s
.
Currently pt minimally responsive as his baseline per rehab
staff. Cannot answer questions re: pain, discomfort.
Past Medical History:
1. Recent hospitalization for sepsis at [**Hospital1 18**] thought [**2-23**] ESBL
Klebsiella osteomyelitis of L ischium vs. decubiti ulcers
2. Candidal fungemia [**8-26**] at [**Hospital1 2177**] tx c imipenem, vanc, caspo.
3. Quadriplegia s/p C4/C5 fracture [**2-23**] MVA [**2130**]
4. Thalamic hemorrhage [**2133**]
5. Diabetes
Social History:
lives at rehab, unclear [**Name2 (NI) **]/ETOH history
Family History:
Noncontributory
Physical Exam:
GEN- middle aged man lying supine, arms in flexed position.
VS- 96.1, 108, 208/122, 14, 100% RA
HEENT- Op clear, MMM. Moves eyes spontaneously
LUNGS- Coarse rhonchi diffusely. No wheeze
HEART- RRR, S1, S2, no murmur
ABDOM- G tube in place. + Erythema around site of G tube entry.
Abdomen distended mildly but not tender. Hypoactive BS.
EXTRE- wwp, no edema; denuded and atrophic muscles over legs,
clubbing
NEURO- quadriplegic. Occasional will respond to commands such as
closing eyes, showing teeth.
Pertinent Results:
CT abdomen:
1. Extensive fecal material extending from the rectum throughout
the entire colon with rectal wall thickening and likely edema in
association with fecal impaction. These findings raise the
question of stercoral colitis.
2. Probable osteomyelitis of the left ischium and ilium
secondary to a large left sacral decubitus ulcer.
3. No evidence for small bowel obstruction, however, there is
fecalization of small bowel which suggests a functional
obstruction.
4. Multiple anterior abdominal wall abscesses as described
above. Cholelithiasis without evidence for cholecystitis.
5. Gastrostomy tube, IVC filter, and suprapubic catheter
identified.
.
MICRO:
Blood cultures - 2/4 Bottles with GNR's, likely Klebsiella
AEROBIC BOTTLE (Final [**2148-5-6**]):
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. FINAL
SENSITIVITIES.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
NON-FERMENTER, NOT PSEUDOMONAS
AERUGINOSA
|
CEFEPIME-------------- 16 R
CEFTAZIDIME----------- =>16 R
CEFTRIAXONE----------- =>32 R
CIPROFLOXACIN--------- =>2 R
GENTAMICIN------------ =>8 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 4 R
MEROPENEM------------- 1 S
PIPERACILLIN---------- 16 S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ =>8 R
ANAEROBIC BOTTLE (Final [**2148-5-7**]): NO GROWTH.
.
Port a cath placement:
TECHNIQUE/FINDINGS: After informed consent was obtained, the
patient's left upper chest was prepped and draped in a sterile
fashion. Lidocaine with Epinephrine was used to anesthetize the
skin, tract and eventual location of this patient's port. The
subclavian vein was entered with a microcatheter system after
which a tract was made and a port reservoir created within the
subcutaneous tissue. The port was then sutured in place using a
zero-silk suture. The catheter was then measured so the eventual
length would place it in the distal SVC. The vascular entrance
site was then dilated to 9 French after which a peel-away sheath
was placed and the catheter advanced. The catheter was then
joined to the subcutaneous port without incident.
Final chest x-ray demonstrates no kinks in the catheter,
catheter tip in the distal SVC. The catheter was accessed within
the angiography Suite to ensure appropriate infusion and
aspiration. It was then flushed with heparinized saline.
Throughout the procedure, the tract and subcutaneous port
location were irrigated with orthopedic solution.
The overlying skin was closed with a running 2-0 Vicryl suture
(absorbable and no need to remove).
IMPRESSION: Placement of an 8 French subcutaneous port via the
left subclavian vein with the tip in the right atrium. No
complications. The catheter is ready for use.
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
Brief Hospital Course:
Pt was [**Hospital 70882**] transferred to [**Hospital1 18**] only to have his G tube
replaced by IR as it had become clogged. Given that he was
chronically vented, he was admitted to the ICU.
His G tube was replaced successfully by IR. There was
difficulty obtaining consent. If he is transferred from your
facility again, please document who to contact for consent, and
correct phone numbers for this person.
In anticipation of fixing the clogged G tube, he had a CT scan
in the emergency room which showed mutiple fluid filled pockets
in the abdominal wall. One of these pockets was aspirated and
showed only clotted blood. It was felt that these were most
likely due to his heparin injections and so heparin sc was
discontinued.
In the emergency room, upon seeing the abdominal wall pockets of
fluid, the emergency room staff were concerned that these could
be abscesses. Blood cultures were obtained and 2 out of 4
bottles grew gram negative rods. He was initially treated with
Zosyn, but once the culture demonstrated that it was unlikely to
be pseudomonas, and the resistance pattern was consistent with
an ESBL resistant Klebsiella, Pt was switched to Meropenem.
Meropenem was started on [**5-7**] for a 10 day course. Last day of
Meropenem is [**2148-5-16**]. it was presumed that his PICC line was
the source. This was removed and a port-a cath was placed by
IR.
Pt has a history of autonomic dysregulation, this was treated by
continuing his regimen of metoprolol.
Of note, pt was maximally impacted and constipated on arrival,
he required an [**First Name9 (NamePattern2) 70883**] [**Last Name (un) 49666**] regimen.
Medications on Admission:
Insulin - lantus 38 u qhs
Nystatin 1000 u 5cc susp. qid PO for thrush
Senna/Colace
Nexium 40 mg qd
Zinc 220 mg qd
Vitamin C 500 mg [**Hospital1 **]
Lopressor 25 tid
Lipitor 80 mg qd
Heparin SC tid
Cefepime [**4-21**] --> changed to IV Zosyn to continue until [**5-9**]
Discharge Medications:
1. Meropenem 500 mg IV Q6H
2. Heparin Flush (100 units/ml) 2 ml IV DAILY:PRN
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
4. Combivent 103-18 mcg/Actuation Aerosol Sig: Four (4)
Inhalation four times a day.
5. Novolin R Sliding Scale
FSBG 150-200 give 2 units
FSBG 201-250 give 4 units
FSBG 251-300 give 6 units
FSBG 301-350 give 8 units
FSGB 351-400 give 10 units
FSBG > 401 [**Name8 (MD) 138**] MD
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
7. Tylenol elixer
650 mg q4:prn
8. Fleet enema
PR QD
9. Dulcolax Suppository
PR QD
10. Lantus
38units QHS
11. Vitamin C
500 mg [**Hospital1 **] per GT
12. Zinc
220 mg qd per GT
13. Colace liquid
100 mg [**Hospital1 **] per GT
14. Senokot
5ml [**Hospital1 **] per GT
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Rehab
Discharge Diagnosis:
Line infection with gram negative rod bacteremia
Discharge Condition:
stable
Discharge Instructions:
The physician at the rehab facility needs to be made aware of
any fevers, changes in vital signs. Please also monitor the
surgical site on his chest for signs of bleeding or infection.
G tube has been replaced and may be used. Suprapubic catheter
has been replaced.
Followup Instructions:
Monitoring by physician at long term care facility
Completed by:[**2148-5-9**]
ICD9 Codes: 0389, 5990, 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4133
} | Medical Text: Admission Date: [**2100-9-3**] Discharge Date: [**2100-9-11**]
Date of Birth: [**2017-4-11**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / Benazepril /
Etodolac / Indomethacin / Naproxen / Sertraline / Oxycodone
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
T10 TRANSPEDICULAR CORPECTOMY WITH INTERBODY INSTRUMENTED FUSION
T9 TO T11, DEEP BONE BIOPSY, AND POSTERIOR INSTRUMENTED FUSION
T8 TO T12 WITH ALLOGRAFT AND AUTOGRAFT
History of Present Illness:
She had 2 months of progressive back pain radiating to her
bilateral flanks. She was undergoing work up and treatment with
spinal injections but the pain progressed and she developed
bilateral LE weakness so she presented to an OSH ED ([**Location (un) 8641**] in
NH). CT at the OSH reportedly showed a T10 compression lesion
without evidence of cord compression. She was sent to [**Hospital1 18**] and
admitted to the ortho spine service for further work up and
treatment. CT C and T spine along with CT torso showed several
masses (lungs, liver, soft tissue and bone) concerning for
metastatic disease; specificially raising suspicion for
melanoma. The patient went to the OR on [**9-4**] in an attempt to
obtain tissue for diagnosis and decompress the T10 mass for pain
relief. There were no clear complications of the surgery but,
post-operatively it was felt that she warrented ICU admission
for monitoring. Her PACU course was notable for 2 hours of low
urine output. She received 500ccs of NS.
.
The patient does report pain in her back and subjective feeling
of SOB. She is nauseous. She denies recent weight change,
fevers, chest pain, abdominal pain. She denies numbness or
tingling.
Past Medical History:
Type II Diabetes Mellitus (Non-Insulin Dependent)
COPD on continuous 2 L home O2 (sometimes does not use if not
exerting herself)
Possible History of Myocardial Infarction
Hypertension
Hypercholesterolemia
Arthritis
Anxiety with claustrophobia/panic attacks
?Coronary Artery Disease (Q-waves present on EKG, negative
stress test per patient in [**1-/2100**])
Appendectomy
s/p lysis of adhesions
Cholecystectomy
s/p hysterectomy
Social History:
She lives in [**Location (un) 3844**] in subsidized housing. lives alone.
retired, used to own a grocery store with her husband. previous
[**Name2 (NI) 1818**] (quit 14 years ago, smokes 2 ppd x50 years). Denies EtOH
or IVDU.
Family History:
unable to obtain
Physical Exam:
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL
Cardiovascular: normal S1/S2, no murmurs
Peripheral Vascular: 2+ peripheral pulses
Respiratory / Chest: bibasilar crackles
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: No edema
Skin: Warm
Neurologic: [**6-9**] muscle strength in LLE, [**4-9**] muscle strength in
hip flexors of RLE. Sensation intact throughout.
Pertinent Results:
Labs On Admission:
[**2100-9-3**] 05:15PM BLOOD WBC-9.5 RBC-4.34 Hgb-12.0 Hct-37.3 MCV-86
MCH-27.8 MCHC-32.3 RDW-14.6 Plt Ct-318
[**2100-9-3**] 05:15PM BLOOD Neuts-87.7* Lymphs-10.1* Monos-0.6*
Eos-1.2 Baso-0.3
[**2100-9-3**] 06:37PM BLOOD PT-12.0 PTT-24.1 INR(PT)-1.0
[**2100-9-3**] 05:15PM BLOOD Glucose-179* UreaN-21* Creat-1.0 Na-139
K-4.9 Cl-104 HCO3-23 AnGap-17
[**2100-9-4**] 08:05PM BLOOD CK(CPK)-229*
[**2100-9-4**] 11:36PM BLOOD ALT-22 AST-30 LD(LDH)-172 AlkPhos-85
TotBili-0.1
[**2100-9-4**] 08:05PM BLOOD Calcium-8.6 Phos-6.2* Mg-1.6
.
[**2100-9-3**] CT Abd/Pelvis:
IMPRESSION:
1. Large 4.6 cm left lower lobe mass concerning for a neoplastic
process. At least two other nodules are identified within the
lungs, one in the left lower lobe and a second in the right
upper lobe.
2. Additional soft tissue lytic lesion in the posterior right
iliac bone.
3. Multiple soft tissue masses, one along the left and right
lateral abdominal wall, and a second in the left labia and
possible third in the left upper chest wall. Lesions are
concerning for neoplastic process. Hypodense lesion in segment
IVb of the liver which is incompletely evaluated but may also
represent a metastatic or neoplastic process.
Conglomerate of findings raises concern for melanoma as a
primary source.
.
[**2100-9-3**] CT T Spine:
IMPRESSION: Large lytic mass infiltrating the T10 vertebral body
and pedicle on the right with resultant severe central canal
stenosis. The effect of this stenosis on the cord are better
evaluated on the comparison MR study.
.
[**2100-9-4**] CXR:
Mild cardiomegaly is unchanged. Left lower lobe retrocardiac
mass is better visualized in prior CT. There is no evident
pneumothorax or pleural
effusions. Increased opacity in the left lower lobe is
consistent with new
atelectasis. Right IJ catheter tip is in the mid SVC. There is
no overt CHF.
Brief Hospital Course:
BRIEF MICU COURSE:
Ms. [**Known lastname 16968**] was admitted to the MICU for low urine output and
post-op monitoring. She was noted to have new acute renal
failure, likely due to dehydration and contrast recieved during
the CT scan. She was given LR boluses x 2 liters for low urine
output. Her urine output during ICU stay was 15-30cc/hr. Her
mental status was appropriate. She recieved morphine for pain
control. Ortho spine recommended not starting SC Heparin until
72 hours post-op. She will need a TLSO brace to get out of bed.
Her hematocrit was trending down from 37 to 28, likely from
blood loss after surgery and dilutional from fluids. She was
noted to be CO2 retaining after surgery, likely from chronic
COPD and sedation with hypoventilating. This was improving on
discharge from the ICU.
Medications on Admission:
Home Medications:
Aspirin 325 mg PO daily
Restoril 30 mg PO daily
Diovan 320 mg PO daily
Metformin 500 mg PO BID
Spiriva 18 mcg 1 Capsule PO daily
Misoprostol 100 mcg 0.5 tablets PO BID:PRN
Tylenol 650 mg 2 tablets PO BID
Symbicort 2 HFA INH [**Hospital1 **]
Amlodipine 10 mg PO daily
Crestor 20 mg PO daily
Paxil 20 mg PO daily
Ativan 0.5 mg PO daily
Darvocet 100/650 mg 1 tablet PO TID
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2100-9-11**]
ICD9 Codes: 5849, 486, 2851, 7907, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4134
} | Medical Text: Admission Date: [**2134-7-2**] Discharge Date: [**2134-7-20**]
Date of Birth: [**2104-6-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
End Stage Liver Disease secondary to HBV/HCV
Major Surgical or Invasive Procedure:
liver transplant [**2134-7-2**]
History of Present Illness:
Pt is a 30M with hemophilia A, HIV, HCV, HBV, and cirrhosis with
portal hypertension, varices, and recurrent ascites who was
admitted on [**2134-7-2**] for a liver transplant. For the past 6
months he has required therapeutic paracentesis q1-2 weeks.
Last tap on [**2134-6-30**] for 5 liters.
Past Medical History:
1. HIV: since age 7, secondary to transfusions. CD4 nadir
163 in [**1-11**] as noncompliant w/ HAART, developed resistance. Last
CD4 was 222 in [**4-15**] on HAART.
2. Hemophilia: c/b hemarthrosis, bone cysts, joint destruction,
narcotic dependence, s/p left knee synovectomy
3. Cirrhosis, pursuing liver transplant
- Hepatitis B
- Hepatitis C
- known to have portal hypertension with esophageal
varices and gastropathy noted in [**2134-2-10**].
- worsening liver function thought secondary to exacerbation of
HIV resistant to lamivudine, with change in meds to atazanavir,
ritonavir, and truvada
- admission for hepatic encephalopathy at the end of [**1-15**]
4. HBV/HCV as above
5. Pseudotumor with a bone graft and tendon shortening in L arm
6. Chronic Pain, narcotic dependence
7. Nephrolithiasis
8. status post MVA [**12-12**]
9. Splenic hematoma
10. LLE cellulitis- s/p surgery [**5-13**] at [**Hospital1 2025**]
11. history of narcotic dependence
12. Depression
Social History:
h/o ETOH abuse in distant past, no h/o DTs or withdrawal,
several drinks only in last 7 years. Also hx of IVDU (heroin)
several yrs ago - has not used in a few years. Patient born and
raised in [**Hospital1 1474**]. Parents divorced when he was a child.
Infected with HIV at age 7. Not working - has worked in the past
doing AIDS education at schools. Lives at the Embassy health
rehab.
Family History:
mother - premenopausal breast cancer, mild hypertension
father - hypertension, lymphedema (?)
maternal uncle - has Hemophilia A
several cousins - hemophilia A
four half-siblings in good health
Physical Exam:
Temp - 100.1F, Pulse - 98, BP - 118/68, 98% RA, 94.3kg
General - NAD
HEENT - EOMI B/L, PERRLA B/L, scleral icterus present, no thrush
Neck - no LAD, no bruits
Lungs - coarse LLL
CV - RRR, 3/6 systolic murmur
Abd - ascites present, NT, ND, +BS
Ext - 3+ B/L edema
Skin - jaundice
Neuro - AA&O x 3
Pertinent Results:
On admission:
Na - 127, K - 4.6, Cl - 100, CO3 - 21, BUN - 18, Cr - 0.7, Gluc
- 119
WBC - 5.1, Hct - 26.7, Plat - 95
PT - 29, PTT - 88.3 INR - 3.0
AST - 126, ALT - 48, AP - 216, TBil - 3.6, Alb - 2.3
CXR - L base haziness, possible atelectasis
EKG - SR, no ectopy
Brief Hospital Course:
Pt is a 29M admitted on [**7-2**] for liver transplant. Pt was give
50 units/kg Factor VIII prior to procedure and 20 units/kg
q12hours postoperatively. In addition HBIG was given intraop as
well as postop. Procedure went without incidence and pt was
transfered to the SICU, intubated in stable condition. Please
see OP note for details. Post-operatively factor VIII level was
92. Duplex ultrasound of the liver on POD 0 showed normal
hepatic artery and portal vein flow. On POD 1 pt began having
significantly increased bloody output from the JP and his
hematocrit decreased from 30 to 25. However, the decision was
made not to reexplore the pt. and to continue the factor VIII
replacement. Over the next two days the JP output decreased
with continued factor VIII replacement and his hematocrit
stablized after transfusion with 2units pRBCs. On POD 2 pt was
extubated without difficulty and on POD 3 pt was restarted on
his home HIV meds of Kaletra, Tenofovir, and Emtricitabine. On
POD 4 pt was transfered to the floor and his diet was advanced.
While on the floor pt was noted to become bradycardic to a HR in
the low 40s, with the lowest being 28. Pt. remained
asymptomatic through the bradycardic events. He was seen by
cardiology who felt that the episodes were physiologic sinus
bradycardia and were not concerned given the lack of symptoms.
Cardiology recommended pt wear [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts montior as an
outpatient and would follow up with him in the clinic. On POD
6, [**7-9**], the pt recieved his second dose of tacrolimus 0.5mg
which were being dosed based on levels secondary to interaction
with his HIV medications. After recieving the tacrolimus the
pt. was noted to have a seizure episode resoliving after [**2-12**]
minutes. Stat CT was negative for a bleed and the patient was
transferred to the ICU. At that time it was noted that his Mg
was slightly low (1.6) and this was repleted. At this time his
Remeron was stopped because of its ability to lower seizure
threshold. He was started on Keppra which was later stopped as
the patient had no further seizure episodes, a negative MRI, and
a negative EEG. At that time it was felt that the seizure was
most likely due to tacrolimus toxicity. On [**7-14**] pt was noted
to complain of significantly increased pain and had elevated
liver enzymes. A CT was done which showed only a small hematoma
and significantly dilated loops of bowel. At that time it was
felt that the pain was secondary to constipation and the
elevated liver enzymes were a result of dehydration. With an
aggressive bowel regimen the pt. had a bowel movement and
reported significant improvement in pain. Pt had no further
acute episodes and was discharged back to his [**Hospital1 1501**] facility on
[**7-20**], POD 17.
Medications on Admission:
Spironolactone 50mg qDay
Lasix 40mg qDay
Atazanavir 300mg qDay
Mirtazapine 12 qHS
Tenofovir 300 qDay
Emtricitabine 200 qDay
Ritonavir 100 qDay
Reglan 10 QID
Clotrimazole 10 QID
ranitidine 150 qDay
hydromorphone 16 q3-4 hours
oxycontine 140mg q8 hours
lactulose 30mL [**Hospital1 **]
ferrous sulfat 325 qDay
quinine
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
ML PO DAILY (Daily).
2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
6. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
8. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Prograf 0.5 mg Capsule Sig: dose to be adjusted by
Transplant Office based on levels Capsule PO per transplant
office: check with [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] RN at [**Hospital1 18**] Transplant Office
for dose [**Telephone/Fax (1) 10575**].
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
14. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Dulcolax 10 mg Suppository Sig: One (1) Rectal qday prn as
needed for constipation.
17. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q2H (every
2 hours) as needed.
18. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
19. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
21. Oxycodone 160 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q8H (every 8 hours).
22. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO every eight (8) hours.
23. Tacrolimus - pt is to follow up with the transplant clinic
for FK levels and dosing per levels.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2542**] - [**Hospital1 1474**]
Discharge Diagnosis:
S/P Liver Transplant
HCV
HBV
HIV
Hemophilia
Bradycardia,resolved
Discharge Condition:
stable
Discharge Instructions:
Call Transplant office [**Telephone/Fax (1) 673**] for:
* fevers/chills
* nausea/vomiting
* inability to take medication
* increased abdominal pain
* decreased urine output
* any bleeding
* redness/swelling/drainage from wound
.
Take all your medications as instructed. Do not restart home
medications unless instructed.
.
Labs every Monday and Thursday for cbc, chem 10, Calcium, phos,
AST, Tbili, amylase, lipase, U/A, prograf trough. Fax results to
[**Telephone/Fax (1) 673**]. attn: [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **]
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2134-7-29**] 10:40
Call Dr.[**Last Name (STitle) 22830**] (Cardiologist)([**Telephone/Fax (1) 12468**] to schedule
follow up in 1 month otherwise [**9-21**], at 1020 located [**Hospital Ward Name 23**]
7 on the [**Location 29083**]:
ECHO LAB TESTING Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2134-7-22**] 11:00
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2134-7-29**] 10:00
Call Dr. [**Last Name (STitle) 2148**] to schedule a follow-up appt to discuss pain
medications ([**Telephone/Fax (1) 4170**]
Completed by:[**2134-7-20**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4135
} | Medical Text: Admission Date: [**2128-1-13**] Discharge Date: [**2128-1-15**]
Date of Birth: [**2103-8-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
overdose/suicide attempt with risperdal, Celexa, ativan
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
24 yo F with a h/o depression and anxiety, otherwise healthy
presented to ED by EMS after taking "about 100 pills" including
ativan, celexa, risperdal. She was awake and alert upon arrival.
Vitals were p 120 BP 130/90 rr 20 sats 98% RA, afebrile.
Approximately 30 minutes after arrival in ED, she became
increasingly lethargic, was intubated for airway protection.
This was complicated by R mainstem intubation revealed on CXR
which was then pulled back intro trachea. OG tube was placed and
pt recieved 50g of activated charcoal. Tox consult was called
and recommended supportive care wnd serial ECGs to assess for QT
and QRS prolongation.
Past Medical History:
1. Depression/Anxiety
- followed for psych at [**Hospital1 18**]
- previous suicidal gestures (scratching wrist with razor blade
and taking 20 pills and spitting them up)
Social History:
Ms [**Known lastname 29088**] reports no tobacco or illicit drug use history. She
drinks only occassionally. According to psychiatry, that patient
has a history of suicide attempts. Reportedly, lives with her
ex-boyfriend, who looks after her finances and medications.
Family History:
Father w/ alcoholism
Physical Exam:
On admission to the [**Hospital Unit Name 153**]:
VS: AF, HR 96, BP 121/57, RR 16, sats 100% on PS 5/5 FiO2 0.4
Gen: sedated on propofol, skin without flushing, no dryness or
sweating.
HEENT: pupils 2mm PERRL. Anicteric. OP clear with ETT, OGT.
chest: CTA bilaterally
CV: RRR, no m/r/g
abd: obese, soft, NT/ND, no organomegaly
ext: no c/c/e
Neuro: no rigidity, sedated.
.
On transfer to the floor:
Tm 100.9 at 0700, Tc 96.7, BP 111/70, HR 88-107, RR 16, sats 97%
RA
G: Obese female, NAD, WN, WD
HEENT: Clear OP, MMM, mild tonsilar edema
Neck: Supple, No LAD, no thyromegaly
Lungs: CTA, BS BL, No W/R/C
Cardiac: RR, tachy. NL S1S2. No murmurs
Abd: Soft, NT, ND. NL BS.
Ext: No edema. 2+ DP pulses BL.
Neuro: Grossly intact.
Pertinent Results:
.
Labs on admission [**1-13**]:
WBC 11.9, Hct 34.9, MCV 77, Plt 352
(diff: 77.8N, 19.0L, 2.5M, 0.4E, 0.4B)
PT 12.9, PTT 20.3, INR(PT) 1.1
Na 136, K 3.7, Cl 101, HCO3 21, BUN 18, Cr 0.7, Glu 108
ALT 17, AST 15, LD(LDH) 129, CK(CPK) 127, AlkPhos 68, TotBili
0.2
Alb 4.2
[**2128-1-13**]: BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2128-1-13**]: URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
.
[**2128-1-13**] ABG pO2-300* pCO2-41 pH-7.34* calHCO3-23 Base XS -3
.
[**2128-1-13**]: URINE Clear, USG 1.008, Blood-TR, Nitrite-NEG,
Protein-NEG, Glucose-NEG, Ketone-NEG, Bilirub-NEG, Urobiln-NEG,
pH-5.0, Leuks-NEG,
RBC-0-2, WBC-0-2, Bacteri-OCC, Yeast-NONE, Epi-0
.
Labs on discharge [**1-15**]:
WBC 8.6, Hct 31.3, MCV 79, Plt 282
Na 138, K 3.7, Cl 105, HCO3 24, BUN 10, Cr 0.6, Glu 106
Mg 2.0 Iron 40, calTIBC 413, Ferritn 47, TRF 318
.
IMAGING:
CXR [**1-13**]: The endotracheal tube has been withdrawn and now
terminates approximately 1-2 cm above the carina. Patchy opacity
in the left lung base is unchanged. There have been no other
changes in the 30-minute interval.
.
CXR [**1-13**]: Right mainstem endotracheal intubation. Possible
opacity in the left retrocardiac region may represent
atelectasis. NG tube in satisfactory position.
.
CXR [**1-14**]: Rapid resolution left lower lobe pneumonia consistent
with aspiration etiology
.
EKG [**1-13**]: Sinus tachycardia. Non-diagnostic repolarization
abnormalities. No previous tracing available for comparison.
Rate 124, PR 116, QT/QTc 304/377.85.
.
EKG [**1-14**]: Sinus tachycardia. Rate 112, PR 136, QT/QTc
346/412.42.
.
EKG [**1-15**]: (my read) NSR, rate 83, left axis, flattened T waves
in III, aVF, no other ST or Twave changes. QT/QTc 378/418.
Brief Hospital Course:
24 yo F with a h/o depression and anxiety, presented to ER after
overdose/suicide attempt with risperdal, celexa, and ativan.
.
1. Drug overdose: Ms. [**Known lastname 29088**] was awake and alert upon arrival
to the ER. She was afebrile, with a HR 120, BP 130/90, RR 20,
sats 98% RA. However, approximately 30 minutes after arrival in
ED, she became increasingly lethargic and was intubated for
airway protection. This was complicated by R mainstem intubation
revealed on CXR which was then pulled back into trachea. OG tube
was placed and pt recieved 50g of activated charcoal. Toxicology
consult was called and recommended supportive care and serial
ECGs to assess for QT and QRS prolongation. The patient was
admitted to the [**Hospital Unit Name 153**] where she was observed overnight and was
extubated the following day without incident. She was noted in
the [**Hospital Unit Name 153**] to have had a low-grade fever of 100.4. She was
evaluated by psychiatry, with the plan for in-patient placement
after she receives medical clearance. Post-extubation, she was
transferred to the floor where she remained afebrile. She had no
events on telemetry and her vital signs remained stable. Her
risperidal and celexa were held and she was given ativan prn for
anxiety. Psychiatry followed her on the floor and agreed with
this plan. She has been cleared from a medical standpoint and
will be transferred to [**Hospital1 **] 4 today for inpatient psychiatric
care.
.
2. Respiratory: After extubation, her only complaint has been of
a sore throat and some mild epigastric/subxiphoid tenderness.
CXR post-extubation is most consistent with an aspiration
pneumonitis, due to the rapid resolution of the LLL infiltrate.
She has been given cepacol prn for her throat pain.
.
3. Fever: Ms. [**Known lastname 29088**] had a low grade fever and mild
leukocytosis on admission, both of which have since resolved.
Fever may have been from atelectasis/aspiration pneumonitis.
.
4. F/E/N: Given full diet upon transfer to the floor. Her
electrolytes were checked daily and repleted as necessary. No
IVF were needed.
.
5. Proph: Pneumoboots for DVT ppx.
.
6. Access: 2 peripheral IVs
.
7. CODE: FULL
.
8. Comm: [**Name (NI) 1785**] [**Name (NI) 29088**] (mother): [**Telephone/Fax (1) 29089**]
.
9. DISPO: To [**Hospital1 **] 4 for inpatient psychiatric hospitalization.
Medications on Admission:
Celexa 40 mg qd
Lorazepam 0.5 mg [**Hospital1 **] prn for anxiety
Risperdal 0.5 mg [**Hospital1 **]
Risperdal 0.5 mg qd prn for anxiety
Wellbutrin 100 mg qd
Levlen
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
2. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Suicide attempt/overdose
2. Aspiration pneumonitis
Discharge Condition:
Stable. BP 100/62, HR 90. RR 20, sats 95% on RA.
Discharge Instructions:
1. Please call your PCP or go to the ER if you develop any of
the following symptoms: fevers >101, chills, shortness of
breath, sputum production, nausea, vomiting, chest pain,
palpitations, or any other medications.
2. Please call your psychiatrist or go to the ER if you have any
suicidal thoughts.
Followup Instructions:
1. Please follow up with your psychiatrist as recommended by the
inpatient psychiatry team.
2. Please follow up with your PCP 1-2 weeks after discharge.
ICD9 Codes: 5070, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4136
} | Medical Text: Admission Date: [**2135-2-22**] Discharge Date: [**2135-2-23**]
Date of Birth: [**2077-12-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Jaundice.
Major Surgical or Invasive Procedure:
1. Endoscopic Retrograde Cholangiopancreatography (ERCP) with
stent placement
History of Present Illness:
57 y/o M with metastatic esophageal adenocarcinoma to liver and
lung p/w obstructive jaundice . He is s/p previous esophageal
stenting of the distal esophagus. Tbili today was 31. He was
referred in to [**Hospital1 18**] for ERCP for evaluation of obstructive
jaundice. ERCP was uncomplicated, a large biliary stricture was
noted and a metal stent was placed.
.
Currently he feels lethargic as he has intermittently for the
past few days, no nausea or vomiting, no pain anywhere, no
constipation or diarrhea, good PO intake normally but decreased
PO intake yesterday. No fevers, chills, rigors or sweats.
Weight loss. No chest pain or SOB, rest of review of systems is
negative.
Past Medical History:
h/o ETOH abuse and polysubstance abuse
history of PE (noted incidentally on a CT, anticoagulated on
coumadin)
Metastatic poorly differentiated adenocarcinoma of the
esophagus, diagnosed [**10-7**], metastatic to liver and lung
Social History:
h/o ETOH abuse and polysubstance abuse (opiates / heroin) denies
IVDU, 60pk yr history of smoking
Family History:
- Brother with GERD
- Denies any FH of cancer or heart disease
- Extensive family history of EtOH abuse
Physical Exam:
Upon admission:
VS: T 98.0 HR 87 BP 75/46 RR 12 O2 sat 97% on RA
GEN: NAD, AOX3
HEENT: MM Dry, JVP flat at 30 degrees, sclera icteric
CARD: RRR, no m/r/g
PULM: CTAB
ABD: soft, enlarged firm nodular liver, non tender, non
distended
EXT: WWP, no c/c/e
NEURO: AOx3, able to move all 4 extremities, very soft spoken
and at times very mildly confused. Able to recall his
medications.
SKIN: Jaundice
.
At discharge:
GEN: jaundice, cachetic without acute distress
HEENT: EOMI, icteric, MMM, no jvd, no thyromegaly or thyroid
nodules
RESP: CTA b/l with good air movement throughout, decreased BS
throughout
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: distended, typanic, +b/s, nontender
EXT: 3+ edema to above knees
SKIN: diffuse jaundice. no rashes no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. 2+DTR's-patellar
and biceps. +Asterixis
Pertinent Results:
Labs:
[**2135-2-22**] 08:55AM BLOOD WBC-16.7*# RBC-3.06*# Hgb-8.5*#
Hct-26.0*# MCV-85 MCH-27.7 MCHC-32.6 RDW-18.7* Plt Ct-245
[**2135-2-22**] 02:15PM BLOOD WBC-11.4* RBC-2.46* Hgb-6.8* Hct-21.4*
MCV-87 MCH-27.5 MCHC-31.6 RDW-18.8* Plt Ct-200
[**2135-2-23**] 03:36AM BLOOD WBC-18.5*# RBC-2.85* Hgb-8.1* Hct-24.5*
MCV-86 MCH-28.6 MCHC-33.3 RDW-18.5* Plt Ct-252
[**2135-2-22**] 02:15PM BLOOD Neuts-97* Bands-0 Lymphs-0 Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2135-2-22**] 08:55AM BLOOD PT-27.4* PTT-36.0* INR(PT)-2.7*
[**2135-2-23**] 03:36AM BLOOD PT-21.6* PTT-33.2 INR(PT)-2.0*
[**2135-2-22**] 08:55AM BLOOD Glucose-93 UreaN-18 Creat-0.9 Na-133
K-3.7 Cl-98 HCO3-25 AnGap-14
[**2135-2-22**] 02:15PM BLOOD Glucose-88 UreaN-18 Creat-0.8 Na-136
K-3.5 Cl-103 HCO3-23 AnGap-14
[**2135-2-23**] 03:36AM BLOOD Glucose-85 UreaN-20 Creat-0.9 Na-136
K-3.6 Cl-104 HCO3-24 AnGap-12
[**2135-2-22**] 08:55AM BLOOD ALT-43* AST-100* LD(LDH)-311*
AlkPhos-1088* Amylase-15 TotBili-30.6* DirBili-24.9* IndBili-5.7
[**2135-2-22**] 02:15PM BLOOD ALT-31 AST-78* LD(LDH)-262* AlkPhos-834*
TotBili-23.4*
[**2135-2-23**] 03:36AM BLOOD ALT-37 AST-85* AlkPhos-821* TotBili-25.4*
[**2135-2-22**] 08:55AM BLOOD Albumin-2.4* Calcium-7.8* Phos-2.9
Mg-2.9*
[**2135-2-22**] 02:15PM BLOOD Albumin-1.9* Calcium-6.7* Phos-3.5 Mg-2.5
[**2135-2-23**] 03:36AM BLOOD Calcium-6.9* Phos-4.2 Mg-2.6
[**2135-2-22**] 03:14PM BLOOD Lactate-1.7
[**2135-2-22**] 04:46PM BLOOD Lactate-1.5
.
Pathology:
[**2-23**] sputum cytology pending
.
Microbiology:
[**2-23**] sputum AFB pending
[**2-22**] urine culture pending
[**2-22**] blood culture pending
.
Imaging:
[**2-22**] ERCP: Successful biliary cannulation. A severe diffuse
dilation was seen at the middle third of the common bile duct
and upper third of the common bile duct with the CBD measuring
18 mm in maximal diameter. There was also moderate dilation of
the intrahepatic ducts as well. A single stricture that was 20
mm long was seen at the middle third of the common bile duct.
Successful placement of a 6cm by 10FR fully covered metal
Wallflex biliary stent (REF 7[**Numeric Identifier 84630**]) was placed
successfully in the main duct. Otherwise normal ercp to third
part of the duodenum.
[**2-22**] CXR: In comparison with study of [**2133-10-30**], there is large
area of
opacification with apparent cavitation in the left mid zone.
This is
consistent with cavitary process for which TB must be also
considered. An
area of patchy opacification at the right and left bases also
are seen,
raising the possibility of multifocal infection. Central
catheter extends to mid portion of the SVC. Esophageal stent is
in place.
[**2-23**]: In comparison with study of [**2-22**], the cavitary lesion in
the left
upper zone is again seen. The multiple nodules seen on CT are
difficult to
appreciate. There are some patchy areas in the right lung that
could also
represent foci of infection.
[**2-24**] Chest CT: There are multiple pulmonary arterial filling
defects, which appear acute. These include filling defects to
the right middle lobe (2:28), right lower lobe (2:39), right
upper lobe (2:27), lingula (2:33), left lower lobe (2:35) and
possibly the left upper lobe (2:17). However, no definite
pulmonary infarcts are identified and no evidence for right
heart strain is present. Small bilateral pleural effusions are
present.
In the left upper lobe is a thin-walled space, 4.1 x 3.8 cm,
containing no
fluid or debris, surrounded by a 9 x 6.5 cm region of
consolidation. Additional areas of consolidation or developing
abscesses are present in the right middle lobe (2:32) and right
lower lobe (2:41, 42). In the right upper lobe is a probable
bronchocele (2:24) adjacent to an area of consolidation (2:30).
Mild apical emphysema is present. Millimeter sized pulmonary
nodules described on the prior examination are less evident on
this study, probably subsumed in consolidations. Debris in the
right main stem bronchus (2:25), documents aspiration. A long
mid esophageal stent which contains fluid and debris, new since
the prior study. A stent previously spanning the
gastroesophageal junction is now in the stomach. The GE junction
mucosa is markedly thickened, similar to prior study. The aorta
and SVC are of normal caliber. Left paratracheal lymph nodes
measuring up to 11 mm. Soft tissue, difficult to evaluate is
present along
the inferior anterior mediastinum adjacent to the pericardium
(2:51), could be infiltrating tumor. The heart appears normal.
Although, this study is not tailored for evaluation of the
subdiaphragmatic region. There is heterogeneous attenuation of
the liver, suggestive of diffuse metastatic disease. A metallic
stent is seen within the region of the
CBD, better evaluated and visualized on the recent ERCP. The mid
stent
appears narrowed and possibly kinked, but this appearance is
similar to that seen on the ERCP. A Wallstent is seen within the
stomach. Ascites is
present. There is probable soft tissue surrounding the celiac
axis (2:60),
but evaluation is limited on this early arterial study. BONE
WINDOWS: No suspicious sclerotic or lytic lesions are present.
IMPRESSION: 1. Bilateral pulmonary emboli. The patient has
reported history of pulmonary
emboli, but no prior imaging available at [**Hospital1 18**] to permit
assessment of the progression. No evidence for heart strain, or
pulmonary infarct.
2. Multifocal consolidation and developing abscesses including a
probable
pneumatocele in the left upper lobe, are probably due to
aspiration. These
findings suggest a multifocal infection, which could bacterial
or tuberculous, although no signs of prior tuberculosis are
present. The new lung lesions are probably not metastases, but
re-evaluation after antibiotic treatment is suggested. 3. Small
bilateral pleural effusions.
4. Ascites, multifocal liver metastases, possibly extending to
prevascular
mediastinum. Probable soft tissue encasing the celiac axis. 5.
Biliary stent which does appear kinked in its mid section but
unchanged from the earlier study. 6. Marked esophageal
thickening at the GE junction with gastroesophageal stent now in
the stomach.
Brief Hospital Course:
57 y/o with metastatic esophogeal adenocarcinoma on pallative
chemotherapy presented for jaundice and biliary obstructon for
ERCP. Post operative course complicated by transient
hypotension and mental status changes.
#Biliary obstruction: Concern for possible cholangitis. He went
for ERCP with stent placement. Blood cultures were drawn and
are pending at the time of discharge. He was given Zosyn for
two doses then a total 8 day course of levofloxacin/flagyl.
#Hypotension: Resistant hypotension with transient AMS after
ERCP was concerning for severe sepsis / septic shock. The
correlation to the ERCP made bactermia from cholangitis the most
worisome infectious etiology. However, his hypotension quickly
resolved and his mental status improved. Blood cultures are
still pending at the time of discharge. He was continued on an
8 day course of oral levo/flagyl.
#Cavity pulmonary lesion: Pt complains of cough with brown
sputum and small hemoptysis for two weeks. This finding was
first seen on chest xray and then next on chest CT and had not
been previously visualized per report from his outpatient
oncologist. In setting of his lung metastases the differential
includes post obstructive abcess vs multilobar pneumonia vs
malignancy. Radiology does not feel that this is TB given its
appearance on chest CT. He was covered for infectious
etiologies with an 8 day course of levo/flagyl. His sputum was
sent for gram stain, culture, AFB stain, and cytology which were
all pending at the time of discharge.
#Jaundice: ERCP suggests extrahepatic jaundice likely [**3-2**] known
malignancy. LFT's were trending down after ERCP.
#Coagulopathy: INR elevated to 2.7 likely secondary to
nutritional deficiency. Received vitamin K once.
#PE: Known PE's on Lovenox daily as an outpatient. Lovenox held
for 5 days prior to ERCP and then for 48 hours after ERCP. His
dose was increased to twice daily to be restarted the day after
discharge, when his INR would be less than 2.
#Metastatic esophogeal cancer: On pallative chemotherapy,
followed in [**Location (un) 1514**] by Dr. [**Last Name (STitle) **]. He was contact[**Name (NI) **] during the
patient's stay. Palliative care was consulted and will send a
note with recommendations to Dr. [**Last Name (STitle) **].
#GERD: A PPI was continued.
#Code Status: FULL CODE during this admission.
Medications on Admission:
FENTANYL - 150 mcg patch q72 hours
LORAZEPAM - 0.5 mg 1-2 tabs qhs prn
OMEPRAZOLE - 40mg po bid
ONDANSETRON HCL - 8 mg q8hrs prn
compazine 10mg po q6hrs prn nausea
OXYCODONE - 5 mg Tablet - [**3-3**] Tablet(s) by mouth every 6-8 hours
Tylenol prn
colace 100mg po bid
multivitamin daily
Discharge Medications:
1. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for anxiety or nausea: do not take if driving or drinking
alcohol.
3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
6. oxycodone 5 mg Tablet Sig: 2-3 Tablets PO every 6-8 hours as
needed for pain.
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. multivitamin Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
10. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: last day [**2135-2-28**], for pneumonia.
Disp:*7 Tablet(s)* Refills:*0*
11. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
12. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous once
a day: continue taking your dose at before the hospitalization.
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal Cancer
Pulmonary Embolism
Cavitary lung lesion secondary to pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for an ERCP and stent
placement. After the procedure you had low blood pressures that
required observation in the ICU. You were noted to have an
abnormality on your CXR thought to be an infection, you will
need to complete your course of anitbiotics. You are now
improving and will be going home.
The following changes were made to your medications:
- START levofloxacin and metronidazole (antibiotics), take until
[**2135-2-28**]
- RESTART lovenox tomorrow, [**2135-2-23**]
Followup Instructions:
Please make an appointment to see your PCP and oncologist once
you leave the hospital. You will need follow up for your
pneumonia.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4137
} | Medical Text: Admission Date: [**2155-3-29**] Discharge Date: [**2155-4-7**]
Service: MEDICINE
Allergies:
Motrin / Sulfa (Sulfonamide Antibiotics) / Lisinopril
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
89 y/o female with MMP including severe AS s/p bioprosthetic AVR
([**2155-2-13**]), dCHF (EF>55%), afib (on coumadin), CRI (baseline Cr
1.3-1.6), HTN, HLD, and history of pulmonary edema after
surgery, who was re-hospitalized for CHF exacerbation after her
AVR, and was discharged from rehab to home on [**2155-3-26**]. She now
presents with worsening dyspnea and lower extremity edema. She
was noted to have gained 5 lbs at rehab, and her outpatient
lasix regimen (40 mg daily) was increased to 80 mg daily
yesterday. She was noted to be 87% RA this AM by VNA. She was
asked to come to [**Hospital1 **] for evaluation. Of note, at rehab, she had
VRE UTI that has not been treated (she was on cipro, then amox
-> resistant to both).
.
In the ED, initial VS - 97.5, 84, 110/81, 20, 92% 4L NC. She
denied CP. PTA patient received 1 ntg spray. Exam notable for
somnolence, decreased BS at right base. Labs notable for INR
2.6, Hct 31.1, Cr 1.3, lactate 1.6. Bcx and Ucx pending. CXR
showing worsening right sided pleural effusion and pulmonary
congestion. EKG showing atrial fibrillation, LAD, LBBB (old),
?ST depressions I, aVL. CT head without focal process. She was
given 600 mg IV linezolid for UTI noted at rehab. She also was
given 750 mg IV levaquin for ?pneumonia. Bipap was attempted,
but her ABG was 7.41/60/108. The ABG, combined with her
somnolence, led to intubation with versed and fentanyl. She
dropped her pressures to SBP 60-70, and a CVL was placed in the
ED. She is admitted for CHF exacerbation and SIRS.
.
Access - 2 piv, CVL
.
ROS: as per HPI. Per daughter, patient's speech has been garbled
in past (required neuro c/s last admission). She is also "loopy"
with torsemide, and is therefore on lasix. No recent chest pain,
cough, sputum, dysuria, abdominal pain, fevers, chills, nausea,
vomitting, neurologic symptoms such as focal weakness, black
outs, or recent seizures. Denies sick contacts or recent travel.
Past Medical History:
Hypertension
Atrial fibrillation on Coumadin
Chronic diastolic CHF
Severe aortic stenosis (AV area 0.6 cm?????? on [**10/2154**] OSH echo)
Compression fracture s/p kyphoplasty
Hypothyroidism
Osteoarthritis
Osteoporosis
Chronic renal insufficiency (baseline Cr 1.3)
Probable Alzheimer's dementia (mild)
T10 compression fracture s/p vertebroplasty in [**10/2154**]
S/p appendectomy
S/p hysterectomy
S/p hernia repair
S/p bilateral cataract surgery
Social History:
Recently discharged from rehab but usually lives with husband
who is also healthcare proxy, four adult children. Retired clerk
in admitting dept at [**Hospital 13128**].
# Tobacco: Denies
# Alcohol: Denies
# Drugs: Denies
Family History:
Daughter s/p valve replacement due to rheumatic fever. Sister
with breast cancer, brother with skin cancers, another sister
died at age 47 of stomach cancer (and her daughter died of
pancreatic cancer).
Physical Exam:
GEN: intubated, heavily sedated
HEENT: PERRL, anicteric, MMM, JVP 8 cm, no carotid bruits, no
thyromegaly or thyroid nodules
RESP: crackles R > L base, decreased BS at R base, dullness to
percussion at R base
CV: irregular, S1 and S2 wnl, grade III HSM heard best at LSB
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 1+ BLE pitting edema
SKIN: no rashes/no jaundice/no splinters
NEURO: intubated, sedated, PERLL
Pertinent Results:
Admission Labs:
[**2155-3-29**] 12:30PM BLOOD WBC-6.8 RBC-2.93* Hgb-10.0* Hct-31.1*
MCV-106* MCH-34.0* MCHC-32.0 RDW-17.6* Plt Ct-230
[**2155-3-29**] 12:30PM BLOOD Neuts-65.9 Lymphs-18.9 Monos-12.4*
Eos-1.6 Baso-1.1
[**2155-3-29**] 12:30PM BLOOD PT-27.0* PTT-32.1 INR(PT)-2.6*
[**2155-3-29**] 12:30PM BLOOD Glucose-104* UreaN-22* Creat-1.3* Na-144
K-3.7 Cl-99 HCO3-38* AnGap-11
[**2155-3-29**] 12:30PM BLOOD Calcium-9.3 Phos-4.1 Mg-2.1
Discharge Labs:
[**2155-4-7**] 06:20AM BLOOD WBC-5.7 RBC-2.96* Hgb-9.8* Hct-30.4*
MCV-103* MCH-33.3* MCHC-32.4 RDW-16.1* Plt Ct-383
[**2155-4-7**] 06:20AM BLOOD PT-19.7* PTT-33.4 INR(PT)-1.8*
[**2155-4-7**] 06:20AM BLOOD Glucose-83 UreaN-26* Creat-1.3* Na-141
K-3.3 Cl-97 HCO3-34* AnGap-13
[**2155-4-7**] 06:20AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9
STUDIES:
CHEST (PORTABLE AP) Study Date of [**2155-3-29**]
IMPRESSION:
1. Worsening right-sided pleural effusion. Stable left-sided
pleural effusion with retrocardiac opacity which may represent
combindation of effusion and atelectasis, underlying
consolidation can not be excluded.
Mild pulmonary edema.
2. Stable cardiomegaly and widened mediastinum, status post
surgery.
CT HEAD W/O CONTRAST Study Date of [**2155-3-29**]
IMPRESSION: No acute intracranial process. Chronic involutional
changes.
Portable TTE (Complete) Done [**2155-3-31**]
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The ascending aorta is mildly dilated. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse.
Moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2155-3-11**], no change.
Brief Hospital Course:
# Respiratory Distress: Patient intubated in the ED due to
somnolence and respiratory distress. The patient was easily
extubated after arrival to the MICU and BIPAP used for 1 day.
Given her diastolic CHF, history of pulmonary edema, lower
extremity edema, weight gain, and interstitial fluid on CXR,
most likely etiology was felt to be volume overload, pulmonary
edema. There was an unclear precipitant, we considered
worsening valvular disease, ECHO showed moderate to severe (3+)
mitral regurgitation and moderate to severe [3+] tricuspid
regurgitation. ACS was felt to be less likely given
radiographic findings and lack of chest pain with negative
biomarkers. In addition, she had a recent cardiac cath ([**2155-2-11**])
with normal coronaries. PE also felt to be less likely given
lack of pleuritic chest pain, lack of tachycardia, and alternate
explanation on radiograph. Pneumonia also seemed unlikely lack
of fevers, cough, sputum, sick contacts, and focal infiltrate on
CXR. Patient was placed on a lasix drip and diuresed net -4L
over two days and then lasix drip was transitioned to 40 IV BID
of lasix and the patient continued to have good urine output and
was able to wean down to 3L 02. Cardiology was consulted and
agreed with aggressive diuresis. She was transitioned to the
floor and diuresis was continued with IV Lasix boluses initially
with good effect. She was transitioned to 80mg PO Lasix daily
for 4 days prior to discharge. PT [**Hospital 13131**] rehab placement,
however the family refused as she had bounced back twice from
rehab for CHF exacerbations. She was ultimately discharged home
with VNA and telemonitoring on 80mg of Lasix daily. She was on
room air at time of discharge with minimal pedal edema.
# Hypercarbia: The patient had serial VBGs in the ICU with PCO2
in the 60s but normal pH. Although prior to her valve surgery
her C02 was in the high 40s, it may be that her chronic
metabolic alkalosis (due to increasing amounts of diuretics) has
caused a chronic respiratory compensation. She was aklalemic
with pc02 in the 40s on the floor and had a normal pH with c02
in the 60s. Her mental status did not appear any different with
a c02 of 40 and a c02 of 60.
# Atrial fibrillation: Patient continued on coreg and her HR was
well controlled. INR at goal on admission but coumadin held in
the ICU due to concern that the patient would require more
procedures. She was bridged with heparin gtt. On the floor her
coumadin was uptitrated and her INR was uptrending at the time
of discharge.
# CAD: recent cardiac cath ([**2155-2-11**]) is with normal coronaries.
Patient continued on aspirin, statin, coreg.
# HTN: Patient's blood pressure well controlled on coreg and
with diuresis.
# HLD: Continued statin.
# CKD: Cr 1.3, baseline Cr 1.3-1.6. Despite aggressive diuresis
the patient's creatinine remained stable at 1.3.
# UTI: rehab notes documenting VRE resistant to cipro, pcn,
vanc, and levaquin. Sensitive to tetracycline. Unclear if true
pathogen or contaminant as patient was without fever,
leukocytosis or urinary symptoms. Empiric antibiotics were not
given and U/A was repeated and the culture was negative.
# Delirium/somnolence: per prior chart review and prior
admissions, patient has been noted to be somnolent most
pronounced in the late afternoons. She is alert in the mornings.
Most likely she has an element of sundowning that manifests as
lethargy in the PM.
# Osteoporosis: Continued calcium, vitamin D and alendronate
regimen qTues
# Hypothyroidism: TSH was checked and was slightly elevated at
8.0 and free t4 was low normal at 4.4 so her levothyroxine dose
was not changed
- check TSH and free t4 as an outpatient.
# Fe deficiency anemia: Continued home iron.
Medications on Admission:
1. aspirin 81 mg
2. simvastatin 20 mg
3. levothyroxine 50 mcg
4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation once a day.
6. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. multivitamin, stress formula Oral
9. alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
10. cholecalciferol (vitamin D3) 400 unit DAILY (Daily).
11. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
12. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. lasix 80 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
4. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
6. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day.
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
Primary:
acute on chronic diastolic heart failure
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 13130**],
It was a pleasure taking part in your care. You were admitted to
[**Hospital1 18**] because of a heart failure exacerbation- excess fluid on
your lungs and body. You required intubation (a breathing tube
and breathing machine) and a stay in the Medical Intensive Care
Unit to help you breath while they removed fluid from your body.
You responded well to the medication (lasix) and you were
quickly able to have the breathing tube removed. Over the course
of a few days, you were able to breath on your own without
oxygen.
We continued to use Lasix to remove excess fluid from your body.
At the time of discharge you were greatly improved and stable on
80mg of Lasix, by mouth daily. You will continue this dose at
home. You will continue to need monitoring and physical therapy
at home to help keep you strong and avoid hospitalizations.
We made the following changes to your medications:
- INCREASE lasix to 80mg by mouth daily
- DECREASE carvedilol to 3.125 mg by mouth twice a day
- INCREASE warfarin (coumadin) to 2.5 mg by mouth daily at 4pm
The following medications were not changed in dose.
1. aspirin 81 mg
2. simvastatin 20 mg
3. levothyroxine 50 mcg
4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation once a day.
6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. multivitamin, stress formula Oral
8. alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
9. cholecalciferol (vitamin D3) 400 unit DAILY (Daily).
10. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
11. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
You have very close follow-up with your primary care doctor
scheduled for tomorrow morning.
You have follow-up in the heart failure clinic in one week with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. If you have concerns prior to your appointment
on [**4-15**], please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 13132**] Failure, at
[**Telephone/Fax (1) 13133**].
Followup Instructions:
Please follow-up with your doctors at the [**Name5 (PTitle) 4314**] below:
Department: INTERNAL MEDICINE
When: TUESDAY [**2155-4-8**] at 10:15 AM
With: [**First Name8 (NamePattern2) 1141**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIOLOGY
When: TUESDAY [**2155-4-15**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 13132**] Failure, [**Telephone/Fax (2) 13133**]
Building: [**Location (un) 830**], [**Hospital Ward Name 23**] 7, [**Location (un) 86**] [**Numeric Identifier 718**]
Campus: [**Hospital Ward Name **]
Department: ADULT SPECIALTIES
When: TUESDAY [**2155-4-22**] at 5:00 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 8645**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: ADULT SPECIALTIES
When: MONDAY [**2155-4-28**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD, PHD [**Telephone/Fax (1) 8645**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2155-4-14**]
ICD9 Codes: 4280, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4138
} | Medical Text: Admission Date: [**2116-2-14**] Discharge Date: [**2116-2-23**]
Date of Birth: [**2040-10-10**] Sex: M
Service:
ADMISSION DIAGNOSIS: Positive stress test.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post coronary artery bypass graft times four.
HISTORY OF THE PRESENT ILLNESS: The patient is a 75-year-old
man who was referred to the [**Hospital6 2018**] for cardiac catheterization secondary to a routine ETT
which revealed 2.5 to 3 mm downsloping ST segment changes in
V4 through V6. There were also 1.5 to [**Street Address(2) 1766**] depressions in
the inferior leads. Stress thallium imaging revealed a
reversible defect in the basilar portion of the inferolateral
wall. Ejection fraction approximately 55%. The patient
denied any anginal symptoms, chest pain, lightheadedness,
claudication symptoms.
PAST MEDICAL HISTORY:
1. Asthma.
2. Hypercholesterolemia.
3. BPH, status post TURP approximately 20 years ago.
ADMISSION MEDICATIONS:
1. Lipitor 10 mg q.d.
2. Lopressor 50 mg b.i.d.
3. Isosorbide 10 mg t.i.d.
4. Beconase nasal spray q.d.
5. Flovent inhaler two puffs q.d.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient is
an elderly man in no acute distress. Vital signs:
Temperature 96.8 degrees Fahrenheit, heart rate 49, blood
pressure 129/61, respirations 18, 99% on room air. HEENT:
Normocephalic, atraumatic. EOMI. PERRL, anicteric. The
throat was clear. Neck: Supple, midline, without masses or
lymphadenopathy. No bruit or JVD. Cardiovascular: Regular
rate and rhythm without murmurs, rubs, or gallops. Chest:
Clear to auscultation bilaterally. Abdomen: Soft,
nontender, nondistended, without masses or organomegaly.
Extremities: Warm, noncyanotic, nonedematous times four.
Good distal pulses.
LABORATORY DATA ON ADMISSION: CBC 6.6/13.7/40.2/205.
Chemistries 142/4.5/107/27/24/1.2. INR 1.2.
HOSPITAL COURSE: The patient came in for outpatient cardiac
catheterization which revealed an ejection fraction of
approximately 50% and a right dominant coronary artery system
with a severe three vessel disease. The patient was admitted
post catheterization because of left main lesion as well as
oozing from the groin site.
The patient was placed on a nitroglycerin drip to keep
systolic blood pressures in the 120-140 range. The patient
was also maintained on a heparin drip for anticoagulation.
He was preopped for a coronary artery bypass graft in the
standard fashion.
On [**2116-2-17**], the patient was taken to the Operating Room for
a coronary artery bypass graft times four. The patient had
LIMA to mid LAD, saphenous vein graft to descending LAD,
descending RCA and OM. The patient tolerated the procedure
well.
The patient was taken to the CSRU postoperatively for closer
monitoring. The patient was extubated on postoperative day
number zero. On postoperative day number two, the patient's
chest tubes were removed. He was subsequently transferred to
the floor without event.
On postoperative day number three, the patient's pacer wires
were removed. In the middle of the day of postoperative day
number three, the patient had an episode of atrial
fibrillation and was rate controlled using 20 mg of IV
Lopressor and 300 mg of IV Amiodarone. The patient
maintained a heart rate between 100-110 with systolic blood
pressures 85 or greater. The patient spontaneously converted
back to normal sinus rhythm after approximately three to four
hours of atrial fibrillation.
The patient otherwise continued to work with Physical
Therapy. A hematocrit was found to be 22 and 25 on repeat.
The patient received 2 units of packed red blood cells for
this. This helped with his previous orthostatic symptoms of
dizziness as well as orthostatic hypotension. The patient
was then cleared by Physical Therapy for discharge to home
and subsequently discharged to home on postoperative day
number six.
At that time, the patient was tolerating a regular diet, and
had adequate pain control on p.o. pain medications and not
having any anginal symptoms or orthostatic symptoms.
DISCHARGE CONDITION: Good.
DISPOSITION: To home.
DISCHARGE DIET: Cardiac.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Lipitor 10 mg q.d.
3. Percocet 5/325 one to two q. four hours p.r.n.
4. Colace 100 mg b.i.d.
5. Flovent 110 micrograms inhaler two puffs b.i.d.
6. Beconase nasal spray q.d.
7. Lasix 20 mg b.i.d. times seven days.
8. Potassium chloride 20 mEq q.d. times seven days.
9. Lopressor 12.5 mg b.i.d.
10. Amiodarone 400 mg q.d.
11. Ambien 5-10 mg q.h.s. p.r.n.
DISCHARGE INSTRUCTIONS: The patient should follow-up with
Cardiology within one to two weeks. Address the need for
continued diuresis as well as adjustment of cardiac
medications at that time. The patient should follow-up with
Dr. [**Last Name (STitle) 1537**] in four weeks time. Encourage continuing incentive
spirometry and ambulation.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2116-2-23**] 09:51
T: [**2116-2-23**] 10:25
JOB#: [**Job Number 22447**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4139
} | Medical Text: Admission Date: [**2150-3-28**] Discharge Date: [**2150-4-2**]
Date of Birth: [**2070-7-7**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
SAH
Major Surgical or Invasive Procedure:
[**2150-3-28**]: R EVD placement
[**2150-3-28**]: Cerebral angiogram with coiling
History of Present Illness:
Mrs. [**Known lastname 88864**] is a 79 yo Right handed woman who presents with
new onset SAH. Per her husband, the patient had a similar event,
possibly as young as 17 when an operation was performed "on the
back of her head."
This a.m., she informed her husband that she was abruptly
feeling
warm and soon thereafter became diaphoretic. After this, she was
noted to have some mild weakness of her left arm and to become
progressively more somnolent.
Here at the [**Hospital1 18**] ED, she was noted to have vertical nystagmus
at
rest. She seemed to be lethargic, with some commands on the
right, but not the left, side. she was obtunded with agonal
breathing so she was intubated for airway protection and sedated
with propofol. She became hypertensive to the 210s systolic, so
IV nicardipine gtt was started along with nimodipine A stat head
CT showed diffuse SAH ([**Doctor Last Name **] III).
Past Medical History:
1. HTN on ACE and thiazide
2. HL on statin
3. Aneurysmal SAH at 17y/o with "5wks in a coma" but "now it's
calcified" and no subsequent Neuro f/u as far as the husband
knows
4. other PMH unknown, but husband says no other health problems,
and no Neurologic deficits prior to today
Social History:
Married, lived in a retirement community with husband;
reportedly independent in ADLs. + ETOH while watching TV,
patient reports about 3+ wine glasses of scotch.
Family History:
Unknown
Physical Exam:
On admission:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 3 [**Doctor Last Name **]: 3
Gen: Intubated and sedated.
HEENT: NCAT, MMM
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro: (prior to angio) Eyes open to noxious. No commands.
Pupils
equal and reactive (4 to 2mm). Discs sharp. EOM appear full.
Face
symmetric. Both arms appear purposeful and anti-gravity. Legs
purposeful as well.
Discharge: Expired
Pertinent Results:
Head CT [**2150-3-28**]:
HEAD CT: There is diffuse subarachnoid hemorrhage predominantly
in the
posterior fossa also in the suprasellar cistern and extending
predominantly to the right sylvian fissure and interhemispheric
fissure as well as convexity sulci. There is mild
ventriculomegaly seen. There is a rim calcification identified
in the prepontine interpeduncular region, which could represent
calcified aneurysm.
Head CTA [**2150-3-28**]:
CT angiography of the head demonstrates a calcified and
thrombosed
aneurysm at the basilar artery with possible filling of the
small portion of the aneurysm and its medial portion.
Additionally, there appears to be a small aneurysm at the tip of
the basilar artery, which may be distinct
aneurysm, measuring approximately 3 mm.
Neck CTA [**2150-3-28**]:
Negative for vascular anomalies.
Head CT [**2150-3-28**]:
IMPRESSION: Left frontal approach EVD ends in the left frontal
[**Doctor Last Name 534**]. Minimal amount of intraventricular hemorrhage. No
hydrocephalus. Extensive SAH.
Head CT [**2150-4-1**]:
IMPRESSION:
Status post coiling of right basilar tip aneurysm and left
frontal
ventriculostomy catheter insertion. Slight reduction in the size
of lateral and third ventricles and stable appearance of the
dilated temporal horns. Redistribution of hemorrhage in the
lateral ventricles and third ventricle. Extensive subarachnoid
hemorrhage, predominantly right-sided, and no evidence of a new
hemorrhage in the brain parenchyma.
Head CT/CTA [**2150-4-1**]:
The parenchymal hemorrhage and edema, surrounding the left
frontal approach shunt catheter, has increased now measuring
approx 2.6 x 1.9 cm, previously 1.5 x 1.2 cm. The tip of the EVD
is unchanged. Mild increase in the blood in both lateral
ventricles, with minimal increase in the ventricular size. Blood
also seen within third and fourth
ventricles. CTA read- pending re-cons, but pre-lim negative for
further aneurysms.
Brief Hospital Course:
79F who presented with a extensive, diffused SAH. Patient
underwent an emergent EVD placement into the left frontal [**Doctor Last Name 534**].
A CTA was suggestive of possible small aneurysms at the basilar
tip (around a previously thrombosed aneurysm) and
possibly at the R PCA. A four vessel angio revealed one aneurysm
at the basilar tip which was secured with two coils on [**3-28**]. She
was admitted to the Neuro ICU for close monitoring. On [**3-29**],
patient was noted to be confused, CIWA scale ordered, pt
received Ativan x2 for agitation.
On [**3-30**], her HCT dropped to 25.9 thus to maintain consistent
cerebral perfusion she was transfused 2 units. Post transfusion
HCT was 32.7. Moreover, her drain was increased to 20 cm H20.
She continued to remain stable. She was able to tolerate oral
food thus speech and swallow was deferred. On [**3-31**], her HCT
remained stable.
[**Date range (1) 88865**]: patient was found to be more lethargic in the morning
after recieving 5mg of Valium for what apeared to be withdrawl
symptoms. A non contrast head CT was ordered which showed a new
left ventricular hemorrhage, we initiated TPA flushes thru her
ventriculostomy with little effect. She became more lethargic
and tachypneic in the evening and was intubated for respiratory
distress. Her EVD continued to clot off and discussion was had
with the family regarding the need for a new EVD to placed on
the left side. Her respiratory status remained poor and there
was concern for sepsis. A family meeting was held to discuss
goals of care on [**4-2**] and the family decided to make her CMO and
not go foward with a new EVD.
The was made CMO and expired.
Medications on Admission:
1. Quinapril
2. HCTZ
3. atorvastatin
<< No anticoagulants or anti-platelet agents, confirmed with
husband >>
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Subarachnoid hemorrhage
Basilar tip aneurysm
Left 6th cranial nerve palsy
Anemia
Altered Mental Status
Fever
Respiratory Failure
Intraventricular hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2150-4-7**]
ICD9 Codes: 2762, 2859, 431, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4140
} | Medical Text: Admission Date: [**2130-10-14**] Discharge Date: [**2130-10-18**]
Service: MEDICINE
Allergies:
Neosporin
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
fevers, loose stools, left facial droop and inability to
ambulate
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 634**] is an 87 year old male with a history of atrial
fibrillation, hypertension and subdural hematoma diagnosed
[**2130-10-4**] in the setting of supratherapeutic INR who presents
from rehab with fevers, loose stools, left facial droop and
inability to ambulate. The patient was recently admitted from
[**2130-10-10**] to [**2130-10-13**] for fevers, fatigue and diarrhea. Per
nursing staff at that time of discharge on [**2130-10-13**] the patient
had no focal neurologic deficits on exam and was ambulating with
a walker but did appear to have proximal muscle weakness. He had
intermittent fevers during this hospital stay to as high as
100.9 on [**2130-10-12**]. He had blood and urine cultures which were
negative as well as a swab for influenza A. He was initially
treated empirically for clostridium difficile given report of
diarrhea but subsequently did not have additional bowel
movements and c. diff toxin assay was never sent and flagyl was
discontinued. He did suffer a fall on [**2130-10-11**] with trauma to
the head but serial CT scans did not convincingly show worsening
of his subdural hematoma. He had baseline head and [**Doctor Last Name **] pain
which is improved when he lies down but this was not worsened
after his fall. Per notes the patient was doing well at rehab on
the night of discharge. At approximately 12PM this afternoon he
was noted to be leaning towards the right and to have a left
sided facial droop. At that time he was alert and oriented x 3
but was complaining of neck pain and headache. Per the patient
these are chronic complaints. The pain was on the left side of
his head and he was noted to be leaning towards the right side.
He was transferred to [**Hospital1 18**] for further evaluation.
.
In the ED, initial vs were: T: 100.4 P: 107 BP: 200/90 R: 18 O2
sat 95% on RA. Labs were notable for a WBC count of 8.7 with 75%
neutrophils. Chemistries were notable for a creatinine of 1.3.
He had a stat head CT which did not show significant change from
priors. EKG showed atrial fibrillation at a rate of 118,
leftward axis, normal intervals, no acute ST segment changes, no
change from prior dated [**2130-10-10**]. He had a CXR which did not
show any acute abnormalities. He was seen by both neurology and
neurosurgery who felt that his presentation could be consistent
with an infection exacerbating his previous brain injury versus
a new ischemic stroke. They did not recommend lumbar puncture
given midline shift. He was thus treated empirically for
meningitis with vancomycin 1 gram IV x 1, ceftriaxone 2 grams IV
x 1, levofloxacin 750 mg IV x 1 and flagyl 500 mg IV x 1. He
also received diltiazem 10 mg IV x 1. Foley placement was
unsuccessful and he required cystocopy guided foley catheter
placement. He had a CT of the abdomen, results are pending.
Peripheral IV access was unable to be obtained and a central
line was placed. He is admitted to the MICU for further
management.
.
On arrival to the ICU he is alert and oriented x 3, but his
speech is slurred and he has difficulty answering questions. He
reports that he had a headache and neck pain today but that
these are not new complaints. He does not recall having new
weakness. He denies blurry vision or photophobia. No chest pain,
shortness of breath, nausea, vomiting, abdominal pain,
constipation, dysuria, hematuria, leg pain or swelling. He has
had intermittent diarrhea. He denies cough or congestion. No new
rashes. He has had intermittent low grade fevers over the past
five days. He has chronic difficulty initiating urinary stream
but denies frank urinary retention. All other review of systems
negative in detail.
Past Medical History:
Subdural Hematoma [**10-4**]
Atrial Fibrillation
Hypertension
Hypothyroidism
Vertigo
BPH
Social History:
Social History: The patient lives alone at home and is very high
functioning, is the CEO of his own business. Denies tobacco,
alcohol or illicit drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 99.8 BP: 148/78 P: 126 R: 15 O2: 99% on 4L
General: Alert, oriented x3, slightly slurred speech, difficulty
responding to questions linearly, 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: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neurologic: PERRL, CN II-XII tested and intact, mild left facial
droop, strength 5/5 in the upper extremities bilaterally, right
leg [**3-12**], left leg withdraws to pain but does not move to
command, toes downgoing bilaterally, sensation intact to light
touch throughout, reflexes 2+ and symmetric in the biceps,
triceps, patellar, brachioradialis. Gait not tested. Finger to
nose intact.
Pertinent Results:
[**2130-10-13**] 07:50AM BLOOD WBC-7.8 RBC-4.32* Hgb-14.2 Hct-40.8
MCV-94 MCH-32.8* MCHC-34.8 RDW-14.1 Plt Ct-198
[**2130-10-17**] 06:07AM BLOOD WBC-6.1 RBC-3.77* Hgb-12.2* Hct-35.9*
MCV-95 MCH-32.2* MCHC-33.8 RDW-14.9 Plt Ct-176
[**2130-10-16**] 06:27AM BLOOD PT-15.2* PTT-25.0 INR(PT)-1.3*
[**2130-10-14**] 02:05PM BLOOD PT-13.4 PTT-22.4 INR(PT)-1.1
[**2130-10-13**] 07:50AM BLOOD Glucose-91 UreaN-18 Creat-1.1 Na-136
K-3.2* Cl-99 HCO3-28 AnGap-12
[**2130-10-16**] 06:27AM BLOOD Glucose-73 UreaN-19 Creat-1.3* Na-139
K-3.3 Cl-102 HCO3-27 AnGap-13
[**2130-10-15**] 03:38AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.8
[**2130-10-14**] 05:00PM BLOOD Type-[**Last Name (un) **] Temp-38.6 pO2-71* pCO2-33*
pH-7.41 calTCO2-22 Base XS--2 Intubat-NOT INTUBA
[**2130-10-14**] 02:14PM BLOOD Glucose-94 Lactate-1.9 Na-138 K-4.2
Cl-97*
CT head [**10-14**]: Similar appearance of CT head from [**2130-10-11**] demonstrating mild rightward shift, subarachnoid blood,
left hypodense subdural collection and blood layering over the
tentorium, unchanged.
CT abd/pelvis [**10-14**]: Diverticulosis without diverticulitis
MRI head [**10-15**]: Unchanged left-sided frontal, temporal and
parietal subdural collection with similar pattern of midline
shifting towards the right. Foci of hemorrhage with evidence of
magnetic susceptibility, right to the midline in the frontal
lobe, extending along the falx in the convexity; no other new
lesions are identified.
CT head [**10-15**]: No new intracranial hemorrhage or developing
hydrocephalus.
Unchanged left-sided subdural collection with unchanged
rightward shift of
midline structures.
Carotid U/S: <40% stenosis bilaterally
Brief Hospital Course:
87 year old male with a history of atrial fibrillation,
hypertension and subdural hematoma diagnosed [**2130-10-4**] s/p in the
setting of supratherapeutic INR who presents from rehab one day
after hospital discharge with left facial droop, inability to
ambulate found to have an ischemic stroke.
.
#. s/p Ischemic stroke: One day prior to admission, the patient
was able to ambulate with a walker although he had significant
proximal muscle weakness in the lower extremities at baseline.
On admission, the patient had a left sided facial droop, was
leaning to the right side, and noted left leg weakness that
prohibited ambulation. He was admitted to the MICU for further
care. CT on [**10-14**] demonstrated stability of his prior SDH, but
MRI on [**10-15**] revealed three small ischemic strokes in MCA
distribution with hemorrhagic conversion. Neurosurgery and
Neurology were consulted. A repeat CT confirmed stabilization of
SDH, so Neurosurgery did not feel intervention was necessary and
requested 3 month f/u. Neurology posited that the stroke was
unlikely to be cardiac in origin, suggesting that the SDH may
have led to small vessel compression or vessel sludging and
resulted in the stroke. In the interim, the patient's facial
droop resolved, his left leg weakness returned to his prior
basline, and q4 neuro checks were stable so he was transferred
to the medicine floor. Per neurology's recommendations, he was
started on Keppra for seizure prophylaxis and restarted on his
home ASA with a plan to restart his Coumadin 2-3 weeks after his
SDH. On the floor, he remained on q4 neuro checks, with goal
sbp's in the 100-140's and an INR goal <1.5. To evaluate for a
source of emboli, he had a carotid U/S that revealed <40%
stenosis bilaterally.
.
#. Atrial Fibrillation: Patient with RVR in the ED in the
setting of missed medication doses, but no evidence of cardiac
ischemia or significant volume overload. Since admission, the
patient has remained intermittently tachycardic to 140's, but
asymptomatic. His rate was originally thought to be related to a
concern for infection, but there was no obvious source of
infection found as an inpatient. On the medical floor, he
continued his home Amiodarone 200mg, Metoprolol 75mg PO TID, and
Diltiazem 180mg SR daily. He continued to have hr's into the
130-140's, so his Diltiazem was increased to 240mg SR daily with
improved heartrates below 100.
.
#. Fevers: Patient had low grade fevers (99~'s) and mild
diarrhea for the past week of unclear etiology. He was worked up
with blood cultures, urinalysis, influenza DFA, and C. diff
toxin tests that were all negative. At the time of discharge, he
had no diarrhea or other localizing symptoms, but continued to
have occasional temperature elevations to 99.0 which the primary
team thought was likely [**1-9**] to his intracranial process. Blood
cultures from [**10-10**] were confirmed negative and 11/5,[**10-13**],& [**10-14**]
were no growth to date, but a final result was still pending.
.
#. Subdural Hematoma: Patient's head CT on admission from [**10-14**]
and from [**10-15**] was stable from prior to admission. He was
followed by Neurology and Neurosurgery and continued on Keppra
500mg PO BID for seizure prophylaxis as well as Q4H neurologic
checks.
.
#. Hypertension: Patient hypertensive on admission with sbp's in
the 200s in the setting of not taking medications. On transfer,
his blood pressure was well-controlled with sbp's in 100-110's,
where it remained until discharge. He was continued on his home
Metoprolol 75mg TID and Diltiazem SR was increased from 180 to
240mg daily. His home Lasix 60 mg daily was held in the context
of an episode of an sbp in the 90's and in the absence of fluid
overload on exam.
.
#. Urinary Retention/Benign Prostatic Hypertrophy: Patient with
distended bladder and inability to place foley catheter in the
emergency room. Urology was called to place cystoscopy guided
foley. He completed 3 days of Bactrim DS for Foley trauma and
Urology asked that his Foley to remain in place until Urology
outpatient followup.
.
#. Hypothyroidism: A recent TFTs within normal limits. He was
continued on his home Levothyroxine 75mcg daily.
.
#. Code: FULL CODE
Medications on Admission:
Levothyroxine 75 mcg daily
Amiodraone 200 mg PO daily
Diltiazem 180 mg SR daily
Trazodone 12.5 mg QHS:PRN
Tylenol 325 mg PRN
Metoprolol Tartrate 75 mg PO TID
Lasix 60 mg daily
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
1. Ischemic stroke with hemorrhagic conversion
2. Subdural hemorrhage
3. Atrial Fibrillation
4. Hypertension
Discharge Condition:
Symptoms resolved. Baseline proxmial muscle weakness of lower
extremities unchanged. Able to ambulate with walker.
Discharge Instructions:
You were admitted to the hospital due to symptoms of a left
facial droop and some weakness in your left leg. In the
hospital, you were found to have had a small stroke. The
Neurology and Neurosurgery teams saw you and felt that you did
not require any intervention. Your weakness and facial droop
resolved and after being monitored for changes in your
neurologic status, you were discharged to a rehabilitation
facility.
.
In the hospital, you had a catheter placed to help drain urine
from your bladder. The Urology team asked that you keep the
catheter in place until you could be re-evaluated in their
offices as an outpatient. Please follow-up with them as
indicated below.
.
Medications:
Diltiazem - This medication was INCREASED from 180mg daily to
240mg daily
Lasix - This medication was STOPPED
Coumadin - This medication should be RESTARTED in one week,
[**10-25**] at a dose of 2mg once a day at bedtime
Followup Instructions:
Neurosurgery: Please follow-up with Dr. [**First Name (STitle) **] at his offices in
the [**Hospital3 **] Deaconness on [**11-9**] at 3:30PM.
.
PCP: [**Name10 (NameIs) 357**] [**Name11 (NameIs) 702**] with Dr. [**Last Name (STitle) **] on [**10-24**] 3:30 PM
at [**State 58071**]in [**Location (un) 1411**], MA.
.
Urology: Please follow-up with Dr. [**Last Name (STitle) **] in the [**Hospital 159**] Clinic
[**Street Address(1) 58072**] in [**Location (un) 620**] to have your catheter removed. You
can call: ([**Telephone/Fax (1) 58073**] to schedule this appointment.
ICD9 Codes: 5849, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4141
} | Medical Text: Admission Date: [**2180-12-8**] Discharge Date: [**2180-12-18**]
Date of Birth: [**2098-8-2**] Sex: F
Service: SURGERY
Allergies:
Codeine / Oxycodone / tramadol / Dicloxacillin
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
large bowel obstruction
Major Surgical or Invasive Procedure:
exploratory laparotomy, LOA, transverse colectomy (Right
colostomy, Left mucous fistula)
History of Present Illness:
82F with a recent admission for [**Last Name (un) 17147**] I diverticulitis
managed conservatively with antibiotics. While in house she had
two episodes of abdominal distension and bilious emesis
concerning for ileus versus partial bowel obstruction. They
subsequently resolved with NGT decompression and she was
ultimately discharged to rehab yesterday. At the time she was
passing flatus and moving her bowels. She now presents from
rehab
with worsening abdominal distension and several bouts of bilious
emesis. She has not passed flatus or moved her bowels since
leaving the hospital.
Past Medical History:
Past Medical History: diverticulitis, hypertension,
hyperlipidemia, DVT's, tubal pregnancy
Past Surgical History: cholecystectomy, appendectomy,
hysterectomy, ex lap for SBO, s/p ventral hernia repair
Social History:
Lives mostly alone, although granddaughter lives with her on the
weekends. No smoking, EtOH a few times a year, no illicits.
Family History:
Noncontributory
Physical Exam:
On presentation to [**Hospital1 18**]:
Vitals: 98.4 82 108/66 16 93 2L
GEN: A&O, uncomfortable
HEENT: No scleral icterus, dry membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, three large ventral hernias which
are non-reducible and mildly tender to palpation
Ext: 1+ edema bilaterally, Warm well perfused
Pertinent Results:
CT abd - Small-bowel obstruction secondary to a complex ventral
hernia with transition point evident in the right lower quadrant
with collapsed bowel leaving a ventral hernia as detailed above.
[**2180-12-8**] WBC-13.7* Hct-36.3 Plt Ct-407
[**2180-12-12**] WBC-19.8* Hct-37.5 Plt Ct-421
[**2180-12-14**] WBC-13.5* Hct-24.8* Plt Ct-233
[**2180-12-7**] Glucose-94 Creat-0.9 Na-137 K-4.5 Cl-97 HCO3-33*
AnGap-12
[**2180-12-13**] Glucose-97 Creat-1.2* Na-135 K-4.0 Cl-101 HCO3-25
AnGap-13
[**2180-12-14**] Glucose-88 Creat-1.1 Na-135 K-3.8 Cl-100 HCO3-27
AnGap-12
Brief Hospital Course:
82F with history sigmoid diverticulitis, multiple ventral
hernias and colonic obstruction, admitted to the ACS service on
[**2180-12-8**] from rehab with a large bowel obstruction. She was
taken to the operating room for transverse colectomy with
colostomy and mucous fistula and tolerated the procedure well.
She was admitted to the TICU intubated, on levophed, with low
UOP, and in afib. During the course of her short stay in the ICU
she was extubated, was fluid resuscitated, her pressors were
weaned, and her atrial fibrillation was controlled, initially
with an amio ggt, then by PO amio once she tolerated sips.
Events by day in the ICU were:
[**12-11**]: admitted TSICU, still intubated. on levophed.
[**12-12**]: bolus albumin PRN, UOP improved. amiodarone bolus for
a.fib w/ RVR. converted back to sinus at 11pm. left aline
replaced into radial artery (ulnar stopped drawing back).
episode of desaturation at 5pm, difficult to ventilate - CXR OK,
significant secretions, likely mucous plug - improved with
suctioning
[**12-13**]: Extubated in am. Received 20 IV lasix. Off pressors for
about 2 hours, hypotensive on transfer from bed to chair, back
in a-fib. Received 50 ml of 25% albumin, 150 mg bolus of
amiodarone and was re-started on levo 0.03. Converted back to
sinus. continued off levo.
On [**12-14**] she was transferred to the floor. That evening she was
noted to be tachycardic on telemetry and an ECG confirmed atrial
fibrillation. She converted back to NSR after IV metoprolol 5 mg
x 1. Her vital signs were routinely monitored and she remained
hemodynamically stable throughout the remainder of her hospital
course. Her amiodarone and diltizem were continued from her
prior hospitalization. However, her simvasatin was decreased
from 20 mg to 10 mg daily given the FDA recommendation to not
exceed 10 mg of simvastatin while taking either of diltiazem or
amio for risk of myopathy. She was instructed to follow up with
her primary care provider after discharge from rehab.
Her prior dose of coumadin for chronic afib was held
perioperatively, and restarted on [**12-17**]. Her INR at discharge on
[**12-18**] was 1.5 and she was ordered for 3mg of coumadin that
evening.
After transfer to the floor, she was noted to have gas and
liquid stool output in her ostomy bag. On [**12-15**] she was started
on a clear liquid diet. On [**12-16**] she was advanced to a regular
diet which she tolerated well. She continued to pass stool and
gas via her colostomy.
A foley catheter was placed perioperatively and removed on [**12-15**]
at which time she voided adequate amounts of urine without
difficulty.
Physical therapy was consulted to assess her mobility who
recommended discharge to rehab when medically stable.
She was started on IV vancomycin and zosyn empirically given
spillage intraoperatively. Her WBC was trended and decreased
appropriately from 19.8 initially postop to 7.4 on [**12-16**]. Her
antibiotics were completed on [**12-18**] and she continued to remain
afebrile.
On [**12-18**], she was discharged to rehab with 2 surgical drains in
place and instructions to follow up in the Acute Care Surgery
clinic in [**2-24**] weeks.
Medications on Admission:
enalapril, simvastatin, HCTZ, vitamin D
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. diltiazem HCl 120 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 **]
Discharge Diagnosis:
Large bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with a bowel obstruction. You
were taken to the operating room because of this and underwent
transverse colectomy with colostomy and mucous fistula.
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.
*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 [**5-30**] 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.
*Your staples will be removed 10-14 days after your surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
While you were in the hospital some changes were made to your
medications. Please follow up with your primary care provider
after leaving the rehab facility to discuss your current
medications.
Surgery Follow up Appointment:NEEDED
Acute Care Surgery Clinic
[**Hospital1 69**]
[**Hospital **] Medical Office Building
[**Hospital Unit Name 58920**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: ([**Telephone/Fax (1) 2537**]
***Note: Please call the number listed above to schedule a
hospital follow up appointment in 2 to 3 weeks from your
hospital discharge.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2180-12-18**]
ICD9 Codes: 0389, 5845, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4142
} | Medical Text: Admission Date: [**2135-5-21**] Discharge Date: [**2135-6-22**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6378**]
Chief Complaint:
Healing abdominal wound s/p right colectomy
Major Surgical or Invasive Procedure:
s/p right hemicolectomy and a right inguinal
herniorrhaphy.
s/p Small bowel resection, drainage of a
pelvic abscess, debridement of the anterior abdominal wall in
the left lower quadrant and an ileostomy
History of Present Illness:
The patient initially presented with a positive Hemoccult.
Following which he underwent a colonoscopy, which revealed a
cecal mass with high-grade dysplasia. On [**2135-5-5**] he underwent
an extended right colectomy and a right inguinal hernia repair.
His postoperative course was complicated by an anastomotic leak.
A drain was placed on [**5-16**] and the patient was D/Cd on [**5-20**].
The patient developed fever to 100.4 and was readmitted on [**5-21**]
with a RLL pneumonia. He was started on Vancomycin and Zosyn
but continued to have recurrent fevers. He was evaluated by
hematology for a WBC ct. >150K, they stated this was due to a
leukomoid reaction on top of his underlying MDS. On [**5-21**] he
developed SOB which CXR revealed to be due to CHF he was
diuresed with Lasix. On [**5-30**] he had a ex lap with small bowel
resection, drainage of pelvic abscess, debridement of abdominal
wall and ileostomy. Post-op he was admitted to the SICU for
management of his low urine output/ARF. Repeat imaging has
revealed that the abscess has decreased in size. He was
transferred out of the SICU on [**6-4**]. His improving CHF,
decreasing WBC, and absence of fevers have enabled the patient
to be surgically cleared and his care has been transferred to
medicine.
Past Medical History:
1. PERIPHERAL EDEMA
2. DYSPHAGIA
3. ITP4.
4. GBS like peripheral neuropathy
5. GASTROESOPHAGEAL REFLUX
6. NECK PAIN
7. CHRONIC CONJUNCTIVITIS
8. PERIPHERAL VASCULAR DISEASE
9. Hemorrhoids
10. SEROUS OTITIS
11. BENIGN PROSTATIC HYPERTROPHY
12. HYPERTENSION
13. Right Colon Cancer
14. Rectal ulcers
15. MDS
Social History:
Violinist, no alcohol, no drug use
Family History:
No colon cancer
Physical Exam:
98.0, 140/70, 75, 20, 97%RA
Gen: comfortable, NAD
Heent: MMM, PERRL
Neck: supple
Chest: CTAB (after Lasix)
Cor: 2/6 systolic murmur, RR, nl S1 S2
Ab: NABS, NT/ND, colostomy in place, VAC dressing intact
Ext: 3+ pitting edema BLE with some capillary damage RLE
Pertinent Results:
[**2135-5-21**] 06:03PM GLUCOSE-112* UREA N-17 CREAT-0.9 SODIUM-132*
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-22 ANION GAP-14
[**2135-5-21**] 06:03PM ALBUMIN-2.9* CALCIUM-7.7* PHOSPHATE-2.8
MAGNESIUM-1.8
[**2135-5-21**] 06:03PM WBC-22.2* RBC-3.43* HGB-10.5* HCT-30.7*
MCV-89 MCH-30.5 MCHC-34.1 RDW-15.0
[**2135-5-21**] 06:03PM PLT SMR-LOW PLT COUNT-85*
[**2135-5-21**] 06:03PM PT-15.0* PTT-43.9* INR(PT)-1.5
Brief Hospital Course:
ID:
While on the medicine service the patient remained afebrile and
his white blood cell count continued to decrease. He completed
an 18 day course of vancomycin to treat sputum cultures which
grew oxacillin resistant staph aureus. He also completed a 14
day course of zosyn.His abcess grew beta lactamase positive
Bacteroides fragilis and enterococcus sensitive to vancomycin.
The patient's antibiotics were then discontinued and the patient
remained afebrile without leukocytosis until [**6-14**] when pt
developed a temperature to 101.9. CT imaging of his abdomen
revealed multiple abcesses and thus the patient completed a 5
day course of IV vanc/cipro/flagyl/fluconazole during which time
his abscess resolved without the need for drainage by IR.
Cardiovascular:
While recovering from surgery the patient developed congestive
heart failure. An echo was performed and it demonstrated no
significant changes since his last echo in [**2131**]. The patient
has a history of hypertension and was continued on lisinopril 40
mg qd. He quickly responds to Lasix for chest pressure d/t CHF.
Volume Status:
At first the patient had a great deal of anasarca with an
albumin of 2.2. The patient responded well to IV lasix and upon
discharge his peripheral edema was much improved. His albumin
on D/C remained at 2.2, with a goal of 3.0.
Nutrition
The patient has had a long convalesence marked by poor po intake
resulting a low albumin which contributed to his peripheral
edema. In order to address this the patient's po intake was
supplemented with TPN in order to ensure adequate calories. TPN
was supplemented with standard electrolytes, 10U insulin, 10mg
zinc, and 40mg Famotidine. On D/C, we are holding Phos and Mg
until these electrolytes normalize.
Pulmonary: CT scan of the thorax on [**6-15**] revealed bilateral
pleural effusions, bilateral lower lobe atelectasis and small
percardial effusion. Using incentive spirometer. The patient's
pulmonary status improved with gentle diuresis along with the
use of incentive spirometer.
Anemia: The patient last received 1 U pRBCs on [**6-6**] with
appropriate bump in HCT. From then on his HCT remained
approximately 30. His anemia was believed to be secondary to his
myelodysplastic syndrome.
ITP: The patient has a history of ITP and was thus continued on
20 mg of prednisone qod with an increase to 20 mg qd when the
patient was febrile to prevent adrenal insufficiency. Hold all
heparin.
Dispostion: Since his fever on [**6-15**], the patient has remained
afebrile and continues to improve. He has been cleared by both
physical therapy and general surgery to begin acute physical
therapy and rehabilitation. He is clear for transfer to [**Hospital 7825**] center in Woodburne.
Medications on Admission:
1. Latanoprost 0.005% Ophth. Soln. 1 DROP OU HS 2. Lisinopril 20
mg PO QD hold for bp below 100 3. Acetaminophen 325-650 mg PO
Q4-6H:PRN 4. Miconazole Powder 2% 1 Appl TP TID:PRN 5. Albuterol
Neb Soln 1 NEB IH Q4H:PRN 6. Nystatin Ointment 1 Appl TP
QID:PRN 7. Atenolol 25 mg PO QD 8. Oxycodone 5-10 mg PO
Q4-6H:PRN 9. Dorzolamide 2%/Timolol 0.5% Ophth. 2 DROP OU
10. Pantoprazole 40 mg PO Q24H 11. Piperacillin-Tazobactam Na
4.5 gm IV Q8H 12. Prednisone 15 mg PO QD 13. Terazosin HCl 2 mg
PO HS 14. Hydromorphone 1-4 mg IV Q3-4H:PRN
15. Tobramycin-Dexamethasone Ophth Susp 1 DROP OU HS QOD
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: [**12-10**] nebulizer
treatment Inhalation Q4H (every 4 hours) as needed.
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: Two (2) Drop
Ophthalmic Q12H (every 12 hours).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
6. Tobramycin-Dexamethasone 0.1-0.3 % Drops, Suspension Sig: One
(1) Drop Ophthalmic HS QOD ().
7. Terazosin HCl 2 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB IH
Inhalation Q3-4H () as needed.
9. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
12. Miconazole Nitrate Powder Sig: One (1) Appl Miscell.
TID (3 times a day) as needed.
13. Morphine Sulfate 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q12H (every 12 hours).
14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
15. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QOD (every
other day).
16. Hydromorphone HCl 2 mg/mL Syringe Sig: [**12-10**] ml Injection
Q3-4H () as needed.
17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-10**] Sprays Nasal
QID (4 times a day) as needed.
18. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
19. Lasix 20 mg Tablet Sig: One (1) 1 Tablet PO twice a day.
Disp:*60 tablets* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Cecal Cancer
right lower lobe pneumonia
Pelvic abcess
Anasarca
Hypoalbuminemia
Hypertension
h/o Myelodysplastic syndrome
h/o Idiopathic Thrombocytopenia
Discharge Condition:
Good
Discharge Instructions:
Please return to the emergency room if you experience fever,
chills, difficulty breathing or light headedness.
Followup Instructions:
Dr. [**Last Name (STitle) 838**] will see you at [**Hospital6 **] at Woodbourne.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6384**] MD, [**MD Number(3) 6385**]
ICD9 Codes: 5849, 4280, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4143
} | Medical Text: Admission Date: [**2200-4-18**] Discharge Date: [**2200-4-28**]
Date of Birth: [**2127-1-27**] Sex: M
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
male with the sudden onset of dysarthria and left-sided
hemiparesis and numbness. The symptoms began an hour before
Emergency Room admission.
The patient has a history of basal artery stenosis and a
history of intermittent left-sided hemiplegia and was begun
on Coumadin in the past for these symptoms.
PAST MEDICAL HISTORY: (Past Medical History includes)
1. Coronary artery disease.
2. Atrial fibrillation; status post a coronary artery bypass
graft one year ago.
3. History of gastrointestinal bleed.
4. Prostate cancer.
5. Status post appendectomy.
6. Status post diagnosis of severe basal artery
insufficiency.
7. History of transient ischemic attacks.
MEDICATIONS ON ADMISSION: The patient's medications on
admission included aspirin, Lipitor, metoprolol, lisinopril,
digoxin, Prilosec, and Detrol.
ALLERGIES:
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient's temperature was 98.2, heart rate
was 64, blood pressure was 162/64, respiratory rate was 18,
and oxygen saturation was 95% on room air. His pupils were
equal, round, and reactive to light. Extraocular movements
were full. He had decreased strength in the left side, leg
and arm. Cranial nerves were intact. Cardiovascular
examination revealed a respiratory rate. The chest was clear
to auscultation.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 7.2, hematocrit
was 39.6, and platelets were 222. INR was 2.5, prothrombin
time was 19.5, and partial thromboplastin time was 28.3.
Sodium was 141, potassium was 4.6, chloride was 105,
bicarbonate was 23, blood urea nitrogen was 18, creatinine
was 0.7, and blood glucose was 91.
PERTINENT RADIOLOGY/IMAGING: A magnetic resonance imaging
showed multiple small strokes.
HOSPITAL COURSE: The patient was admitted to the Neurology
Surgical Intensive Care Unit and was seen by the Stroke
Service.
The patient was taken to the angio suite by Dr. [**Last Name (STitle) 1132**]. On
[**2200-4-22**], the patient underwent a basilar artery stent
procedure without complications.
Postoperatively, he was awake, alert and oriented times
three. Extraocular movements were full. Visual fields were
full. Pupils were symmetric and reactive. No pronator
drift. No hematoma in the groin. Positive pedal pulses.
His condition remained stable. He remained on heparin for
his history of atrial fibrillation, and Plavix and aspirin
for his stent procedure.
He remained in the Intensive Care Unit until [**2200-4-24**]
when he was discharged to the floor. He remained
neurologically stable. Awaiting Coumadin to be therapeutic
before discharged to home.
DISCHARGE DISPOSITION: He was discharged on [**2200-4-28**]
with an INR of 1.9. Heparin was discontinued. He was also
discharged on aspirin 325 mg p.o. once per day and Plavix 75
mg p.o. once per day along with all his prior medications.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 100 mg p.o. twice per day.
2. Tolterodine 1 mg p.o. twice per day.
3. Aspirin 325 mg p.o. once per day.
4. Plavix 75 mg p.o. once per day.
5. Digoxin 0.25 mg p.o. once per day.
6. Atorvastatin 20 mg p.o. once per day.
7. Tocopheryl 400 units p.o. once per day.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP: He was to follow up with
Dr. [**Last Name (STitle) 1132**] in two weeks' time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2200-4-28**] 11:17
T: [**2200-5-2**] 08:17
JOB#: [**Job Number **]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4144
} | Medical Text: Admission Date: [**2130-7-23**] Discharge Date: [**2130-7-31**]
Date of Birth: [**2081-11-3**] Sex: M
Service: MEDICINE
Allergies:
lorazepam
Attending:[**First Name3 (LF) 11839**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
48M w/ PMHx of Stage 4 NSCLC s/p thoracotomy in [**2126**] as well as
chemo/radiation at [**Company 2860**] completed [**2127**] with known mets followed
by Oncologist at [**Hospital1 2025**] as well as hx of post obstructive pneumonia
and left lung collapse with left mainstem endobronchial tumor
([**2128**]), recently admitted to [**Hospital1 18**] with thoracic mets and
mechanical compression of spinal cord s/p emobilization of met
lesion ([**6-20**]) and s/p T3-6 laminectomy, T1-8 posterior fusion,
T3-5 interbody fusion ([**6-21**]), PEG placement ([**6-28**]) presenting
with acute dyspnea requiring ET intubation.
Up until few days prior to admission, was walking around house
with walker, teaching son to drive. Last 24 hrs, feeling more
weak and more lethargic, also with AMS.Also had begun coughing
more with thick secretions, difficulty coughing them up, gagging
more and more. This morning, worse, so called EMS. Was hypoxic
at home so was nasotracheally intubated in the field. No fevers,
no nausea, no vomiting, loose stool potentially [**12-29**] lactulose,
not requiring additional pain meds.
In the ED, initial VS were:
99 125 115/72 20 100% (intubated with 500 x 20 5 peep 50%)
Pt arrived via EMS from home with wife. Did not tolerate CPAP.
Nasaltracheal intubation by EMS. Unsure of location. Hypoxic to
80s when first arrived. Signed DNR in chart but patient and
family asked for resuscitation at this time
Endotracheal intubation pursued with 20 etomidate, 120 succs and
intubated with 7.5 ETT. Patient with reportedly good color
change.
Vanco/cefepime dosed. Examination notable for cachexia,
diminished breath sounds on left, sunken left chest, power port
(per wife) on left chest, and gtube site intact. There was no
edema and cardiac exam simply sinus tach. CXR performed with
whiteout on left (known). CT head and CTA chest ordered, and
patient to complete before transfer to MICU.
On transfer to MICU, patient's VS.
99 110 100/65 20 100%
On arrival to the MICU, patient's VS.
97.2 108 116/63 17 100% (500 x20 Peep 5 FiO2 100%)
Review of systems:
(+) Per HPI
(-) Further ROS not conducted as patient intubated, sedated.
Past Medical History:
PAST MEDICAL HISTORY:
# Non-Small Cell Lung CA. LLL Mass. s/p thoracotomy at [**Hospital6 **] in [**2127-9-28**]. s/p chemotherapy and
radiation at [**Hospital3 328**], completed in [**2127-11-28**].
# Hyperlipidemia.
# Episodic headaches. These are bifrontal. Imaging has been
negative for metastatic disease.
# History of hepatitis in childhood. He thinks that this was
hepatitis B.
# Right Hand Cellulitis, secondary to foreign body.
PAST SURGICAL HISTORY:
#Thoracotomy at [**Hospital3 **] in [**2127-9-28**].
Social History:
Lives at home in [**Location (un) 3786**] with wife and two children. Works as
respiratory therapist at Mt Aubrun. Wife works as an
administrative assistant at [**Hospital1 18**]. 25+ pack-year h/o smoking,
quit with cancer diagnosis. Denies EtOH, drugs.
Family History:
No history of lung cancer in family.
Physical Exam:
T 37 HR 93 BP 102/48 RR 22 O2 sat 100%
General: sedated, intubated
HEENT: pupils equal adn reactive, sclearae anicteric, MMM
Neck: supple, no LAD, no JVD
Lungs: decreased breath sounds to left
Abdomen:g-tube in place, no tenderness, soft and non-distended
EXT:No c/c/e
Neuro: sedated
Pertinent Results:
[**2130-7-23**] 12:34PM BLOOD WBC-29.1* RBC-3.97* Hgb-10.4* Hct-34.5*
MCV-87 MCH-26.3* MCHC-30.2* RDW-16.3* Plt Ct-543*
[**2130-7-24**] 03:32AM BLOOD Neuts-95.3* Lymphs-3.3* Monos-1.1*
Eos-0.2 Baso-0
[**2130-7-23**] 12:34PM BLOOD PT-15.2* PTT-25.7 INR(PT)-1.4*
[**2130-7-24**] 03:32AM BLOOD Glucose-117* UreaN-23* Creat-0.7 Na-142
K-4.5 Cl-110* HCO3-26 AnGap-11
[**2130-7-27**] 06:00AM BLOOD ALT-9 AST-21 AlkPhos-77 TotBili-0.4
[**2130-7-24**] 03:32AM BLOOD Albumin-2.9* Calcium-11.3* Phos-2.1*#
Mg-1.7
[**2130-7-23**] 6:58 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2130-7-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
BETA STREPTOCOCCI, NOT GROUP A. 10,000-100,000 ORGANISMS/ML..
.
[**2130-7-23**] CT Head
IMPRESSION: Multiple metastatic lesions scattered throughout the
brain.
.
[**2130-7-23**] CTA Chest
IMPRESSION:
1. No evidence of pulmonary embolus. Some pulmonary arterial
branches are slightly narrowed due to encasement by tumor.
2. Diffuse mediastinal and hilar confluent soft tissue density
consistent with neoplastic infiltration. Accompanying complete
left-sided lung collapse along with moderate size complex
pleural effusion and pleural thickening.
3. Innumerable nodular pulmonary metastases on the right with
superimposed ground glass opacities that could represent
atypical infection or additional areas of lymphangitic spread
Brief Hospital Course:
48M w/ PMHx of extensive metastatic NSCLC (stage IV) s/p
thoracotomy ([**2126**]), chemoRT ([**2127**]), hx of post obstructive pna &
left lung collapse with left mainstem endobronchial tumor
([**2128**]), met embolization and mechanical decompression of spinal
cord due to cord compression ([**2129**]) presenting with acute
dyspnea, found to be in respiratory distress requiring
intubation. Patient had short stay in [**Hospital Unit Name 153**] briefly and after
extubation, was transferred to oncology [**Hospital1 **] for further
management. Has had episodes of desaturation possibly related to
accident removal of oxygen nasal cannula and anxiety. Started on
XRT on [**2130-7-27**], 5 fractions planned, but since goals of care
changed to comfort oriented, long term prognosis poor,
completion of XRT deferred. DNR/DNI status discussed on
[**2130-7-27**].On the night of [**2130-7-28**] pt became very dyspneac and
agitated. He was given morphine and alprazolam for dyspnea with
minimal relief and then thorazine, which did help patient. On
[**2130-7-29**] pt was transitioned to CMO. He was treated with scheduled
thorazine, morphine and alprazolam. He was non-arousable but
remained comfortable. On [**2130-7-30**] at 20:50 patient expired.
Medications on Admission:
On transfer from [**Hospital Unit Name 153**]:
1. Azithromycin 250 mg PO/NG QDAILY
2. Acetaminophen 650 mg PO/NG Q6H:PRN pain
3. ALPRAZolam 0.75 mg PO/NG TID:PRN anxiety
4. Metoclopramide 10 mg PO/NG QID PRN nausea
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
6. Morphine Sulfate 2-4 mg IV Q4H:PRN pain
7. Polyethylene Glycol 17 g PO/NG DAILY constipation
8. Piperacillin-Tazobactam 4.5 g IV Q8H
9. Dexamethasone 3 mg PO/NG DAILY
10. Pantoprazole 40 mg IV Q24H
11. Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **]
12. Fentanyl Patch 125 mcg/h TP Q72H
13. Gabapentin 600 mg PO/NG Q8H
14. Heparin 5000 UNIT SC TID
15. Vancomycin 1250 mg IV Q 12H
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic Lung Cancer
Brain Metastasis
Anxiety
Shortness of Breath
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 486, 2762, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4145
} | Medical Text: Admission Date: [**2150-8-1**] Discharge Date: [**2150-8-5**]
Date of Birth: [**2096-5-5**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54 y/o man with end stage liver disease c/b renal failure now on
HD who was recently admitted for same here, d/c'd supposedly for
hospice care who was also getting o/p HD Tu Th Sa. Today he was
supposed to get dialysis, but complains that this was not
possible b/c his HD cath was "clogged". He reportedly had a
"friend" bring him to [**Hospital1 **] for HD and further mgmt. On arrival in
the ED he is found to be AF and HD stable, but massively volume
overloaded, with sats in the 70's on RA, and with MS changes
concerning for SBP. He is admitted for urgent HD for volume
overload.
Past Medical History:
cirrhosis ([**1-1**] EtOH)
h/o hepatic encephalopathy
h/o SBP
h/o esophageal varices (EGD [**2148**])
C.diff positive (currently on Flagyl)
likely HRS
Diabetes
Social History:
h/o EtOH abuse (reports being sober x 6 months).
+ smoker (1ppd).
Divorced, has 2 children.
lives with female friend who helps take care of him
Family History:
alcoholism
Physical Exam:
VS: 97.5 87 105/48 20 96% on NRB
HEENT - icteric, jaundiced, disheveled, chronically ill
appearing
COR:RRR no MRG
PULM:diminished breath sounds on the right
ABD:Massively distended, + fluid wave.
EXT:4+ pitting edema with cellulitis lt shank
NEURO:somnolent but arrousable, oriented only to person and
place (not year or reason for admssion); moves all four.
Pertinent Results:
None
Brief Hospital Course:
54 year old man with end stage liver disease, not a candidate
for transplant, who was recently admitted for liver failure and
? HRS, now HD dependent who presents to the ED stating that he
couldnt get his usually scheduled HD today because his "line was
clotted", in volume overload, desaturating on room air, and with
altered mentation concerning for SBP. Pt initially went to the
MICU, but pt and family decided that he should be CMO and then
discontinued dialysis treatment. He was transferred to the floor
and treated with morphine prn for tachypnea and pain, lorazepam
prn for agitation and anxiety and scopolamine patch for control
of secretions. He expired.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5856, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4146
} | Medical Text: Admission Date: [**2151-3-16**] Discharge Date: [**2151-3-22**]
Date of Birth: [**2120-4-17**] Sex: F
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Transfer from [**Hospital **] Hospital MICU for neurologic compromise, at
request of family for second opinion.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
30-year-old woman with metastatic squamous cell carcinoma of
unknown primary. At [**State 792**]Womens', about [**3-1**], she
developed pseudomonal urosepsis and vaginal bleeding from tumor
extension/anti-coagulation. She was transfered to [**State 40074**]Hospital after an arrest. Her course was complicated by
post-hypotensive coma as well as subarachnoid hemorrhages and
intraparenchymal bleeds. Neurologists at RIH felt she had a
poor prognosis, but communication between the medical team and
family was strained and transfer was arranged to [**Hospital1 18**] for a
second opinion.
Her outside course in more detail:
Patient transferred from Women and [**Hospital 60658**] Hospital to [**Hospital **]
Hospital [**2151-3-1**] with weaknes, vag bleeding x several days,
fever 102.5, hypotension, hypoxic 84% on 4L NC, tachypnic to 30,
with labs significant for lactate 6.3, wbc <1.0, plt 9, hgb 8.9,
and INR greater than lab threshold. Intubated for airway
protection (ABG 7.39/26.5/73.6) and placed on levophed.
.
Placed on [**Last Name (un) 2830**]/vanc/fluc/gentamicin for neutropenic fever and
thrush initially. IVC filter placed [**3-2**]. CT abdomen
consistent with large necrotic pelvic mass - not sampled [**12-18**]
coagulopathy. [**3-3**] results from Blood Cx from W+I:
[**2-28**] PICC Bld Cx: pseudomonas [**Last Name (un) 36**] to zosyn, cipro, cefepime,
[**Last Name (un) 2830**]
-- staph epi- [**Last Name (un) 36**] to vanc
[**2-28**] Peripheral Bld Cx: pseudomonas as above
[**2-28**] Urine Cx: pseudomonas as above
Abx changed to vanc, zosyn, cipro, fluc, azith. Pressors weaned
off by [**3-3**]. Completed 7 days of vanc/fluc, 13/14 days of
cipro/zosyn. Continued to have recurrent fevers.
.
Seen by Urology who did not change stents given severe
coagulopathy and worsening renal function. Found to be in DIC
and supported with daily blood products. Seen by heme and GCSF
started. Despite aggressive blood product repletion patient
poorly responsive [**12-18**] alloimmunization. Plt count 1 on [**2151-3-5**].
Supported on TPN for nutrition then switched to tube feeds.
Developed renal failure with Cr peak of 2.9. Seen by renal who
felt was c/w ATN.
.
Head CT done [**3-10**] with bilateral SAH and L temporal parenchymal
hematoma. Also with multiple masses consistent with metastasis.
Placed on Dilantin. Neurosurgery consulted. Felt secondary to
low platelets with no surgical intervention indicated.
.
Mult family meetings given poor prognosis. Initially decided
not to escilate care and make DNR [**3-11**]. Then progressed to
withdrawal of care [**3-12**] with plan to extubate [**3-13**]. However
there was dissent among neurologists about patient's ability to
recover from the SAH while awaiting family members and the
patient was changed to full code. Given 48 hours off sedation
with out change in mental status (last morphine was [**2151-3-13**]).
Transferred to [**Hospital1 18**] for further work up.
.
On arrival to the [**Hospital Unit Name 153**] the patient was intubated and
non-sedated.
Past Medical History:
- Retroperitoneal Squamous Cell Carcinoma of unknown primary, dx
[**10-21**], s/p XRT (last tx [**2150-2-23**]), s/p cisplatin (last dose 3/22)
- L hydroureter obstruction, s/p R ureteral stent [**2151-1-28**]
- h/o LLE DVT on coumadin
- laser conization of cervix [**2147**]
Social History:
Lives with husband and 4 y.o. son.
Family History:
Non-contributory
Physical Exam:
VS - Tm 101.7 Tc 99.7 P 123 BP 137/75
Resp - PCV Pinsp 26 R 16 FiO2 50% Rate 8, breathing 20, Sat 100%
Gen - lying in bed unresponsive
HEENT - OP clear, PERRL
Neck - supple
Cor - RRR
Chest - diffuse ronchi
Abd - Mass in LLQ, nephrostomy with yellow clear output
Ext - diffuse anasarca x 4 ext
Neuro - PERRL, corneal reflex, gag reflex, Dolls eyes, spont mvt
of head with out purpose side to side
Pertinent Results:
[**2151-3-16**] 11:02PM PT-14.6* PTT-29.1 INR(PT)-1.3*
[**2151-3-16**] 11:02PM PLT SMR-LOW PLT COUNT-86*
[**2151-3-16**] 11:02PM WBC-3.7* RBC-2.78* HGB-8.6* HCT-25.8* MCV-93
MCH-31.1 MCHC-33.5 RDW-14.9
[**2151-3-16**] 11:02PM CALCIUM-7.1* PHOSPHATE-5.1* MAGNESIUM-1.7
[**2151-3-16**] 11:02PM ALT(SGPT)-23 AST(SGOT)-19 ALK PHOS-101
[**2151-3-16**] 11:02PM estGFR-Using this
[**2151-3-16**] 11:02PM GLUCOSE-96 UREA N-113* CREAT-2.3* SODIUM-150*
POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-28 ANION GAP-16
[**2151-3-21**] 06:02AM BLOOD WBC-9.5 RBC-2.78* Hgb-8.8* Hct-25.7*
MCV-93 MCH-31.7 MCHC-34.2 RDW-14.6 Plt Ct-26*
[**2151-3-17**] 04:30AM BLOOD Neuts-80.4* Bands-9.3* Lymphs-4.1*
Monos-3.1 Eos-1.0 Baso-0 Atyps-1.0* Metas-1.0*
[**2151-3-21**] 06:02AM BLOOD Fibrino-406*
[**2151-3-21**] 06:02AM BLOOD Glucose-120* UreaN-79* Creat-1.8* Na-144
K-3.6 Cl-110* HCO3-23 AnGap-15
[**2151-3-17**] 04:30AM BLOOD ALT-19 AST-18 LD(LDH)-313* AlkPhos-104
Amylase-37 TotBili-0.8
[**2151-3-21**] 06:02AM BLOOD Calcium-7.4* Phos-3.6 Mg-2.2
[**2151-3-17**] 04:30AM BLOOD Albumin-2.3
[**2151-3-19**] 08:32AM BLOOD Type-ART Temp-38.2 Tidal V-500 PEEP-5
FiO2-40 pO2-104 pCO2-50* pH-7.36 calTCO2-29 Base XS-1
-ASSIST/CON Intubat-INTUBATED
[**2151-3-17**] 02:08AM BLOOD Lactate-1.6
.
[**2151-3-17**] MRI head:
FINDINGS: The sagittal T1 images demonstrate several areas of
high signal along the sulci bilaterally which could be secondary
to subarachnoid hemorrhages. There are several areas of
hyperintensities at the convexity which could be intraaxial and
could be related to hemorrhage within the metastatic lesions but
in absence of gradient echo images, this could not be further
confirmed. A CT would help for further assessment if indicated.
There is increased signal seen in both basal ganglia region as
well as along the rolandic region bilaterally which is
suggestive of global hypoxic injury to the brain. There are
several areas of brain edema identified in the left frontal and
parietal lobe and both temporal lobes, which are suspicious for
areas of metastatic disease with surrounding edema. There is no
hydrocephalus or midline shift seen. No herniation is
identified.
Images through the skull base demonstrate soft tissue changes in
the sphenoid sinus which could be due to retained secretions
from intubation.
There is increased signal seen along the sulci on FLAIR images
at the convexity which could be secondary to subarachnoid
hemorrhage. A CT would help for further assessment and exclude
proteinaceous material within the sulci. Gadolinium-enhanced MRI
would also help for further assessment.
.
pCXR [**2151-3-17**] 5:01am:
FINDINGS: No prior comparisons. Tip of the ETT projects roughly
5 cm above the carina. A right IJ central venous line is at the
level of the mid SVC. Tip of the NGT is below the edge of the
image. IVC filter and probable NU stent catheter on the left
also noted.
Heart and mediastinum are unremarkable allowing for technique,
no sizeable pneumothorax.
There is a somewhat wedge-shaped opacity at the right lung base
which could represent aspiration or pneumonia. No other
confluent infiltrates are appreciated
.
pCXR [**2151-3-17**]. 1:46pm:
1. Mild pulmonary edema.
2. Vague right lower lobe opacity most likely represents
pulmonary edema though if opacity persistent after diuresis,
aspiration and pneumonia will become considerations.
3. ETT 4 cm above the carina with NG tube advancement into the
stomach.
.
EEG [**2151-3-18**]:
Abnormal portable EEG due to the slow and disorganized
background and bursts of generalized slowing. These findings
indicate a
widespread encephalopathy. Medications, metabolic disturbances,
and
infection are among the most common causes. Subarachnoid
hemorrhage is
another possible explanation. There were no areas of prominent
focal
slowing, and there were no epileptiform features
.
Trans-thoracic echocardiogram [**2151-3-18**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No pericardial effusion.
.
pCXR [**2151-3-19**]:
Mild left lower perihilar opacification has improved, probably
resolving edema. There is more rightward mediastinal shift,
suggesting new atelectasis in the right lung. Enlargement of the
right hilus could represent adenopathy. Whether to pursue this
would depend upon clinical circumstances. Heart size normal. ET
tube in standard placement. Nasogastric tube passes below the
diaphragm and out of view. No appreciable pneumothorax or
pleural effusions
.
pCXR [**2151-3-20**]:
Increasing opacification of the lungs could be due to mild
pulmonary edema and multiple micrometastases, worsened slightly
since [**3-19**] at 10:57 p.m. Heart size is normal. There is no
pleural effusion. The ET tube and right PICC line in standard
placements. Nasogastric tube passes below the diaphragm and out
of view. No pneumothorax.
.
Microbiology:
[**3-17**]- Blood cultures: no growth to date on [**12-18**] bottles
[**3-18**]- Blood cultures: no growth to date on [**4-21**] bottles
[**3-20**]- Blood cultures: no growth to date on [**2-17**] bottles
.
[**3-17**]- Urine culture: no growth (final)
[**3-18**]- Urine culture: no growth (final)
[**3-20**]- Urine culture: no growth to date
.
[**3-17**]- Stool: negative for Cdiff toxin
[**3-18**]- Stool: negative for Cdiff toxin
.
[**3-18**]- Swab from Nephrostomy:
GRAM STAIN (Final [**2151-3-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
.
[**3-18**]- Sputum: Source: Endotracheal.
GRAM STAIN (Final [**2151-3-18**]):
[**9-9**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2151-3-20**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
.
[**3-20**]- Sputum: Source Endotracheal.
GRAM STAIN (Final [**2151-3-20**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): YEAST(S).
.
[**3-20**]- Catheter tip (IV):
WOUND CULTURE (Final [**2151-3-21**]): No significant growth
Brief Hospital Course:
30 yo F with metastatic squamous cell carcinoma of unknown
primary who presented to OSH [**3-1**] with pseudomonal urosepsis,
vaginal bleeding from tumor extension/anti-coagulation. Course
complicated by sub arachnoid hemorrhages and intraparenchymal
bleeds as well as potential hypotensive brain injury with poor
prognosis per neurology. Transferred here for second opinion on
poor prognosis.
.
# Neurologic - The patient was seen by the Neurology consult
service and underwent MRI head which revealed lesions suspicious
for metastases, possible hemorrhages, and findings consistent
with hypoxic brain injury. EEG was performed and revealed
encephalopathy. The patient's neurologic exam (performed after
sedation removed >48 hours) revealed intact brainstem function
without evidence of higher cortical activity. She had some
metabolic abnormalities which were corrected (hypernatremia,
hyperphosphatemia), but neurologic exam was unchanged. A family
meeting on [**2151-3-19**] was held and these findings communicated with
the patient's family. Final neurologic assessment was that the
patient was unlikely to regain meaningful neurologic
functioning. At the request of her family, she will be
transferred closer to her home in [**Doctor Last Name **], to Women and
[**Hospital 60658**] hospital.
.
# Respiratory Failure - Pt arrived on pressure support
ventilation, which was changed to Assist control to make patient
more comfortable. She was originally intubated for airway
protection, and it is felt she could likely be weaned from the
ventilator although she would be extremely high risk for
aspiration. Due to family request to move patient to a hospital
closer to home, she will remain intubated until transfer, with
plan to extubate upon arrival to Women and [**Hospital 60658**] hospital with
initiation of full palliative care and compliance of DNI status.
.
# Fevers/Infection - Per outside hospital records, the patient
grew pseudomonas from blood and urine. At OSH, she was treated
with 7 days of vancomycin, as well as 13 days (of 14-day planned
course) of Ciprofloxacin and Zosyn. She was intially continued
on Cipro/Zosyn. CXR [**3-17**] revealed ? pneumonia vs atelectasis at
the R lung base. Continues to spike fever. Could have still
seeding of nephrostomy tube. Urology at OSH against pulling
tube because coagulopathy and may not be able to replace.
Fevers also may be from head bleed, cancer, or drug. She was
continued on zosyn and vancomycin to complete a >14 day course.
She continued to have fevers. Antibiotics were discontinued on
[**3-21**]. No further infectious course was identified and the fevers
may have been due to underlying malignant process.
.
# Squamous Cell Cancer - unknown primary. The patient was seen
by the oncology consult service who contact[**Name (NI) **] her outside
hematologist Dr. [**Last Name (STitle) 73107**]. Upon discussion with him it was noted
that the patient had progression of her disease after systemic
therapy with topotecan and cisplatin. She then proceed to XRT
with cisplatin which she was unable to tolerate this secondary
to thrombocytopenia (40-50K). Given this we were unable to
offer her additional therapy. Hematology/Oncology service at
[**Hospital1 18**] confirmed her grim prognosis and expective survival in
terms of weeks to months with no further available treatment.
.
# h/o DVT - patient with head bleed which is contraindication to
anti-coagulation. IVC filter in place. Patient was on
pneumoboots while in hospital.
.
# Hypernatremia - Improved from OSH. Total body volume
overloaded. Water Deficit 2.5 L. She was continued on free H20
boluses and D5 1/2 NS and corrected.
.
# Acute Renal Failure - stable, likely [**12-18**] hypotension leading
to ATN that is slowly improving.
.
# Access - R IJ changed sterilly over wire [**3-7**]
.
# FEN - tube feeds are held in route in anticipation of
extubation.
.
.
# Code Status: After multiple discussion with family and the
doctor accepting the patient at Women and [**Hospital 60658**] Hospital( Dr.
[**Last Name (STitle) 73107**] at RI. She was made DNR/DNI and the plan is that she
will be transferred to WIH and extubated there upon arrival with
initiation of full palliative care. The family understood this;
all questions were answered and they wished to proceed. They
understand that there is no ICU at WIH and no further advanced
pulmonary support can be offered.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever or pain.
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**4-23**]
Puffs Inhalation Q2-4H (every 2 to 4 hours) as needed.
3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: 25-100 mcg
Injection Q2H (every 2 hours) as needed for comfort.
5. Insulin Regular Human 100 unit/mL Solution Sig: 2-10 units
Injection ASDIR (AS DIRECTED): per sliding scale for blood
sugars > 150mg/dl.
6. Midazolam 1 mg/mL Solution Sig: 1-2 mg Injection Q2H (every 2
hours) as needed for comfort.
7. Phenytoin Sodium 50 mg/mL Solution Sig: One [**Age over 90 1230**]y
(150) mg Intravenous Q8H (every 8 hours).
8. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg
PO DAILY (Daily).
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-17**]
Drops Ophthalmic QID (4 times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Hypoxic brain injury
2. Cranial hemorrages (sub arachnoid and parenchemal)
3. Pseudomonal sepsis, completed antibiotic course
4. Metastatic Squamous cell carcinoma of unknown primary.
5. Thrombocytopenia
6. Blood loss anemia
Discharge Condition:
Intubated, stable
Discharge Instructions:
You are being transferred to another hospital, intubated, with
the plan to extubate upon arrival to Women's and Infants
hosptial and initiation of palliative care.
.
Your antibiotics were stopped [**2151-3-21**] (Vancomycin 1000mg q24 and
Aztreonam 1000mg q8) as your micorbiology data has been negative
and your course for pseudomonal sepsis has been completed. If
you continue to have fevers, blood cultures should be repeated.
Followup Instructions:
As directed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 431, 2760, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4147
} | Medical Text: Admission Date: [**2101-1-13**] Discharge Date: [**2101-1-29**]
Date of Birth: [**2039-1-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
Fatigue, lightheadedness, CP, SOB and fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61 female with a h/o right Wilms tumor, s/p nephrectomy on the
R in [**2078**] and nephrectomy on the L on [**1-4**]/008 for a lower pole
renal mass with pending pathology who now presents with SOB, CP
and fever. The patient reports that she was suffering from
constipation and took a dulcolax which resulted in a large BM
this morning around 2am. She started to feel fatigued and
lightheaded afterwards. THen she developed a fever to 102 and
chest pain that was sharp and located over her R sternum and L
shoulder. It was pleuritic and non radiating. She also started
to develop mild SOB and was brought to the ED. Reportedly at
home her BP was high over the last days after she was discharged
from the hospital, ranging between 150 and 180 systolic.
.
Of note, she underwent L nephrectomy on [**1-4**] and has been doing
fine since. The operation and postoperative phase went without
complications. She has been doing well at home afterwards and is
able to ambulate a flight of stairs without complications. He
was dialyzed yesterday without complications
.
On arrival in the ED she was hypotensive with blood pressure of
106/52 which then decreased further to 76 over palp systolic.
Other Vitals 98.3 100 95%on 2LNC. CT significant for large
pleural effusions b/l and moderate to large pericardial
effusion. More focal opacity again seen in the right lower lobe.
Again findings are suspicious for endobronchial lesion with
post-obstructive pneumonia although infectious pneumonia and
aspiration cannot be excluded. Also large amount of
pneumoperitoneum, possibly post-surgical. The patient also
received Ceftriaxone, Azithromycin and Zosyn. She received one
dose of dexamethasone due to her absolute adrenal insufficiency.
She received Tylenol, Fentanyl 50mcg and Morphine 2mg for pain.
.
On ROS, she denies recent antibiotic use other than one
preoperative dose of antibiotics. Otherwise she denies abdominal
pain, changes in the color of her stool or urine. She denies any
sick contacts.
Past Medical History:
Wilms tumor
HTN
PSH:
Right nephrectomy [**2078**]
CCY-open
C-section x 2
Tubal ligation
Social History:
none
Family History:
none
Physical Exam:
Vitals
General Appearance
HEENT
COR
LUNG
ABD
EXT
Neuro
Pertinent Results:
[**2101-1-13**] 04:06PM PT-12.3 PTT-33.2 INR(PT)-1.0
[**2101-1-13**] 12:50PM LACTATE-2.0
[**2101-1-13**] 12:45PM GLUCOSE-106* UREA N-20 CREAT-5.6* SODIUM-134
POTASSIUM-3.6 CHLORIDE-92* TOTAL CO2-30 ANION GAP-16
[**2101-1-13**] 12:45PM estGFR-Using this
[**2101-1-13**] 12:45PM CK(CPK)-15*
[**2101-1-13**] 12:45PM CK-MB-2 cTropnT-0.03*
[**2101-1-13**] 12:45PM WBC-18.4* RBC-3.64* HGB-9.8* HCT-30.2* MCV-83
MCH-27.0 MCHC-32.5 RDW-14.4
[**2101-1-13**] 12:45PM NEUTS-85.8* LYMPHS-9.1* MONOS-3.6 EOS-1.4
BASOS-0.2
[**2101-1-13**] 12:45PM PLT COUNT-388#
.
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2101-1-13**] 7:39 PM
CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST
Reason: LT NEPHRECTOMY, NOW RT PLEURITIC CP, FRVER.
Field of view: 38 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman with recent L nephrectomy, now with R
pleuritic CP, fever, dyspnea.
REASON FOR THIS EXAMINATION:
evaluate for PE, evaluate for intraabdominal process.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 61-year-old woman with recent left nephrectomy, now
with right pleuritic chest pain, fever, dyspnea.
COMPARISON: CT of the chest [**2101-1-1**], CT of the abdomen
[**2100-11-30**].
TECHNIQUE: MDCT-acquired axial images of the chest, abdomen and
pelvis were obtained with IV contrast. Images of the chest were
also obtained without IV contrast. Multiplanar reformatted
images were also displayed.
CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There is a new
moderate-to- large pericardial effusion. The pericardial
effusion measures of simple fluid attenuation, no definite
enhancing wall is identified.
Multiple prominent mediastinal lymph nodes are again seen,
slightly larger compared to prior chest CT. Enlarged right hilar
lymph node (3A:37) measures 17 mm in short-axis dimension,
little changed from prior.
New large bilateral pleural effusions with associated
atelectasis are identified. A more focal consolidation is again
seen within the right lower lobe. Previously described multiple
pulmonary nodules are not well evaluated on the current study.
There is no evidence of pulmonary embolism.
CT OF THE ABDOMEN WITH IV CONTRAST: There is a large amount of
pneumoperitoneum, possibly post-surgical in nature. Free fluid
seen scattered throughout the abdomen and pelvis, also
presumably post-surgical. The liver, pancreas, spleen appear
unremarkable. Patient is status post bilateral nephrectomies. No
definite recurrent mass is identified within the nephrectomy
beds.
Visualized portions of bowel appear unremarkable. There is no
evidence of obstruction. Normal appendix is identified.
Surgical staples seen in the anterior left abdominal wall.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid, bladder
appear unremarkable. Heterogeneous enhancing uterus consistent
with fibroid uterus is noted. Free fluid seen tracking into the
pelvis.
BONE WINDOWS: No suspicious lytic or blastic lesions are
identified.
IMPRESSION:
1. New moderate-to-large pericardial effusion.
2. New large bilateral pleural effusions with associated
atelectasis.
3. Focal opacity again seen in the right lower lobe. Again
findings are suspicious for endobronchial lesion with
post-obstructive pneumonia although infectious pneumonia and
aspiration cannot be excluded. As previously recommended,
dedicated bronchoscopy could be helpful for further evaluation.
4. No evidence of pulmonary embolism.
5. Large amount of pneumoperitoneum, possibly post-surgical.
6. Free fluid in the abdomen, presumably post-surgical.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: FRI [**2101-1-14**] 1:15 AM
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2101-1-13**] 12:56 PM
CHEST (PA & LAT)
Reason: Evaluate for PNA
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman with fever, R chest pain. Recently postop
REASON FOR THIS EXAMINATION:
Evaluate for PNA
INDICATION: Fever, right-sided chest pain.
COMPARISONS: [**2101-1-4**].
CHEST, PA AND LATERAL: A dual lumen left internal jugular
approach hemodialysis catheter tip is within the SVC in
unchanged position. There are new, patchy airspace opacities at
the left lung base with a left-sided pleural effusion. A small
right-sided pleural effusion is also likely. Pulmonary
vasculature is within normal limits. Numerous surgical clips
within the abdomen and surgical staples overlying the left flank
are again identified. Free intraperitoneal air is consistent
with recent postoperative status.
IMPRESSION: Interval development of patchy airspace opacity at
the left lung base concerning for pneumonia giving the history.
Left-sided pleural effusion and likely small right-sided pleural
effusion. No evidence of CHF.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Approved: [**Doctor First Name **] [**2101-1-13**] 4:11 PM
.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2101-1-19**] 7:00 PM
CT HEAD W/O CONTRAST
Reason: ? intracranial bleed
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with hypertensive emergency, headache, blurry
vision.
REASON FOR THIS EXAMINATION:
? intracranial bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Hypertensive emergency, headache and blurry vision.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There are hypodensities within the white matter
centered within both occipital lobes extending into the parietal
convexities. There is no evidence for intracranial hemorrhage.
There is minimal mass effect, no shift of normally midline
structures. The [**Doctor Last Name 352**]-white matter differentiation is preserved.
The osseous structures are unremarkable. There is mild mucosal
thickening in the right maxillary sinus. The mastoid air cells
are clear.
IMPRESSION: Findings suspicious for PRES (posterior reversible
encephalopathy syndrome). MR is recommended for further
evaluation if clinically indicated.
Findings discussed with Dr. [**Last Name (STitle) 6499**] via telephone 8:30 p.m.
[**2101-1-19**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16277**]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: [**Doctor First Name **] [**2101-1-20**] 9:13 AM
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2101-1-22**] 3:37 PM
CHEST (PA & LAT)
Reason: ? interval change
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with known PNA and bilateral pleural effusion.
Now developing some low-grade fevers.
REASON FOR THIS EXAMINATION:
? interval change
STUDY: PA and lateral chest, [**2101-1-22**].
HISTORY: 62-year-old woman with known pneumonia and bilateral
pleural effusions. Now with developing low-grade fever. Evaluate
interval change.
There is a left-sided dialysis catheter, unchanged. Cardiomegaly
is stable. There has been improved aeration of the left
retrocardiac region and left base. There is a left small pleural
effusion. Surgical clips are seen within the upper abdomen.
Brief Hospital Course:
# [**Hospital 76591**] Hospital Acquired Pneumonia and Hypotension:
The patient presented with fever, cough, and infiltrate. In
addition she was initially hypotensive in the context of rising
white count and fever, suggesting possible sepsis and adrenal
insufficiency. She was fluid resuscitated and placed on
vancomycin and ceftriaxone for additional coverage. A DFA for
influenza was negative. The patient was also started on
stress-dose steroids for presumed adrenal insufficiency. The
pneumonia resolved clinically and radiographically. On chest
CT, an endobronchial lesion was identified. Pleural effusion
tapping was transudative but cytology was concerning for
malignant epithelial cells. The patient went for a bronchoscopy
that was unable to biopsy the suspected lesion; endobronchial
washings and lymph node biopsies were obtained that were pending
at the time of discharge.
# Pericardial Effusions: The patient's pericardial effusions
were identified on initial imaging. The differential included
uremia, fluid overloaded, and postoperative cytokine release
syndrome. Serial echocardiograms and physical exam did not
reveal tamponade physiology. Given the resolution of the
effusion with volume removal, it was thought to be secondary to
fluid overload; the fluid was never tapped.
# Posterior reversible encephalopathy syndrome (PRES) with
malignant hypertension: The patient had elevated blood pressures
following transfer out of the ICU despite dialysis and
antihypertensive therapy. Twenty four hours later she developed
confusion, sharply diminished visual acuity, and headache. The
diagnosis of PRES was made based on occiptial lobe findings on a
head CT. The patient's blood pressure was subsequently
controlled with a combination of Toprol XL, ace inhibitors, and
hemodialysis. Her headache, confusion, and visual changes
resolved.
# S/P bilateral nephrectomies: The patient was continued on
hemodialysis during her stay.
Medications on Admission:
Docusate Sodium 100 mg [**Hospital1 **]
Epoetin Alfa ASDIR
Oxycodone-Acetaminophen 5-325 mg PO Q4H (every 4 hours) as
needed.
B Complex-Vitamin C-Folic Acid 1 mg DAILY
Sevelamer HCl 800 mg TID
Prednisone 5 mg 2 Tablets PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO BID (2 times a
day).
Disp:*64 Tablet Sustained Release 24 hr(s)* Refills:*0*
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*28 Tablet(s)* Refills:*0*
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for anxiety.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA
Discharge Diagnosis:
Primary:
Lobar post-obstructive Pneumonia
endobrachial lesion noted on chest CT
bilateral pleural effusions with cytology concerning for
malignancy
pericardial effusion
hypertensive emergency/posterior reversible encephalopathy
syndrome
fevers of unknown origin.
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
you were found to have a pneumonia. You also had fluid around
your heart and lungs that decreased after hemodialysis. Your
blood pressures were also very high resulting in headache and
visual changes. These both improved once your blood pressure
was controlled with medications and additional hemodialysis.
You also had a period of fevers. We never identified a cause
for these fevers, but they were likely bacterial in origin.
They resolved with antibiotic therapy.
The results of your pleural fluid cell analysis demonstrated
cells that were suspiscious for malignancy. You had a
bronchoscopy to obtain a sample of the tissue but they were
unable to sample the actual growth. Instead, they sampled
nearby lymph nodes and did a washing to collect cells. The
results of that study are pending and you need to have your
physician contact the [**Hospital1 18**] for followup.
Please continue to take your medications as prescribed. You
should follow up with your physicians as directed below. If you
develop a headache with visual changes, fevers, shortness of
breath, or any other concerns please contact a physician
[**Name Initial (PRE) 2227**].
Followup Instructions:
Please make an appointment to see you primary care physician,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 53192**] after discharge. He and your
nephrologist will have to work together to coordinate your blood
pressure medications with your hemodialysis.
In addition you will need to call Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] arrange for a
urology follow up appointment.
Your primary care physician should also follow up on the results
of your bronchoscopy to arrange the appropriate follow up and
evaluation of the growth in your lung.
You will also need to return to your dialysis on Monday as
planned.
Completed by:[**2101-2-8**]
ICD9 Codes: 0389, 5856, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4148
} | Medical Text: Admission Date: [**2198-11-11**] Discharge Date: [**2198-11-16**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Heparin Agents
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
colonoscopy
Central line placement by VIR
History of Present Illness:
Ms. [**Known lastname 70011**] is a [**Age over 90 **] yo female with severe RA who presented to OSH
with LGIB on [**11-11**]. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric lavage was negative. Initally
the patient was hypotensive with SBP in the 80s. The patient was
given fluids and was transfused 2U of FFP and 2U of PRBC. Only
poor peripheral access was obtained (20G in foot) and therefore
a CVL was attempted. An attempt for a R femoral line was
unsuccessful. A RIJ attempt was unsuccessful as the wire was
traveling in the head. When trying to place a L subclavian line,
the physician in the OSH was unable to withdraw the wire. A CXR
revealed the CVL wire coiled in the IVC filter. The patient is
transfered for IR intervention to withdraw the wire.
.
On arrival to the [**Hospital1 18**], the patient denied any CP, SOB,
abdominal pain, back pain. She denied any BRBPR prior to this
episode. She states that the BRBPR started last two days. The
patient denies ever having had any colonoscopy before. She
denies any LH or dizziness. The patient is s/p recent THR that
was complicated by a DVT. The pt had an IVC filter placed and
was on Heparin sc TID for DVT prophylaxis.
Past Medical History:
PMH:
Rheumatoid Arthritis - c/b chronic right pleural effusion, s/p
recent thoracentesis, felt to be due to RA
HTN
Atrial fibrillation
h/o of CVA with residual L sided weakness
Frequent UTIs
.
PSH:
S/p b/l TKR in [**2193**]
s/p R total hip replacement in [**9-/2198**] complicated by a DVT for
which an IVC filter was placed
Addendum/clarification based on discussion with the PCP ([**First Name5 (NamePattern1) 4468**]
[**Last Name (NamePattern1) 70012**]):
She underwent R THR at [**Hospital3 934**] in [**5-15**] without
complications, discharged on coumadin for DVT prophylaxis.
Readmitted in [**6-14**] with thigh pain and a DVT was seen. On
lovenox, plavix and aspirin, she developed a thigh hematoma
complicated by hypotension, so anticoagulation was stopped and
they placed an IVC filter. She was D/C'd to [**Location (un) 931**] House.
She was readmitted [**8-15**] for chest pain and hypotension and found
to have RA pericarditis, pericardial effusion, and pleuritis.
Placed on steroids. Readmitted [**10-15**] for the same and also
developed A fib which spontaneously recovered. Readmitted [**11-11**]
from rehab because she was placed on heparin SQ despite the IVCF
and developed BRBPR and hypotension.
Social History:
She has been living in a Rehab since her THR in [**9-14**]. Prior to
this, she lived alone with help from her son. She denies ETOH
and tobacco use.
Family History:
Non-contributory
Physical Exam:
Gen: NAD, AAOx3
HEENT: PERRLA, mmm, no dentures in place
NECK: no LAD, no JVD visible
COR: S1S2, regular rhythm, non-radiating systolic murmur [**12-15**]
over precordium, distant heart sounds.
PULM: CTA b/l, no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, nt
Skin: cool extremities, no rash, limited range of motion in UE
joints, ecchymosis in R groin, wire taped to her left shoulder
EXT: 1+ DP, no edema/c/c, dermatosclerotic changes in feet b/l
Pertinent Results:
[**11-11**]: EKG: rate 72, Nsr, no ST changes or TWIs, normal intervals
.
[**11-11**] CXR: Bilateral pleural effusions. Subsegmental atelectasis
right
base. Increased density in the retrocardiac area, which may
represent
atelectasis or consolidation.
.
CT Abdomen/Pelvis:
1. CT colonography unable to be performed due to lack of rectal
tone.
2. Extensive sigmoid diverticulosis. Assessment of the
nondistended colon is limited, but there is an area of
asymmetric wall thickening with mucosal enhancement in a loop of
redundant sigmoid colon low in the left lower quadrant. While
this could be related to recent colonoscopy or represent
inflammatory changes from diverticulosis, given the history of
GI bleeding, a neoplastic process cannot be excluded. Targeted
colonoscopy of this area or single-contrast barium enema could
be performed for further assessment. Given lack rectal tone,
single contrast enema may not be successful.
3. Findings consistent with proctitis.
4. Air in the bladder. Correlate with recent history of Foley
catheter
placement. Given extensive diverticular disease, in the absence
of prior Foley catheterization, this would raise suspicion for
enterovesicular fistula. No areas of asymmetric bladder wall
thickening are identified adjacent to sigmoid colon to indicate
an enterovesicular fistula.
5. Moderate bilateral pleural effusions with associated
bilateral lower lobe atelectasis.
Brief Hospital Course:
A/P: [**Age over 90 **] F with PMH of RA, THR c/b DVT, s/p IVC filter placement,
admitted to MICU with LGIB.
.
1) LGIB: Patient presented to outside hospital with lower GI
bleed and hypotension. She received 2 units of FFP and 2 units
of PRBC's at outside hospital and was subsequently transferred
to [**Hospital1 18**] for further management. She was admitted to the MICU
at [**Hospital1 18**] and GoLytely was administered in preparation for a
colonoscopy. On admission to this institution, she had a large
drop in her hct from 33.8 to 26.6 and was transfused an
additional 2 units of PRBC's and started on IV PPI. She was
subsequently hemodynamically stable for the duration of her
hospital course. EGD/colonoscopy revealed ischemic-appearing
mucosa in the sigmoid colon and severe sigmoid narrowing, which
they were unable to pass with the colonoscope. She underwent a
diagnostic colonography under fluroscopy for further evaluation
of stricture vs. obstructing mass. This study revealed severe
sigmoid diverticulosis and findings consistent with proctitis.
If indeed these findings are consistent ischemic colitis, it may
be related to hypotensive event (reported per PCP) which
occurred at outside hospital. At time of discharge, she was
hemodynamically stable, and no further intervention was advised.
This was discussed with both patient's son and her PCP who
stated their agreement with plan for conservative management.
.
2) Access: At the outside hospital, Ms. [**Known lastname 70011**] had several
unsuccessful attempts at line placement and was transferred with
a guidewire which was felt to be hooked into her IVC filter. IR
found that in fact this was not the case, and they were able to
remove the wire without difficulty. A left SVC triple lumen
catheter was placed by IR for access in the setting of active GI
bleeding, as patient had a tenuous situation with peripheral
IV's.
.
3) Rheumatoid Arthritis - Patient has a long history of RA for
30 years and is on a slow prednisone taper for recent RA
pericarditis & pleuritis. Current dose of 20 mg was continued
to prevent adrenal insufficiency. Her PCP will continue to
manage the slow taper after discharge.
.
4) Leukocytosis: Most likely due to chronic prednisone. No
clinical, radiographic, or other laboratory evidence of
infection.
.
5) Afib: Sotalol was briefly held secondary to concern over
brisk bleeding. Once GI bleeding had subsided, it was
restarted. Heart rate was well-controlled. She is not
currently a candidate for anticoagulation given GI bleed.
.
6) FEN: Received gentle IVFs initially following admission.
Following colonoscopy, diet was slowly advanced from clear
liquids to regular cardiac diet, which patient tolerated well.
Electrolytes were repleted as needed to maintain K>4, Mg>2.
.
7) Prophylaxis: Pneumoboots for DVT prophylaxis. Patient has
IVC filter in place given h/o DVT. PPI for GI prophylaxis.
.
8) Access: L SCV line placed by IR; removed prior to discharge.
.
9) Code status: DNR/DNI
Medications on Admission:
Medications on admission to outside hospital:
Lipitor 10mg QD
Enteric coated Aspirin 81 mg
Nexium 40mg QD
Sotalol 40mg QD
Prednisone 20mg QD
.
Home Meds: included sq heparin
.
Medications on transfer to outside hospital:
Pantoprazole 40 mg PO Q12H
Prednisone 20 mg PO DAILY
Acetaminophen 325-650 mg PO Q4-6H:PRN
Sotalol HCl 40 mg PO DAILY
Atorvastatin 10 mg PO DAILY
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**3-15**]
hours as needed for pain.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 941**] - [**Location 942**]
Discharge Diagnosis:
PRIMARY:
GI bleed
Diverticulosis
Ischemic colitis
Gastritis
CVL wire coiled in IVC filter
.
SECONDARY:
Atrial fibrillation
Hypertension
Rheumatoid arthritis
Pericarditis
Pleuritis
Discharge Condition:
Stable
Discharge Instructions:
You were admitted from [**Hospital **] Hospital with a catheter coiled
in the filter in your inferior vena cava. You were evaluated by
Interventional Radiology, and the catheter was disentangled.
.
You have also been evaluated for the source of your GI bleeding.
Initially you received a blood transfusion to stabilize your
hematocrit. Your colonoscopy showed evidence of diverticulosis
and of ischemia in your sigmoid colon (which means that your
bowel may not be getting adequate blood supply to it). Ischemic
colitis is likely the source of your lower GI bleed. There is no
further intervention necessary for these conditions. Your
bleeding has subsided, and you have been hemodynamically stable
for several days.
.
You should return to the hospital if you experience gross blood
in your stool, shortness of breath, or chest pain.
Followup Instructions:
You will follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 70012**].
ICD9 Codes: 2851, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4149
} | Medical Text: Admission Date: [**2149-11-29**] Discharge Date: [**2149-12-4**]
Date of Birth: [**2072-3-16**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**Last Name (un) 11974**]
Chief Complaint:
Palpitations and NSVT
Major Surgical or Invasive Procedure:
EP Study
History of Present Illness:
The patient is a 77-year-old female with a past history of HTN,
HL, CAD s/p MI x 3 and CABG x 2, ischemic cardiomyopathy (EF 30
%), h/o NSVT s/p ICD (replaced 2 years ago), presenting from
[**Hospital3 **] with NSVT.
.
Of note, patient was admitted to [**Hospital1 18**] in [**Month (only) 956**] after ICD
firing in the setting of VT from a coughing attack. She had
been started on amiodarone on discharge, however, this was
discontinued
in [**Month (only) 547**] secondary to tingling/twitching in her ears and a
swollen throat. She was last seen in the device clinic in [**Month (only) 205**],
with no notable events on review.
.
She presented to [**Hospital3 **] with the initial complaint of
an episode of palpitations that she says began on Wednesday
night. She has been feeling this palpitations for a long time
(many months) but they had always gone away after a few minutes.
This episode, however, lasted for at least an hour and this is
what brought her to the OSH. She denies overt shortness of
breath, abd pain, or nausea. She denies any chest pain but does
endorse some dizziness.
.
On review of systems, she 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. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, syncope or presyncope.
Past Medical History:
Hypertension
Hyperlipidemia
CAD s/p 3 MIs
Cardiomyopathy, EF 25%
NSVT with easily inducible sustained VT on EP study in [**3-/2136**]
-CABG: x2 [**2126**], [**2132**], both done at NEDH
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: [**Company 1543**] Micro [**Female First Name (un) 19992**] 2 ICD placed on [**2136-3-29**].
Exchanged for [**Company 1543**] ICD, EnTrust D154VRC ?in [**2143**] (last
interrogation per [**Hospital1 18**] webOMR notes [**2145-9-7**]).
3. OTHER PAST MEDICAL HISTORY:
Depression s/p ECT
S/p cholecystectomy
S/p hysterectomy
S/p thyroid surgery for a benign mass
S/p cataract surgery
Social History:
Married. Lives at home with her husband and her brother.
-Tobacco history: remote smoking history from age 20 to 30
-ETOH: occasional social drinking
-Illicit drugs: none
Family History:
Mother died of MI at age 38, brother at age 37. Other brother MI
at age 60.
Father lived to age [**Age over 90 **] and was healthy. No family history of
arrhythmia, cardiomyopathies.
Physical Exam:
ADMISSION PHYSICAL EXAM
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD appreciated.
CARDIAC: Rate very irregular, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities but central scar noted,
well-healed, 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.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 2+ PT 2+
Left: Carotid 2+ Radial 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAM
Vitals - Tm/Tc: afeb/97.3 HR: 57-66 BP: 95/50 (90-114/50-67)
RR: 16 02 sat: 98% RA
In/Out:
Last 24H: 1740/2050
Last 8H: 0/675
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Very
pleasant
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM.
NECK: Supple with no JVD appreciated.
CARDIAC: Regular rate and rhythm, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities but central scar noted,
well-healed, 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.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 2+
Left: Carotid 2+ Radial 2+ DP 2+
Pertinent Results:
ADMISSION LABS
[**2149-11-30**] 08:45AM BLOOD WBC-4.9 RBC-4.89 Hgb-15.1 Hct-44.4 MCV-91
MCH-30.9 MCHC-34.0 RDW-13.4 Plt Ct-208
[**2149-11-30**] 08:45AM BLOOD PT-13.5* PTT-30.4 INR(PT)-1.2*
[**2149-11-30**] 08:45AM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-141
K-3.9 Cl-104 HCO3-28 AnGap-13
[**2149-11-30**] 08:45AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.9
.
DISCHARGE LABS
[**2149-12-4**] 07:10AM BLOOD WBC-4.4 RBC-3.76* Hgb-11.9* Hct-35.4*
MCV-94 MCH-31.6 MCHC-33.5 RDW-13.4 Plt Ct-184
[**2149-12-3**] 07:55AM BLOOD PT-12.5 PTT-27.1 INR(PT)-1.1
[**2149-12-4**] 07:10AM BLOOD Glucose-88 UreaN-4* Creat-0.7 Na-140
K-3.8 Cl-101 HCO3-30 AnGap-13
[**2149-12-4**] 07:10AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0
.
IMAGING
[**2149-12-1**] [**Month/Day/Year **]: The left atrium is elongated. The estimated right
atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy. There is severe regional left
ventricular systolic dysfunction with thinning/akinesis of the
inferolateral wall, mild dyskinesis of the inferior wall and
apex. The remaining segments are mildly hypokinetic. Overall
left ventricular systolic function is severely depressed (LVEF=
25 %). 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. The mitral valve
leaflets are elongated. Trivial mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion. IMPRESSION: Mild symmetric
left ventricular hypertrophy with normal cavity size with
extensive regional systolic dysfunction c/w multivessel CAD or
other diffuse process. Compared with the prior study (images
reviewed) of [**2149-3-27**], the findings are similar.
.
[**2149-12-4**] Stress Test: INTERPRETATION: This 77 yo woman s/p MI
x3, CABG in [**2126**] and [**2132**], nonsustained MMVT and s/p ICD was
referred to the lab for arrhythmia evaluation. The patient
completed 9 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol representing an
average exercise tolerance for her age; ~ 4.8 METS. The exercise
test was stopped at the patient's demand secondary to fatigue.
No chest, back, neck or arm discomforts were reported by the
patient during the procedure. The subtle ST segment changes
noted anteriorly are uninterpretable for ischemia in the
presence of the RBBB. No significant ST segment changes were
noted inferiorly or in the lateral precordial leads. The rhythm
was sinus with rare isolated APBs. In additional, rare isolated
VPBs and one ventricular couplet was noted during the procedure.
In the presence of beta blocker therapy, the heart rate response
to exercise was limited. A flat blood pressure response was
noted with exercise; resting standing 94/46 mmHg, peak exercise
104/46
mmHg. Max RPP 8112, % MAX HRT RATE ACHIEVED: 55
IMPRESSION: Average exercise tolerance, however decreased in
exercise
time/exercise tolerance from previous ETT in [**2149-3-18**]. No
anginal
symptoms or objective ECG evidence of myocardial ischemia. No
exercise-induced VT. Blunted heart rate and blood pressure
response to
exercise.
Brief Hospital Course:
77-year-old female with a past history of HTN, HL, CAD s/p MI x
2 and CABG x 2, ischemic cardiomyopathy (EF 25 %), h/o NSVT s/p
ICD (replaced 2 years ago), presenting from [**Hospital3 **] with
NSVT.
.
.
ACTIVE ISSUES:
#. NSVT: Likely etiology is scarring from previous MIs v.
cardiomyopathy. Pt has defibrillator in place that was
investigated upon admission. Pt was on amiodarone in the past,
which worked well for her initially but then discontinued its
use in [**Month (only) 547**] due to adverse side effects. Only symptom has been
palpitations. Before her EP study, pt's symptoms and ectopy were
managed adequately with a lidocaine drip. Incidence of NSVT
decreased, but the patient continued to have some PVCs and
couplets. An EP study was performed, which showed dense scar
along the inferior wall from mid-wall to apex extending to the
infero-lateral wall and distal septum. The base of the heart was
normal. PES with up to triple extra-stimuli induced only
pleomorphic VT that --> to VFL --> external shocks. The pt had
multiple VT morphologies induced with cath manipulation and
burst pacing. The clinical VT was not induced and ablation was
therefore not performed. Pt was continued on metoprolol, and
then started on quinidine and mexilitine after the EP study,
with good control of pt's symptoms and no more ectopy on
telemetry.
.
.
CHRONIC ISSUES:
# CAD: Pt's history of CAD includes 3 MIs and CABG x2 in [**2126**]
and [**2132**]. She is on nitroglycerin at home for chest pain, but
did not need it during the hospitalization. She was continued on
her home lipitor and ezetimibe.
.
# HTN: Documented history of this problem, for which she had
been treated with hydralazine, isosorbide, and lopressor prior
to admission. However, she was slightly hypotensive in-house,
and so her home hydralazine and isosorbide were held, but she
was continued on her home lopressor. Before discharge, she was
transitioned to long-acting lopressor that she will take twice
daily. Pt has adverse reaction to Ace Inhibitors, more
specifically lisinopril as she develops severe mouth sores (so
bad she stopped taking all of her medicines). There was some
thought about starting her on Diovan, but due to her adverse
reaction to ace inhibitors (and their relationship to ARBs), she
was simply continued on lopressor and her isosorbide and
hydralazine were held.
.
# Chronic systolic heart failure: Documented history of this
problem. [**Name (NI) **] during this admission showed an EF of 25%. On
hydralazine and isosorbide at home but was held in-house.
.
# HLD: Documented history of this problem. Pt was continued on
home lipitor and ezetimibe.
.
# Anxiety: Documented history of this problem. Pt was continued
on home oxazepam.
.
TRANSITIONAL ISSUES
# Pt's isosorbide and hydralazine were held during the
hospitalization due to low blood pressures. Recommend
re-checking blood pressures at home and in her PCP's office to
determine the need to re-start these medications.
Medications on Admission:
ATORVASTATIN [LIPITOR] 20 mg Tablet, 1 Tablet PO BID
EZETIMIBE [ZETIA] 10 mg Tablet, 1 Tablet PO daily
HYDRALAZINE HCL 10MG Tablet, 1 Tablet PO TID
ISOSORBIDE DINITRATE 20 mg Tablet, 1 Tablet PO TID
LOPRESSOR 50mg Tablet, 1 Tablet PO TID
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - as directed once a
day
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - as directed once a day
OXAZEPAM 30mg Tablet, 1 Tablet PO TID
Discharge Medications:
1. quinidine gluconate 324 mg Tablet Extended Release Sig: One
(1) Tablet Extended Release PO Q8H (every 8 hours).
Disp:*90 Tablet Extended Release(s)* Refills:*2*
2. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxazepam 30 mg Capsule Sig: One (1) Capsule PO three times a
day.
6. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO BID (2 times a day).
Disp:*180 Tablet Extended Release 24 hr(s)* Refills:*2*
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Discharge Disposition:
Home
Discharge Diagnosis:
ventricular tachycardia
Chronic systolic congestive heart failure
coronary artery disease
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at [**Hospital1 18**].
You were admitted with palpitations caused by ventricular
tachycardia and needed to get intravenous medicine to control
the arrhythmias. An ablation was attempted by Dr. [**Last Name (STitle) **] but he
was not able to complete this procedure because the heart rhythm
that caused the palpitations was not able to be induced during
the procedure. Therefore, you have been started on 2 new
medicines to control the arrythmias, mexilitine and quinidine.
So far, these medicines seem to be working well for you. Please
check your blood pressure at home to make sure you are
tolerating the medicines.
.
We made the following changes to your medicines:
1. START taking mexilitine and quinidine gluconate to control
your ventricular tachycardia
2. CHANGE the metoprolol to succinate, a long acting version and
take only twice daily
3. STOP taking isosorbide mononitrate (Imdur) and hydralazine
for now, talk to Dr. [**Last Name (STitle) **] about restarting these medicines at
your next appt.
4. Eat a banana and drink [**Location (un) 2452**] juice every day with breakfast
to keep your potassium level high.
5. START taking magnesium tablets twice daily to increase your
magnesium levels
Followup Instructions:
.
Department: CARDIAC SERVICES
When: MONDAY [**2150-1-5**] at 11:00 AM
With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None
.
Name: BRIGHT,MARK T.
Specialty: FMILY MEDICINE
Location: [**Hospital **] HEALTH CENTER
Address: 200 [**Last Name (un) 12504**] DR, [**Location (un) **],[**Numeric Identifier 18464**]
Phone: [**Telephone/Fax (1) 18462**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
within 1 week. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above**
Department: CARDIAC SERVICES
When: FRIDAY [**2150-1-2**] at 1:40 PM
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(2) 11975**]
ICD9 Codes: 4271, 4280, 311, 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4150
} | Medical Text: Admission Date: [**2155-11-1**] Discharge Date: [**2155-11-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Cath x 2 with stenting
History of Present Illness:
85y/o M w/ h/o CAD s/p CABG, HTN, Hypercholesterolemia, remote
tobacco history who was in USOH PTA. He had been hospitalized
for a pneumonia ~6 weeks ago, treated and sent home on 2L
oxygen. One month ago he was able to walk up a flight of stairs
(12 steps) without any dificulty or DOE. Up until one week ago
he started noticing that he could not walk up the full flight of
stairs, he would stop at 6 steps [**12-30**] SOB and abdominal
pressure/tightness. 2.5 days ago he could only go up 4 stairs
prior to symptoms starting, he also noticed that he developed a
pressure around his waist that waxed and waned in intensity.
This morning, he quickly became sob with minimal exertion
lasting 30min before recovering his breath. He dressed himself,
washed and shaved and was readily out of breath, developed
pressure around his waist that was worse than before [**9-7**] non
radiating, no LH/dizziness/N/V. He gave himself oxygen which
helped ease both the abdominal tightness and SOB. He called EMS
who found him to have a P: 84, BP: 170/80, R: 24, O2 84% on 2L
then switched to NRB iwth O2 95%, they gave him lasix 40mg and 2
baby asa and was taken to [**Name (NI) 1474**] Hospital. There he was noted
to be in florid heart failure, given NTG, Morpine 2mg+2mg, lasix
40mg, started on NTG drip, 2 baby asa, lovenox 80mg sc, mucomyst
600mg iv, lopressor 2.5mg, and started on Tirofiban. Hct was
46.4, wbc 13.2, BUN 46, Cr 2.3, CK 67, TropI 0.5.
He was subsequently transferred to [**Hospital1 18**] for cardiac
catherization.
Upon arrival to floor patients face was dark red/almost purple,
c/o severe abdominal pressure, non radiating, acutely sob, no
LH/Dizziness, no N/V. He was tachypneic on NRB with sats in the
high 80's/low 90's, JVD ~14cm, heart RRR, lungs with crackles
from bases to [**12-31**] of lung field. He was given 80mg iv lasix, 2mg
of morphine, started on heparin iv, then given additional 100mg
of iv lasix. CXR with pulmonary congestion/edema, sats improved
to the low 90's and no longer was desating with conversation.
ABG's showed 7.39/34/48-> 7.34/39/63-->7.37/39/76. He diuresed
2L total after 180mg of lasix and was no longer in distress,
abdominal pain resolved after 10min on floor. Patient still on
NRB.
ROS: no cough, no PND, no orthopnea, no edema, no N/V/F/CH, no
pleuritic chest pain,
Past Medical History:
PMH:
1. Parkinsons
2. CAD s/p CABG, CHF diastolic dysfunction EF 60-65%
3. PPM [**12-30**] afib
4. HTN
5. hypercholesterolemia
6. peripheral neuropathy
7. Cardiomegaly on CXR and effusion
8. Pulm nodules on CT: 2, 2mm in the LUL
Social History:
SOH:
remote tobacco: used to smoke 1ppd with 1-2 cigars, then
switched to pipe. quit 21yrs ago, no etoh. Married lives with
wife
no ivdu
Family History:
FMH: had one brother that died from MI at age 35, two other
brothers that died at ages 66 and 80 from MI. Brother that died
at 80 died after shovelling snow, immediate death.
Physical Exam:
GEN: moderate distress upon arrival, face dark red, c/o sob and
abdominal pressure, tachypneic
HEENT: EOMI, PERRL, mmdry, o/p clear,
Neck: JVD ~14cm, supple, ?bruit in the left carotid
CV: RRR, paced, no m/r/g, surgical scar appreciated
PULM: crackles [**12-31**] lung field b/l, mild exp wheezes in the lower
bases, no rhonchi, good inspiratory and expiratory efforts
ABD: soft, round, NABS, NT/ND, no hepatic tenderness, no HM, no
HJR, no massess, no pulsatile masses appreciated.
Groin: bruits appreciated in both groins, pulses palpable
Ext: 1+ edema to BK b/l, no c/c, DP/PT both palpable, ext warm
and perfused
Neuro: grossly intact, CN II-XII grossly intact
Pertinent Results:
[**2155-11-1**] 05:42PM TYPE-ART TEMP-36.3 RATES-/24 O2-100 PO2-76*
PCO2-39 PH-7.37 TOTAL CO2-23 BASE XS--2 AADO2-615 REQ O2-98
INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2155-11-1**] 05:42PM O2 SAT-96
[**2155-11-1**] 03:10PM TYPE-ART PO2-63* PCO2-39 PH-7.34* TOTAL
CO2-22 BASE XS--4 INTUBATED-NOT INTUBA
[**2155-11-1**] 03:10PM HGB-14.4 calcHCT-43 O2 SAT-92 CARBOXYHB-0.5
MET HGB-0.8
[**2155-11-1**] 02:59PM GLUCOSE-124* UREA N-48* CREAT-2.3* SODIUM-141
POTASSIUM-5.2* TOTAL CO2-20*
[**2155-11-1**] 02:59PM ALT(SGPT)-14 AST(SGOT)-19 CK(CPK)-58 ALK
PHOS-85 TOT BILI-1.0
[**2155-11-1**] 02:59PM CK-MB-NotDone cTropnT-0.07*
[**2155-11-1**] 02:59PM ALBUMIN-4.2 CALCIUM-8.9 PHOSPHATE-3.8
MAGNESIUM-2.1
[**2155-11-1**] 02:59PM WBC-12.2* RBC-4.70 HGB-14.7 HCT-43.2 MCV-92
MCH-31.2 MCHC-34.0 RDW-14.2
[**2155-11-1**] 02:59PM PLT COUNT-201
[**2155-11-1**] 02:59PM PT-15.0* PTT-139* INR(PT)-1.4
[**2155-11-1**] 02:47PM TYPE-ART TEMP-35.0 O2-100 PO2-48* PCO2-34*
PH-7.39 TOTAL CO2-21 BASE XS--3 AADO2-648 REQ O2-100
INTUBATED-NOT INTUBA
[**2155-11-1**] 02:47PM HGB-14.4 calcHCT-43 O2 SAT-89 CARBOXYHB-0.3
MET HGB-0.9
[**11-3**] Echo
1. The left atrium is mildly dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully
excluded.
3. The aortic valve leaflets (3) are mildly thickened.
4. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
5. There is moderate pulmonary artery systolic hypertension.
[**11-4**] Stress MIBI
1) Moderate, reversible inferior and inferolateral wall
perfusion
defect. 2) Slight hypokinesis of the lateral wall with
calculated ejection
fraction of 46%.
[**11-5**] Cath
1. Selective coronary angiograpy of this right dominant system
revealed
multi-vessel disease. The LMCA contained mild, diffuse disease.
The
LAD was occluded mid vessel and filled via SVG-D. The LCX was
occluded
proximally. The RCA had diffuse disease up to as much as 80%
stenosed.
2. Vein graft imaging revealed patent LIMA-LAD without
significant
disease. The SVG-RPL was totally occluded. The SVG-D1 had
70-80%
lesions proximally.
3. Resting hemodynamics revealed a severely elevated mean PCPW
of
22mmHg. The Cardiac Index by the Fick method was 2.3 l/min/m2.
4. Successful stenting of the SVG to RPL with distal to proximal
overlapping Cypher DESs (3.0x33, 3.0x33, and 3.5x23) (See PTCA
comments).
[**11-7**] Cath
1. Selective angiography of the recently stented SVG to
the RPL revealed widely patent stents. The SVG to the LAD had a
80%
proximal stenosis.
2. Successful stenting of the proximal segment of the SVG to the
LAD
with a 3.5x18mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] with a 4.5x12mm Quantum
MAverick
at 20 atms using Filterwire EZ RX for distal protection (See
PTCA
comments).
Brief Hospital Course:
85y/o M with CAD s/p CABG, diastolic heart failure, HTN,
hypercholesterolemia, p/w 2 day history of USA and acute
pulmonary edema.
1. CV: History c/w UA progressing to ACS.
CAD: Patient arrived on Tirofiban [**12-30**] his ARF and NTG gtt. We
started patient on heparin, asprin full dose, metoprolol,
holding acei, started lipitor. NTG gtt titrated to relieve
pain. Once initially stabalized the pt had no chest pain for
the entire admission. Once resp status stabalize pt sent for a
stress MIBI which demonsrated a reversible inf/inf-lat perfusion
defecit with HK of the lat wall. He was sent to cath where the
pt was found to have multi vessel disease. The SVG-RPL was
stented with overlapping stents. He was brought back for repeat
cath and stenting of the SVG-LAD. With both caths the pt was
prehyd with Na Bicarb and mucomyst. His groin cath sites did
not have evidence of eccymoses or bleeding. He had a small
hematoma on the R which was stable. He also has been
hemodynamically stable throughout the admission. The pt will be
sent out on ASA, plavix, ACEI, lipitor, and B Blocker.
Pump: supposed EF of 60-65% with diastolic heart failure,
patient presently in acute heart failure and hypoxic. Nitro gtt
was given for afterload reduction and lasix for diuresis. Given
morphine here, one dose for pain releif and pulm vasculature
dilation. The patient was oxygenating well but requiring a
non-rebreathing mask at 100%. When the mask was taken off the
pt would desat to the 80's immediately. He was diuresed with
lasix requiring 100mg iv mult time to put out about 2 liters.
He was started on natrecor and sent to the CCU for further
diuresis with close supervision. The diuresis was successful at
relieving the patient's respiratory distress but his Cr. did
rise. The pt was then free from shortness of breath from the
remainder of the hospitalization.
Rhythm: on telemetry, paced.
Medications on Admission:
1. adalat 60mg once a day (nifedipine)
2. atenolol 50mg twice a day
3. avapro 150mg once a day (ibesartan)
4. proscar .05mg once a day
5. finesteride 20mg once a day
6. furosemide 20mg once a day
7. stalebo 100mg qid (parkinsons)
8. Neurontin 300mg qid
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as needed as needed for chest pain: PLease take for
chest pain. If not releived by 3 tabs then go to emergency
room.
Disp:*30 tabs* Refills:*0*
8. Neurontin 300 mg Capsule Sig: One (1) Capsule PO four times a
day.
9. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Stalevo 100 25-100-200 mg Tablet Sig: One (1) Tablet PO four
times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Unstable Angina
Diastolic CHF
CAD
Parkinson's Disease
HTN
Chronic Renal Failure
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as instructed on discharge
paperwork.
You will be given sublingual nitroglycerin tabs. If pain does
not resolve after 3 tabs then call you primary doctor or go to
the emergency room.
I you have shortness of breath, dizziness, fainting,
palpitations, chest pain at rest or chest pain that does not
immediately respond to the nitro please call you doctor or go to
the emergency room.
Followup Instructions:
Please follow up with Dr [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3183**]) with in
2 weeks.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
ICD9 Codes: 4280, 5849, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4151
} | Medical Text: Admission Date: [**2129-7-9**] Discharge Date: [**2129-8-25**]
Date of Birth: [**2050-1-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Haldol / Heparin Agents
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Transfer from [**Hospital1 **] for persistent fevers
Major Surgical or Invasive Procedure:
[**8-12**] AVR (#21 Biocor)
History of Present Illness:
79 yo male with very complicated pmhx including critical AS s/p
valvuloplasty, IDDM, PAF, MRSA pneumonia and c-diff, recently
discharged from [**Hospital1 18**] on [**2129-7-1**] after being admitted for
hypotension, and fevers, thought to be secondary to pseudomnal
pneumonia. The patient was initially on broad spectrum
antibiotics, which were eventually narrowed to Ciprofloxacin
once sensitivities were obtained. The patient was discharged to
[**Hospital3 **] for further treatment and rehab. He completed
his course of Cipro on [**2129-7-4**], but then spiked on [**2129-7-5**].
Vancomycin and Ceftaz were started, cultures were sent. Sputum
culture returned with evidence of pseudomonas, resistant to
Ciprofloxacin, and MRSA. The patient also had an episode of
a-fib with RVR which responded well to oral diltiazem. Given
that the patient has had intermittent fevers since admission to
[**Hospital1 **] and has poor progress in weaning from the ventilator,
the patient's family requested transfer back to [**Hospital1 18**] ICU. In
addition, the family notes great concern over the patients
increasing lethargy.
.
On arrival to the [**Hospital Unit Name 153**], the patient denies pain or difficulty
breathing, able to follow minimal commands. On speaking with
the daughter, she states that her father had the recurrent fever
a few days ago, seemed improved after the antibiotics were
restarted, but then appeared more lethargic yesterday. She
states that at his baseline his is alert, aware of his
surroundings, able to move his L arm, wiggle his toes, and move
his ankles.
Past Medical History:
(obtained from prior dc summary as pt unable to provide)
1. s/p MVC with multiple traumas in [**2-2**] with prolonged 4 month
hospital stay at [**University/College **], with trach placed [**2129-5-25**] after
several intubations for hypercarbic respiratory failure
2. CAD- left heart cath done at [**University/College **] revealed
non-obstructive CAD, severe AS, mod pulm htn, nml EF (60%)
3.chronically depressed mental status critical
4. AS s/p valvuloplasty- done in [**4-4**] at [**University/College **], repeated 2
weeks later
3. A fib
4. chronic b/l pleural effusions
5. anemia
6. MRSA PNA
7. pseudomonal PNA
8. Diabetes
9. chronic, severe generalized myopathy with mild membrane
instability, and evidence for a moderate peroneal
neuropathy at the right fibular neck seen on EMG on [**5-/2129**]
Social History:
Non-smoker. Currently at [**Hospital **] rehab. Has several
children. Daughter [**First Name8 (NamePattern2) **] [**Name2 (NI) 74057**] is a nurse and makes many of his
health decisions.
Family History:
non-contributory
Physical Exam:
vitals: 101.2/108/ 36/ 101/74/ 100% vent:
AC/.60/450(366)/14(22)/5
GEN: elderly male, lying semi-upright, appears somewhat
distressed
HEENT: atraumatic, anicteric sclera, EOMI, dry mucosa, OP clear
NECK: difficult to assess JVP, no LAD, trach in place, site
clean
CV: tachy, irregular, [**2-1**] holosystolic murmur radiates to
axilla, radial pulses equal
LUNGS: coarse BS, crackles at bases B/L, no wheeze
ABD: soft, nt, nd, NABS, G-tube in place, site clean
EXT: 3+ pitting edema, anasarca. Multiple petichiae on UE B/L,
DP pulses faint but palpable. Right PICC site appears clean
NEURO: awake, able to follow commands including open his eyes,
move his tongue, does not move extremities on command or
spontaneously, diminished reflexes B/L
Pertinent Results:
Labs from rehab:
sputum [**7-5**]:
pseudomonas, sensitive to cefepime, ceftaz, gent, imipenem,
zosyn
sputum [**7-1**]:
pseudomonas and MRSA- MRSA sensitive to Bactrim
urine culture [**7-5**]: no growth
blood culture [**7-5**]: 1/4 bottles CNS
ABG [**7-9**]: 7.49/51/89/39
INR- 1.4
CBC [**7-8**]:
.
prior studies-
Echo [**2129-6-27**]:
IMPRESSION: Moderate aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with normal cavity sizes and
regional/global biventricular systolic function. Mild mitral
regurgitation.
.
EEG [**7-5**]:
IMPRESSION: Abnormal portable EEG due to the generalized bursts
of
slowing, including very sharp features and sharp waves in the
central
regions bilaterally. These finding suggest a midline disturbance
but
are not specific with regard to etiology. The sharp features are
evidence of cortical hypersynchrony and could be related to an
epileptic process but also to a metabolic disturbance. There
were no prominent focal areas of slowing. The background reached
acceptable frequencies but was disorganized, raising the
possibility of an encephalopathy, as suggested by the clinical
report.
.
MR HEAD [**6-4**]:
1. No evidence of an acute infarction.
2. Small chronic lacunar infarction in the body of the right
caudate nucleus.
3. Mucosal thickening and air/fluid level of the right
maxillary sinus
consistent with acute sinusitis.
4. No arterial occlusion or evidence of stenosis in the circle
of [**Location (un) 431**].
5. Possible fenestration of the proximal basilar artery.
.
LABS AT [**Hospital1 18**]
[**2129-7-9**] 11:01PM BLOOD
WBC-12.8*# RBC-2.49* Hgb-7.3* Hct-22.8* MCV-92 MCH-29.4
MCHC-32.0 RDW-16.9* Plt Ct-209
Neuts-91.9* Lymphs-3.0* Monos-4.2 Eos-0.5 Baso-0.3
PT-23.7* PTT-51.3* INR(PT)-2.4*
Glucose-113* UreaN-50* Creat-1.0 Na-139 K-4.0 Cl-95* HCO3-41*
AnGap-7*
ALT-74* AST-65* LD(LDH)-153 AlkPhos-256* Amylase-21 TotBili-0.9
Lipase-15
Albumin-2.1* Calcium-8.4 Phos-3.5 Mg-2.3
[**2129-7-9**] 11:17PM BLOOD Type-ART pO2-114* pCO2-56* pH-7.49*
calTCO2-44* Base XS-17 Lactate-1.4
[**2129-7-10**] 03:01PM BLOOD Lactate-1.0
[**2129-7-10**] 10:38AM BLOOD ALT-64* AST-52* AlkPhos-232* TotBili-0.9
[**2129-7-12**] 04:32AM BLOOD WBC-9.3 RBC-2.55* Hgb-7.6* Hct-23.6*
MCV-93 MCH-30.0 MCHC-32.3 RDW-16.9* Plt Ct-264 PT-23.0*
PTT-48.1* INR(PT)-2.3*
Glucose-64* UreaN-51* Creat-1.2 Na-138 K-3.9 Cl-98 HCO3-34*
AnGap-10
Calcium-8.6 Phos-3.8 Mg-2.4
[**2129-7-12**] 08:05AM BLOOD Genta-7.0 TROUGH
[**2129-7-12**] 09:48AM BLOOD Genta-11.4* PEAK
.
ABG'S:
[**2129-7-10**] 12:31PM BLOOD Type-ART pO2-36* pCO2-58* pH-7.46*
calTCO2-42* Base XS-14
[**2129-7-10**] 03:01PM BLOOD Type-ART Temp-36.8 Rates-14/15 Tidal
V-400 PEEP-10 FiO2-40 pO2-72* pCO2-49* pH-7.50* calTCO2-40* Base
XS-12 -ASSIST/CON Intubat-INTUBATED
[**2129-7-11**] 05:31AM BLOOD Type-ART Temp-38.2 Rates-26/14 Tidal
V-450 PEEP-5 FiO2-40 pO2-90 pCO2-53* pH-7.46* calTCO2-39* Base
XS-11 Intubat-INTUBATED Vent-CONTROLLED
[**2129-7-12**] 03:30PM BLOOD Type-ART Temp-36.9 Rates-/32 Tidal V-380
PEEP-5 FiO2-40 pO2-67* pCO2-62* pH-7.38 calTCO2-38* Base XS-8
Intubat-INTUBATED Vent-SPONTANEOU
.
MICRO:
[**2129-7-9**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2129-7-10**] URINE URINE CULTURE-FINAL NO GROWTH
[**2129-7-10**] URINE Legionella Urinary Antigen -FINAL NEGATIVE
[**2129-7-10**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
[**2129-7-10**] 5:22 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2129-7-12**]**
GRAM STAIN (Final [**2129-7-10**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2129-7-12**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
.
[**2129-7-10**] 9:27 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2129-7-12**]**
FECAL CULTURE (Final [**2129-7-12**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2129-7-12**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2129-7-11**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2129-7-11**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
NEGATIVE
.
ECG Study Date of [**2129-7-10**] 2:28:04 AM
Atrial fibrillation with controlled ventricular response.
Occasional
ventricular premature beats. Underlying intraventricular
conduction delay.
Compared to tracing of [**2129-6-27**] no definite change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Rate PR QRS QT/QTc P QRS T
96 0 110 342/395.57 0 -29 123
.
IMAGING
[**2129-7-9**] PORTABLE CXR: IMPRESSION: AP chest compared to [**6-13**]
through [**6-29**]: Severe consolidation in the right lung has
worsened since [**6-27**]. Milder interstitial abnormality in the
left lung probably represents residual edema or scarring.
Moderate cardiomegaly unchanged. Pleural effusion may be
present, but is not appreciable in size. Tracheostomy tube in
standard placement. No pneumothorax.
[**2129-7-12**] PORTABLE CXR: The tracheostomy is in unchanged position.
The diffuse pulmonary process, more severe in right lung, has
not significantly changed since the previous exam but overall is
gradually worsening since [**6-29**]. The bilateral pulmonary
edema is of unchanged stability. The mild cardiomegaly is
stable. Small bilateral pleural effusions are again noted,
although cannot be precisely appreciated due to the fact that
the most lateral costophrenic angles were not included in the
field of view. IMPRESSION: Probable, overall slight worsening of
pulmonary edema and right lower lobe consolidation.
.
[**7-18**] Echocardiogram:
The left atrium is elongated. 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. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is mild
pulmonary artery systolic
hypertension.
.
Chest CT [**2129-7-26**]:
1. Dense calcification of the aortic valve.
2. Pulmonary edema. A component of chronic interstitial lung
disease may be present
.
Colonoscopy [**2129-7-27**]: Multiple diverticuli, no obvious bleeding
Cardiology Report ECHO Study Date of [**2129-8-19**]
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. H/O cardiac surgery. Left
ventricular function.
Height: (in) 76
Weight (lb): 266
BSA (m2): 2.50 m2
BP (mm Hg): 131/71
HR (bpm): 84
Status: Inpatient
Date/Time: [**2129-8-19**] at 11:27
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W038-0:14
Test Location: West SICU/CTIC/VICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *6.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.0 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 70% (nl >=55%)
Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: *3.1 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 40 mm Hg
Aortic Valve - Mean Gradient: 22 mm Hg
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - E Wave Deceleration Time: 239 msec
TR Gradient (+ RA = PASP): *26 to 43 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully
excluded. Overall normal LVEF (>55%). No resting LVOT gradient.
No VSD.
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Normal RV
systolic function.
AORTA: Mildly dilated aortic sinus. Focal calcifications in
aortic root.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Increased AVR
gradient.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral
annular calcification. Mild thickening of mitral valve chordae.
Calcified tips
of papillary muscles. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve
supporting structures. Mild [1+] TR. Moderate PA systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - poor parasternal views. Suboptimal image quality
- poor apical
views.
Conclusions:
The left atrium is markedly dilated. There is mild symmetric
left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded.
Overall left ventricular systolic function is normal (LVEF 70%).
There is no
ventricular septal defect. Right ventricular chamber size is
normal. Right
ventricular systolic function is normal. The aortic root is
mildly dilated at
the sinus level. A bioprosthetic aortic valve prosthesis is
present. The
transaortic gradient is higher than expected for this type of
prosthesis. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse.
Mild (1+) mitral regurgitation is seen. There is moderate
pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2129-7-18**], the aortic valve has been replaced.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD on [**2129-8-19**] 12:35.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2129-8-19**] 4:54 AM
CHEST (PORTABLE AP)
Reason: s/p AVR w/hypotension-r/o PTX
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with AVR w/ hx of pna prior to surgery
REASON FOR THIS EXAMINATION:
s/p AVR w/hypotension-r/o PTX
INDICATION: Pneumonia and AVR surgery.
FINDINGS: In comparison with the study of [**8-17**], the patient is
no longer obliqued. There is again evidence of median sternotomy
and aortic valve replacement. The cardiac silhouette remains
grossly enlarged, though stable. There is again prominence of
interstitial markings. Elevation of the right hemidiaphragm is
again seen, making it difficult to evaluate the lung behind it.
Probable small bilateral pleural effusions.
Tracheostomy tube remains in place. Right central catheter
extends to just above the carina.
IMPRESSION: Little overall interval change.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: FRI [**2129-8-19**] 10:22 AM
[**2129-8-19**] 9:30 am URINE Source: Catheter.
**FINAL REPORT [**2129-8-22**]**
URINE CULTURE (Final [**2129-8-22**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CIPROFLOXACIN--------- =>8 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2129-8-25**] 03:37AM 10.1 2.92* 8.8* 26.5* 91 30.1 33.1 17.0*
177
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2129-8-25**] 03:37AM 177
Source: Line-aline
15.0* 38.4* 1.3*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2129-8-25**] 03:37AM 127* 50* 1.1 142 3.6 107 30 9
Brief Hospital Course:
79 yo male s/p [**Year (4 digits) 8751**] with multiple medical problems, s/p trach
placement in [**2129-4-29**], vent-dependent, who was recently
discharged from [**Hospital1 18**] after being treated for pneumonia,
admitted for persistent fevers and increased lethargy, being
treated for VAP, now with intermittently decreasing HCT and
severe AS.
.
Preoperatively, Balancing blood pressure with volume overload
was challenging, as diuresis limited by hypotension. Hypotension
improved with decreased PEEP. It was felt that his volume
overload and hypotension were most likely secondary to his
atrial fibrillation and severe aortic stenosis. Cardiac surgery
was consulted who felt that valve replacement had only
approximately a 30% chance of success but agreed to perform the
procedure. Prior to surgery he was placed on a lasix drip to
attempt to remove some volume with modest success. He was
transferred to the CCU prior to valve replacement. His platelet
count dropped and he had a negative HIT/SRA.
Patient with slow GI bleed throughout this hospitalization with
black tarry stool. He had evidence of gastritis and duodenotis
on EGD on [**7-18**] without evidence of active bleeding. He had
multiple blood transfusions. He underwent colonoscopy on [**7-27**]
which showed evidence of diverticulosis but no evidence of
active bleeding.
His trach was changed 3x secondary to persistent leak,
tracheomalacia extending to both mainstem bronc's noted,
currently with 8.0 [**Last Name (un) **]. He had evidence of a resistant
pseudomonal VAP sensitive to imipenim and cefepime from culture
results from [**Hospital1 **] and [**Hospital1 18**]. Treated with imipenem and then
cefepime for total of 14d pseudomonal coverage. Also treated
MRSA given sensitivities of sputum culture from OSH (Was on
bactrim [**2039-7-9**], vanc [**2044-7-14**]). His sputum has continued to grow
the same pansensitive organism as previously, likely
colonization.
On [**2129-8-12**] he was taken tot he operating room where he underwent
AVR with 21mm biocor valve. He was transferred to the ICU in
critical but stable condition. He was transfused several times.
His #8 trach was replaced on [**8-14**]. His vasoactive drips were
weaned to off by POD #4. Aggressive diuresis continued. Over the
next week he continued to be diuresed and his betablockers were
restarted. Post operatively the patient was seen by the GI
service as he had intermittant guiac positive stool but no
melana or [**Month/Year (2) **] bleeding, he was transfused w/PRBC's and PPI was
changed to [**Hospital1 **] dosing. He was scoped from above and below just
before surgery, at that time he was found to have diverticulosis
and mild gastritis.
By POD13 it was felt the patient was stable and ready for
discharge to [**Hospital3 **] Center.
Medications on Admission:
meds on transfer:
Aspirin
bacitracin ointment
ceftazidime (started [**7-5**])
vancomycin (started [**7-5**])
citalopram
vitamin B12
thiamine
folate
diltiazem
colace
iron
lasix
atrovent
insulin- 35 units glargine/humalog sliding scale
multivitamins
ranitidine
warfarin
albuterol
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 3 days: Through [**8-28**].
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
14. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. s/p MVC with multiple traumas in [**2-2**] with prolonged 4 month
hospital stay at [**University/College **], with trach placed [**2129-5-25**] after
several intubations for hypercarbic respiratory failure
2. CAD- left heart cath done at [**University/College **] revealed
non-obstructive CAD, severe AS, mod pulm htn, nml EF (60%)
3.chronically depressed mental status critical
4. AS s/p valvuloplasty- done in [**4-4**] at [**University/College **], repeated 2
weeks later
3. A fib
4. chronic b/l pleural effusions
5. anemia
6. MRSA PNA
7. pseudomonal PNA
8. Diabetes
9. chronic, severe generalized myopathy with mild membrane
instability, and evidence for a moderate peroneal
neuropathy at the right fibular neck seen on EMG on [**5-/2129**]
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) **] 1 month or after d/c from rehab
Dr. [**First Name (STitle) **] after discharge from rehab
Completed by:[**2129-8-25**]
ICD9 Codes: 4241, 5990, 4280, 5849, 2875, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4152
} | Medical Text: Admission Date: [**2165-8-25**] Discharge Date: [**2165-8-29**]
Date of Birth: [**2083-11-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Xeloda
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Left sided pleurex catheter placement with IP
History of Present Illness:
History of Present Illness: Mrs. [**Known lastname **] is an 81F with hx of
metastatic breast cancer and recurrent left malignant
hydrothorax who presents with increasing dyspnea over a week.
The pt states that she has had progressive dyspnea for the past
week, walking around the house has become more difficult, and it
has become even worse over the last 2 days prior to admission to
the point that she is now dyspneic with speaking. Per her
daughter, she came to visit this morning and was concerned about
her SOB. She endorses minimal coughing, not productive of
sputum. She denies chest pain, pressure, fever or chills. She
denies lightheadedness, dizziness, throat swelling, pleuritic
CP, new medications. She denies orthopnea but does use 2 pillows
with sleep. Of note, the pt was diagnosed with malignant L
pleural effusion in [**5-4**]. She's had three thoracenteses ([**5-13**],
[**8-1**], [**8-6**]). Prior to these procedures she states she has felt
similarly dyspneic.
.
On the floor, the pt was 96.6 126/67 81 RR33 100%2L. She
continued to endorse dyspnea but denies any pain. Because of
her tachypnea, she was transferred to the ICU where she
underwent pleurex drain placement. The procedure was only
complicated by mild hypotension with SBP 70s which improved to
130s with less than 1 liter of IVF, then she was hypertensive to
170s. On transfer to the floor, she felt her breathing was
stable and very well.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
-metastatic breast cancer: first breast cancer at the age of 57
in [**2140**]; that was an ER positive breast cancer treated with
lumpectomy and radiation at [**Hospital1 107**] [**Doctor Last Name **]-Kettering Cancer
Center. She only took tamoxifen for two years. Then in [**4-/2160**],
she developed a left breast cancer, which was a triple negative
breast cancer, 1.1 cm in size, grade 3 with six positive lymph
nodes. She was treated with lumpectomy and radiation, but
refused chemotherapy.
.
-L sided malignant pleural effusion: s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 576**] x3. tapped and
found to have malignant cells that were ER negative,
adenocarcinoma consistent with her breast cancer.
.
-Hypothyroidism [**2154**]
-Hyperlipidemia - [**2154**]
-Depression per daughter - [**2163**]
-Clavicle fxr - [**2151**]
-Thoracic aneurysm (approx 5 cm) - [**2159**]
-Hypertension - [**2154**]
-Seasonal allergies - childhood
-Melanoma on face: removed, never recurred - [**2152**]
.
PSH
-R breast lumpectomy and node dissection - [**2140**]
-L breast lumpectomy and node dissection - [**2159**]
-Thoracentesis - [**2165-5-13**], [**2165-8-1**], [**2165-8-6**]
Social History:
Lives alone, widowed. Originally from Poland. Emigrated to [**Location (un) 7349**]
in
[**2100**] and lived there until 7 years ago when she moved to [**Location (un) 86**]
to be closer to her 2 daughters who are very active in her care.
Has 4 grandchildren.
Occupation: retired bookkeeper
Smoking history: never
Alcohol: never
Family History:
breast cancer
Physical Exam:
Admission Exam:
.
Physical Exam: T 97.1 bp 120/80 HR 78 RR 22 SaO2 992L
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased breath sounds in lower [**11-26**] left lung, normal
effort, no wheezes
Chest : L pleurex in place with dressings c/d/i, non-tender
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
Skin: diffuse erythematous rash lesions, no excoriations
Ext: no edema
Neuro: no focal deficits
Psych: pleasant, cooperative
.
Discharge Exam:
.
Physical Exam: 97.6, 106/56, 68, 20, 98% 2L NC
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: increased effort. Sound clear bilaterally. SOB with
speaking
Chest : L pleurex in place with dressings c/d/i, non-tender
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
Skin: diffuse erythematous rash lesions, no excoriations
Ext: no edema
Neuro: no focal deficits
Psych: pleasant, cooperative
Pertinent Results:
Admission Labs:
[**2165-8-25**] 10:30PM TYPE-ART PO2-99 PCO2-41 PH-7.42 TOTAL CO2-28
BASE XS-1
[**2165-8-25**] 10:30PM LACTATE-2.3* NA+-125* K+-3.7
[**2165-8-25**] 10:30PM freeCa-1.14
[**2165-8-25**] 06:45PM URINE HOURS-RANDOM UREA N-240 CREAT-37
SODIUM-37 POTASSIUM-9 CHLORIDE-33 TOTAL CO2-LESS THAN
[**2165-8-25**] 06:45PM URINE HOURS-RANDOM
[**2165-8-25**] 06:45PM URINE OSMOLAL-201
[**2165-8-25**] 06:45PM URINE GR HOLD-HOLD
[**2165-8-25**] 06:45PM PT-11.7 PTT-21.7* INR(PT)-1.0
[**2165-8-25**] 06:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2165-8-25**] 06:45PM URINE BLOOD-TR NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
[**2165-8-25**] 06:45PM URINE RBC-1 WBC-11* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
[**2165-8-25**] 06:45PM URINE CA OXAL-RARE
[**2165-8-25**] 05:13PM K+-4.3
[**2165-8-25**] 05:05PM GLUCOSE-116* UREA N-13 CREAT-0.8 SODIUM-124*
POTASSIUM-6.1* CHLORIDE-90* TOTAL CO2-22 ANION GAP-18
[**2165-8-25**] 05:05PM estGFR-Using this
[**2165-8-25**] 05:05PM cTropnT-<0.01
[**2165-8-25**] 05:05PM CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-1.9
[**2165-8-25**] 05:05PM OSMOLAL-260*
[**2165-8-25**] 05:05PM TSH-8.2*
[**2165-8-25**] 05:05PM FREE T4-1.3
[**2165-8-25**] 05:05PM WBC-5.4 RBC-3.88* HGB-11.7* HCT-35.1* MCV-90
MCH-30.2 MCHC-33.4 RDW-14.4
[**2165-8-25**] 05:05PM NEUTS-74.4* LYMPHS-16.4* MONOS-5.9 EOS-2.8
BASOS-0.4
[**2165-8-25**] 05:05PM PLT COUNT-359
.
CXR [**2165-8-25**]:
FINDINGS: Consistent with the given history, there has been
interval
development of bilateral pleural effusions left much larger than
right. There is diffuse engorgement of the vascular pedicle and
indistinctness of the cephalized vascular flow. Findings suggest
superimposed volume overload in addition to the bilateral
pleural effusions. The aorta remains markedly tortuous though
incompletely evaluated given the large left effusion. Calcified
plaque is seen at the arch. Cardiac silhouette size is difficult
to assess but is presumed stable and remaining enlarged. Clips
are present in both axillary regions. Deformities of multiple
left posterolateral ribs are stable. IMPRESSION: Interval
development of bilateral pleural effusions left much larger than
right. There is superimposed pulmonary edema as well.
.
CXR [**8-28**]
FINDINGS: In comparison with the study of [**8-26**], the left Pleurx
catheter
remains in place and there is no evidence of pneumothorax or
recurrent
effusions. Small right effusion persists. Continued prominence
of indistinct pulmonary vessels, consistent with some elevation
in pulmonary venous pressure. Enlargement of the cardiac
silhouette with tortuosity of the aorta persists, as well as
multiple surgical clips in the axillary regions bilaterally.
.
Discharge Labs:
.
[**2165-8-29**] 06:35AM BLOOD WBC-6.6 RBC-3.32* Hgb-10.5* Hct-31.1*
MCV-94 MCH-31.7 MCHC-33.9 RDW-14.2 Plt Ct-265
[**2165-8-25**] 05:05PM BLOOD Neuts-74.4* Lymphs-16.4* Monos-5.9
Eos-2.8 Baso-0.4
[**2165-8-29**] 06:35AM BLOOD Glucose-100 UreaN-16 Creat-0.7 Na-126*
K-4.7 Cl-94* HCO3-25 AnGap-12
[**2165-8-29**] 06:35AM BLOOD ALT-5 AST-13 AlkPhos-55 TotBili-0.5
[**2165-8-29**] 06:35AM BLOOD Calcium-8.2* Phos-4.6* Mg-1.7
[**2165-8-28**] 05:58PM URINE Osmolal-587
[**2165-8-28**] 05:58PM URINE Hours-RANDOM UreaN-633 Creat-214 Na-73
K-53 Cl-88
Brief Hospital Course:
81F with hx of metastatic breast cancer and recurrent left
malignant hydrothorax who presented with increasing dyspnea over
a week, found to have increased bilateral pleural effusions on
the left.
.
# Dyspnea: Patient presented with dyspnea, tachypnea, and mild
hypoxia consistent with increasing malignant hydrothorax. The
patient had a pleurex catheter placed on [**8-26**]. We monitored her
for signs of infection. The patient's symptoms improved;
however, she remained SOB with ambulation throughout her stay.
.
# Hyponatremia: On admission, we found her initial Serum Na to
be 125. We followed her urinary electrolytes along with her
serum sodium. We deemed her results to indicate SIADH. We
placed her on fluid restrictions, however, noticed that she was
taking minimal fluids as is. We monitored her sodium and it
remained stable around 125.
.
# UTI - The patient was found to have E Coli growing in her
urine. She was treated with a course of ciprofloxacin.
.
Oncology - Breast cancer s/p lumpectomy and node dissection on
each breast on 2 different occasions. The patient refused any
chemotherapy.
.
# HTN: Patient stable on home medications.
.
# Hyperlipidemia: stable on home medications.
.
# Hypothyroid: Patient's TSH was found to be high. Her
levothyroxin dose was increased.
Medications on Admission:
LEVOTHYROXINE - 100 mcg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth at bedtime
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - Dosage uncertain
MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Capsule -
1 Capsule(s) by mouth
Discharge Medications:
1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: pre-medicate prior to draining pleurX
catheter.
5. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
1. recurrent left sided malignant hydrothorax
2. metastatic breast cancer
Secondary:
1. Urinary Tract Infection
2. Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital for dyspnea. You underwent
pleurex catheter placement on the left side for your fluid
accumulation around the lungs.
MEDICATION CHANGES:
- INCREASE levothyroxine to 112 mcg.
- START oxycodone as needed for pain
Followup Instructions:
Provider: [**Doctor Last Name 24141**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2165-8-30**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4285**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2165-9-4**] 9:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2165-9-4**]
9:30
Completed by:[**2165-8-30**]
ICD9 Codes: 5990, 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4153
} | Medical Text: Admission Date: [**2132-12-10**] Discharge Date: [**2133-1-23**]
Date of Birth: [**2071-9-13**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Fever, chills, left leg pain, redness and swelling
Major Surgical or Invasive Procedure:
-Left hip disarticulation.
-Diverting descending colostomy.
-Splenic flexure mobilization of the colon.
-Gastrostomy tube placement.
-Repair of incisional hernia.
-Debridement of subcutaneous tissue including muscle of
the left pelvis and gluteus.
-VAC dressing
-IVC filter [**2133-1-2**]
-Primary Wound Closure [**2133-1-6**]
History of Present Illness:
61 yo male with history of rectal carcinoma who presents after a
fall one week ago and BRBPR; now with fevers, chills, left leg
pain, redness and swelling.
Past Medical History:
Rectal cancer s/p resection w/ ileostomy & s/p ileostomy
takedown
Bilateral Knee arthroscopies
s/p Ventral hernia repair
Social History:
Married, owns men's clothing store in [**Location (un) 86**]
Family History:
Noncontributory
Physical Exam:
Vs upon admission:
97.2 HR 100 BP 99/56 RR 18
Gen- Disoriented
Cor- Tachy
Chest- Decreased breath sounds
Abd- soft, NT,ND, surgical scar
Rectum- guaiac positive, normal tone
Extr- left thigh & calf swollen w/ dependent erythema, warmth
Pertinent Results:
[**2132-12-10**] 11:52PM TYPE-ART PO2-161* PCO2-33* PH-7.33* TOTAL
CO2-18* BASE XS--7 INTUBATED-INTUBATED
[**2132-12-10**] 09:31PM GLUCOSE-73 UREA N-49* CREAT-2.5*# SODIUM-138
POTASSIUM-5.1 CHLORIDE-111* TOTAL CO2-16* ANION GAP-16
[**2132-12-10**] 09:31PM ALT(SGPT)-89* AST(SGOT)-185* ALK PHOS-32* TOT
BILI-1.5
[**2132-12-10**] 09:31PM CALCIUM-7.5* PHOSPHATE-7.6*# MAGNESIUM-1.2*
[**2132-12-10**] 09:31PM WBC-3.6* RBC-3.79* HGB-11.9* HCT-32.1* MCV-85
MCH-31.3 MCHC-37.0* RDW-13.9
[**2132-12-10**] 09:31PM PLT COUNT-131*
[**2132-12-10**] 09:31PM PT-16.2* PTT-37.3* INR(PT)-1.8
UNILAT LOWER EXT VEINS LEFT [**2132-12-10**] 12:49 PM
UNILAT LOWER EXT VEINS LEFT
Reason: LOWER EXTREMITY EDEMA AND PAIN
[**Hospital 93**] MEDICAL CONDITION:
61 year old man with L lower extremity edema and pain
REASON FOR THIS EXAMINATION:
assess for dvt
DOPPLER ULTRASOUND STUDY OF LEFT LOWER LIMB VEINS.
FINDINGS: Evaluation for DVT.
FINDINGS: The left lower limb veins are patent and compressible
along their length, there is normal phasic venous flow and
increased venous return with calf compression on color Doppler.
Some generalized edema noted in the subcutaneous tissues. No
collection.
CONCLUSION:
1. No DVT
2. Mild generalized subcutaneous edema noted.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 100046**],[**Known firstname **] [**2071-9-13**] 61 Male [**-5/4324**] [**Numeric Identifier 100047**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: FASCIA LEFT LEG, NECROTIC GLUTEUS LEFT,
LEFT LEG & LEFT PROXIMAL HEAD FEMUR.
Procedure date Tissue received Report Date Diagnosed
by
[**2132-12-10**] [**2132-12-11**] [**2132-12-18**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma??????
Previous biopsies: [**-5/3647**] GI BX'S, 2.
[**Numeric Identifier 100048**] HERNIA SAC.
[**Numeric Identifier 100049**] PORTA CATH GROSS ONLY, DISTAL ILEOSTOMY STOMA.
[**-3/3178**] PROCTECTOMY, PROXIMAL DONUT, DISTAL DONUT.
(and more)
DIAGNOSIS
1. Fascia, left leg (A-B):
- Necrotic fascia and fat with minimal inflammation.
- Necrotic skeletal muscle with acute inflammation.
2. Necrotic gluteus, left (C-D):
- Necrotic fascia and fat with acute inflammation.
- Skin with necrosis of subcutis.
3. Left leg (E-K):
- Skin and soft tissue (fascia, skeletal muscle, fat) with
extensive necrosis and acute inflammation; proximal margin is
focally involved.
- Viable bone at resection margin.
- Patent large vessels with mild-moderate atherosclerosis.
4. Left proximal femoral head (L-N):
- Necrotic soft tissue.
- Unremarkable bone.
Clinical: Necrotizing fascitis.
Gross: The specimen is received fresh in four parts, each
labeled with "[**Known lastname **], [**Known firstname **]" and the medical record number.
Part 1 is additionally labeled "fascia left leg" and consists of
a portion of necrotic muscle and fascia measuring 2.4 x 2.0 x
0.2 cm. A portion of this is submitted for frozen section.
Frozen section diagnosis by Dr. [**Last Name (STitle) **]. Brown is: "Necrotic muscle
and fascia with acute and chronic inflammation." The specimen
is represented as follows: A = frozen section remnant, B =
remainder of tissue.
Part 2 is additionally labeled "necrotic gluteus and leg
muscles" and consists of a 1200 gram aggregate of skin and
necrotic muscle measuring 14 x 14 x 13 cm. In certain areas the
specimen is liquified and the necrosis extends to 0.5 cm of the
epidermal surface. There are no discrete masses identified.
The specimen is represented in C-D.
Part 3 is additionally labeled " left leg" and consists of a leg
resected within the femur, measuring 80 cm long. The foot
measures 22 cm long with white skin over the entire surface.
There are no skin lesions over the foot. There is a linear
surgical defect at the lateral leg, starting 10 cm proximal to
the lateral malleolus extending up to the soft tissue resection
margin. This surgical defect extends down deep to the fascia.
There is a portion of brown, necrotic appearing skeletal muscle
and fascia starting 14 cm from the proximal resection margin,
measuring 13 x 11 cm. The fascia here has been incised
previously. There is viable tissue apparent adjacent to the
tibia and femur, however the tissue is necrotic deep to the
fascia. The vessels are dissected and there are mild
atherosclerotic changes visible within the popliteal vessels.
The dorsalis pedis appears grossly unremarkable. The soft
tissue resection margin does appear involved by necrotic muscle,
however, the skin and the bone appear grossly unremarkable. The
specimen is represented as follows: E-F = femur resection margin
after decal, G-H = soft tissue and skin resection margin, I =
necrotic appearing muscle, J = necrotic appearing fascia, K =
representative sections through popliteal and dorsalis pedis
vessels.
Part 4 is additionally labeled "left proximal head, femur" and
consists of a portion of femur with attached femoral neck and
femoral head measuring 14 x 9 x 3 cm. Attached to the femur,
the portion of skeletal muscle and fascia measuring 9 x 8 x 6
cm. There is focal necrosis within the muscle, particularly
adjacent to bone. The articular cartilage of the femoral head
appears focally eroded over an area measuring 1.7 x 0.8 cm. The
necrotic soft tissue is represented in L. The head of the femur
is hemisected to reveal a grossly unremarkable cortical bone,
with no areas of necrosis or cyst formation within the bone.
The area of articular erosion is represented in M after decal.
The femur and femoral neck are sectioned in the area adjacent to
the necrotic soft tissue to reveal grossly unremarkable bone,
with necrotic adjacent soft tissues. Section of bone adjacent
to necrotic soft tissue is submitted in N after decal.
CT PELVIS W/CONTRAST [**2132-12-16**] 6:14 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: eval for fistula
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p left hip disarticulation for nec [**Hospital **]. with
stool from wound
REASON FOR THIS EXAMINATION:
eval for fistula
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: History of rectal cancer, now status post left hip
disarticulation for necrotizing fasciitis, with stool from the
wound. Evaluate for fistula.
COMPARISON: Study from [**2132-7-2**].
TECHNIQUE: MDCT-acquired contiguous axial images were obtained
from the lung bases to the pubic symphysis. Multiplanar
reconstructions were performed.
CONTRAST: Oral contrast and 145 cc of IV Optiray contrast were
administered due to the rapid rate of bolus injection required
for this study.
CT OF THE ABDOMEN WITH IV CONTRAST: Tiny bilateral pleural
effusions are noted. No parenchymal consolidation or pulmonary
nodules are identified.
An NG tube is seen positioned within the stomach. The liver,
gallbladder, adrenal glands, spleen, right kidney, and pancreas
are normal in appearance. The left kidney demonstrates a
hypodensity which is too small to characterize. There is
diastasis of the anterior abdominal wall rectus muscles.
Scattered retroperitoneal lymph nodes are noted which do not
pathologically enlarge by CT criteria. The stomach and small
bowel are normal in appearance, without any evidence of bowel
wall dilatation or thickening. No free fluid or free air is
seen.
CT OF THE PELVIS WITH IV CONTRAST: Foley catheter is seen within
the bladder. The sigmoid and descending colon are normal in
appearance. Within the left pelvic soft tissues, changes are
seen from recent hip disarticulation. There is fluid, soft
tissue gas, and soft tissue stranding from recent surgery.
Additionally, within the distal most portion of the femoral
veins at the site of amputation, there is a filling defect,
consistent with occlusion.
Within the rectum, in the presacral space there is again noted a
soft tissue thickening, which is seen on the prior study from
[**2132-7-2**], and may reflect change from prior surgery or therapy
for rectal cancer. Additionally, on more inferior images, there
is a possible focal outpouching on the left adjacent to the
coccyx, but this is not clearly defined. Additionally, in the
soft tissues, there is extensive stranding, and soft tissue gas
extending from surgery in that area. More inferiorly, there is a
focal second outpouching which contains gas and fluid, which may
be in the ischiorectal space, and may represent focal
outpouching versus a sinus tract. There is not a significant
amount of inflammatory stranding adjacent to this, making an
abscess less likely.
BONE WINDOWS: Changes are seen from recent surgery within the
left hip. No other suspicious lytic or sclerotic lesions are
identified.
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential
in delineating the anatomy and pathology.
IMPRESSION:
1. There are extensive changes within the soft tissues adjacent
to the left acetabulum, where there has been recent surgery for
left hip disarticulation. There is extensive soft tissue gas and
defect in this area.
2. Within the rectum, there is soft tissue thickening within the
presacral space, which was seen on the prior study, and may
represent changes from prior therapy for rectal cancer.
Additionally, within the rectum, there is a focal area of
outpouching on the left. No definite fistulous tract is
identified. Inferior to this, there is a second area of focal
outpouching which appears to be adjacent to the lower
rectum/anal canal. This study does not definitely identify a
fistula, and cannot exclude the presence of a fistula. Further
evaluation is recommended.
3. Tiny bilateral pleural effusion.
CT ABDOMEN W/CONTRAST [**2133-1-14**] 2:55 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: assess for abscess or fluid collection
Field of view: 38 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p left hip disarticulation for nec [**Last Name (LF) **], [**First Name3 (LF) **]
pus in JP output
REASON FOR THIS EXAMINATION:
assess for abscess or fluid collection
CONTRAINDICATIONS for IV CONTRAST: None.
CT ABDOMEN AND PELVIS
There is comparison from [**2132-12-16**].
CLINICAL HISTORY: Status post left hip disarticulation for
necrotizing fasciitis, pus in JP drain, evaluate for abscess or
fluid collection.
TECHNIQUE: Axial MDCT images of the abdomen and pelvis were
obtained with IV and barium based contrast placed through the
stoma.
FINDINGS: Images of the lower thorax demonstrate an increased
size of the right pleural effusion. There is trace left pleural
effusion, which is decreased in size since the previous exam.
The heart size is normal.
The liver, spleen, pancreas, adrenal glands, and kidneys are
normal. The gallbladder is present. A gastrostomy tube is
present with its tip in the lumen of the stomach. An IVC filter
is present with its tip below the renal veins.
The patient is status post left hemicolectomy. In the bed of the
left colon tracking caudally and medially and terminating in the
mid pelvis, there is an enhancing fluid collection.
CT PELVIS FINDINGS: In the soft tissues of the left hemipelvis,
there is a large multiloculated fluid and gas collection
present. There is heterotopic ossification in this region.
Several drains are seen coursing through this fluid collection.
There is liquefaction of the adjacent pelvic muscles. Thrombus
is seen in the left superficial and deep femoral veins. The
largest diameter of this fluid collection is 15 cm. It extends
from the obturator foramen superiorly to the left iliac crest.
The osseous structures of the left hemipelvis look intact on
this study. There is ulceration of the skin of the left buttock
which is likely related to infection and debridement.
IMPRESSION:
1. Large abscess in the region of the disarticulated left hip,
which extends over the superior aspect of the iliac crest to the
obturator foramen.
1. Additionally, there an abscess or seroma in the left abdomen
in the region of the left colon bed with dependent accumulation
in the pelvis.
2. Thromboses in the left superficial and deep femoral veins.
3. Liquefaction of the left pelvic musculature in the region of
the abscess.
4. These findings were communicated to the clinical service on
[**2133-1-14**].
Brief Hospital Course:
Patient admitted to the trauma service; he was transferred to
the intensive care unit secondary to sepsis. Orthopedics
consulted because of his necrotizing fascitis; he was taken to
the operating room for left hip disarticulation.
Micro: [**1-15**] Cdiff neg [**1-12**] JP drain GNRs (heavy growth ID & S P),
GPC in p, GPRs, G variable; Cdiff neg [**1-11**] Cdiff neg [**12-10**] bld
cx. pan S E. coli.
RADS: [**1-15**] CT abd abscess drained spont [**1-14**] CT abd abscess iliac
crest to the obturator foramen. abscess/seroma left colon bed.
Thromboses in the left superficial and deep femoral veins.
Liquefaction of the left pelvic musculature in the region of the
abscess. [**1-10**] KUB no obs [**1-5**] gastrograffin/ KUB neg
closure/debridement per plastics.
[**12-17**] -OR for colostomy dressing change
[**12-24**] transfer to floor, TF's cycled
[**12-27**]- tube feeds held, erythema @ G-tube site, stoma dusky,
+TTP R abdomen
[**12-29**] - OR for woundvac to L stump
[**12-31**] - OR for wound vac change, washout
[**1-2**] - IVC filter, f/u [**Hospital **] clinic PRN for removal
[**1-6**] - OR s/p I&D, local flap closure, [**Doctor Last Name **] x4: 2
posterior-deep, 2 anterior - superficial.
[**1-7**] - DAT, pain control
[**1-8**] - Rehab screen.
[**1-9**] - SW for coping, bowel regimen restarted.
[**1-10**] - N/V-> switched to IV flagyl and IV vanco, d/c clinda.
lg amt emesis.
[**1-11**] - NGT placed, GT to gravity, NPO. SBO vs narc ileus, Cdiff
neg.
[**1-12**] - Improved clinically, clamped GT, NPO.
+ purulent drainage from JPs, Cx GNR.
[**1-13**] -Started TF cycle PM/clears. Accepted at [**Hospital1 **]. c-diff
neg x2. f/u with PRS about opening wound.
[**1-14**] -CT abd/pelvis-large fluid collection in L hip and bed of L
colon. PRS will likely not drain.
[**1-15**] -hip collection drained spontaneously, NTD on by IR (fluid
collection resolved on CT)
[**1-16**] -JP Cx repeat. Plan is [**Hospital1 **] next week if stable.
No acute issues over the weekend. Pt c/o mild intermittent
"gnawing" abd pain.
[**1-19**] - Pt remains stable. Attending plastics note confirms that
they will not intervene on LLE stump and he is cleared for d/c
from their perspective.
[**2133-1-20**] - comfirmed klebsiella and entercoccus in jp drainage,
pt remains afebrile and stable off abx.
[**2133-1-22**] - LLE stump continues to ooze; JP drains remain in place
with decreased output. Plan is for follow up in [**Hospital 3595**] clinic
1 week from next Tuesday; likely may d/c drains at that time.
Medications on Admission:
Percocet
Hydrocortisone
Ativan
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Zinc Sulfate 220 mg Tablet Sig: One (1) Capsule PO once a
day.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain/fever.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
7. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet
Sustained Release PO Q12H (every 12 hours).
9. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Necrotizing Fascitis Left Leg
Left Hip Disarticulation
Discharge Condition:
Stable
Discharge Instructions:
*Follow up in Trauma & Plastic Surgery Clinic in 2 weeks.
*Follow up with your Primary Doctor after your discharge from
rehab.
Followup Instructions:
1.Call [**Telephone/Fax (1) 6439**] for an appointment in Trauma Clinic; located
in [**Hospital Ward Name **] Bldg, [**Location (un) 470**], [**Hospital Ward Name 517**] and [**Telephone/Fax (1) 26839**] for an
appointment in [**Hospital 3595**] clinic
2.Call Dr. [**Last Name (STitle) **] for an apppointment after you are discharged
from rehab.
3. You have an appointmnent with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**],
MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2133-2-2**] 9:30. [**Hospital Ward Name 23**] Bldg,
[**Hospital Ward Name 516**]
Completed by:[**2133-1-23**]
ICD9 Codes: 0389, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4154
} | Medical Text: Admission Date: [**2124-12-27**] Discharge Date: [**2125-3-14**]
Date of Birth: [**2124-12-27**] Sex: F
Service: NEONATOLOGY
HISTORY OF THE PRESENT ILLNESS: Baby girl [**Known lastname **] [**Known lastname 2302**],
Twin #1 delivered on [**2124-12-27**] at 27 weeks gestation,
weighing 985 grams and was admitted to the Intensive Care
Nursery for management of prematurity.
woman with prenatal screens, which included blood type B
positive, antibody screen negative, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative and group B
strep unknown. The pregnancy was complicated by
monochorionic dye amnionic twin gestation with concern for
twin-to-twin transfusion with polyhydramnios of twin #1 and
oligohydramnios of twin #2. The mother presented in pre-term
sulfate and betamethasone. Spontaneous rupture of membranes
of this twin prompted delivery by cesarean section.
This infant emerged with good respiratory effort, heart rate
and tone. She was given mask CPAP and transported to the
Intensive Care Nursery. Apgar scores were 7 and 8 at 1 and 5
minutes respectively.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: Weight 985 grams (25th to 50th percentile).
Length: 36.5-cm (15th percentile). Head circumference:
25.5-cm (59th percentile). GENERAL: This is a nondysmorphic
pre-term female. SKIN: Without rashes or petechiae. HEAD:
Anterior fontanelle soft, flat, sutures approximated. EYES:
Right eye fused, left eye open with positive red reflex.
ENT: No clefts. THORAX: Symmetric with retracting. LUNGS:
Poor air entry with inspiratory crackles. HEART: Normal S1
and S2 without murmur, pulses 2+ in both upper and lower.
ABDOMEN: Soft, without hepatosplenomegaly, no masses.
GENITALIA: Normal pre-term female. Anus patent. Trunk and
spine straight, intact, without dimple. EXTREMITIES: Hip
stable, reflexes appropriate for gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
#1. RESPIRATORY: Intubated on admission for respiratory
distress syndrome. Received a total of two doses of
Survanta. Maximum ventilator support, pressures 20/5, rate
of 22, 30% to 40% oxygen. Extubated to CPAP around
twenty-four hours of life. Required reintubation for
increased apnea on day of life 12. Extubated again to CPAP
on day of life #26. Weaned off CPAP on day of life #54.
Required supplemental oxygen by nasal cannula until day of
life #72 ([**2125-3-9**]). Remained in room air since with
comfortable work of breathing. Respiratory rate 30s to 50s.
Oxygen saturations greater than 95%.
Treated with caffeine citrate for apnea of prematurity. The
caffeine citrate was discontinued on [**2125-2-17**]. The last
apnea-bradycardia episode on [**2125-3-4**].
#2. CARDIOVASCULAR: The patient was treated with two
boluses of normal saline, the a Dopamine infusion on
admission for low mean blood pressures. Weaned off the
Dopamine on day of life #2. Also treated with four doses of
hydrocortisone during that time for the low mean blood
pressures.
Echocardiogram was done on day of life #12 to evaluate a
heart murmur. Echocardiogram showed no patent ductus
arteriosus and structurally normal heart. A soft
intermittent murmur has been audible during the hospital
course. The patient has remained hemodynamically stable
since the day of life #2. A recent blood pressure 70/52 with
a mean of 60.
#3. FLUIDS, ELECTROLYTES, AND NUTRITION: Initially was
maintained on D5W, then total parenteral nutrition by
umbilical artery catheter and umbilical venous catheter. The
umbilical catheters were discontinued on day of life #5 and a
percutaneous central line was placed. Enteral feeds were
started on day of life #6, but due to formula aspirates, bile
aspirates and abdominal distention, feeds were stopped on day
of life #10. The feeds were resumed on day of life 13 and
progressed to full volume feeds without problems on day of
life #22. The caloric density was gradually increased to a
maximum of 30 calories per ounce with ProMod added.
At discharge, the patient is taking expressed breast milk
with Enfamil powder, 4 calories per ounce and corn oil 2
calories per ounce added to equal 26 calorie per ounce
feedings and has been gaining weight well.
Discharge weight 3175 gm, length 48.5 cm, and head circumference
33.5 cm. :
#4: GASTROINTESTINAL: Slow to advanced feeds initially due
to bile and breast milk aspirates and abdominal distention
thought to be due to the maternal treatment with magnesium
sulfate prior to birth. This all resolved by day of life #13
and has had no further problems.
Treated with phototherapy for indirect hyperbilirubinemia.
Peak bilirubin total 4.7, direct .3.
#5. HEMATOLOGY: Infant's blood type is B negative, direct
Coombs negative. Received a total of two packed red blood
cell transfusions during hospitalization; last transfusion on
[**2125-2-4**]. Recent hematocrit was on [**2125-2-22**] and 29% with a
reticulocyte count of 3.1%.
#6. INFECTIOUS DISEASE: Received a 48 hour course of
Ampicillin and Gentamycin following delivery for rule out
sepsis. Blood culture was negative. CBC was benign.
Received a five-day course of Oxacillin for omphalitis from
day of life 8 to day of life 12. Received a 48 hour course
of Vancomycin and Gentamicin from day of life 10 to day of
life 12 for rule out sepsis with a normal CBC and negative
blood culture.
#7. NEUROLOGY: Head ultrasound done on day of life #2 and
day of life #8 was normal with no intraventricular
hemorrhage. Followup head ultrasounds done on day of life 36
and day of life 76 showed bilateral symmetrical echogenic
thalamic vessels, a finding of uncertain significance. No
ventriculomegaly. No hemorrhage, and no change between
studies. Followup head ultrasound is recommended at
[**Hospital3 1810**] infant followup clinic.
#8. SENSORY: Audiology hearing screening was performed with
automated auditory brain-stem response. Infant passed both
ears.
Ophthalmology: Eyes examined most recently on [**2143-3-15**]
revealing mature eyes bilaterally. Follow up suggested in 6
months with Dr [**Last Name (STitle) 36137**].
#9. PSYCHOSOCIAL: Parents married and have visited at least
once daily, comfortable caring for [**Known lastname **].
CONDITION ON DISCHARGE: This is a 77-day-old, now 37 and
2/7th weeks corrected gestational age infant, stable,
feeding, and growing.
DISCHARGE DISPOSITION: Discharged home with parents.
PRIMARY PEDIATRICIAN: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Telephone #:
[**Telephone/Fax (1) 37151**].
CARE RECOMMENDATIONS:
#1. Feeds: Express breast milk with Enfamil powder and corn
oil added.
#2. Medications: Poly-Vi-[**Male First Name (un) **] 1 cc p.o. daily. Fer-In-[**Male First Name (un) **]
0.25 cc daily
#3. Car seat position screening: Passed.
#4. State newborn screening status: State newborn screens
have been followed per protocol for premature infant. Most
recent on [**2125-2-15**], all within normal limits.
#5. Immunizations received: The patient received the
following two-month immunizations. Received polio vaccine
and hemophilus B vaccine on [**2-28**]. Received DTAP, hepatitis
B, and PCV7 on [**3-1**]. Received Synagis on [**2125-3-10**].
#6. Immunizations recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants
who meet any of the following three criteria: #1 born at
less than 32 weeks; #2 born between 32 and 35 weeks with
plans for day care during RSR season with a smoker in the
household or with preschool siblings; or #3 chronic lung
disease. Influenza immunization should be considered
annually in the fall for pre-term infants with chronic lung
disease once they reach six months of age. Before this age,
the family and other caregivers should be considered for
immunizations against influenza to protect the infant.
FOLLOW-UP APPOINTMENTS: Scheduled, recommended:
#1. Parents have pediatric appointment on [**2125-3-15**].
#2. Early intervention [**Year (4 digits) 28085**] has been made to [**Hospital1 **]
[**Hospital1 **] early intervention program [**Telephone/Fax (1) 37152**].
#3. [**First Name (Titles) **] [**Last Name (Titles) 28085**] has been made to
care group [**Hospital6 **], telephone #
[**Telephone/Fax (1) 37153**].
#4. [**Telephone/Fax (1) **] made to infant followup program at [**Hospital3 18242**]. Telephone #: [**Telephone/Fax (1) 37126**].
DISCHARGE DIAGNOSES:
#1. AGA 27 week preterm female.
#2. Twin #1.
#3. Respiratory distress syndrome, resolved.
#4. Hypotension, resolved.
#5. Infection ruled out times three.
#6. Omphalitis.
#7. Heart murmur.
#8. Indirect hyperbilirubinemia, resolved.
#9. Apnea of prematurity, resolved.
#10. Anemia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**First Name3 (LF) 37154**]
MEDQUIST36
D: [**2125-3-13**] 12:24
T: [**2125-3-13**] 12:31
JOB#: [**Job Number 37155**]
ICD9 Codes: 769, 7742, 4589, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4155
} | Medical Text: Admission Date: [**2109-8-23**] Discharge Date: [**2109-9-5**]
Date of Birth: [**2036-9-15**] Sex: F
Service: CARDIOTHORACIC SURGERY
ADMITTING DIAGNOSIS: Shortness of breath
DISCHARGE DIAGNOSIS: Sternal wound infection/mediastinitis
HISTORY OF PRESENT ILLNESS: This is a 72-year-old female
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] on [**2109-8-5**] who was transferred
from [**Hospital6 3872**]. She was admitted there for
hypercarbic respiratory failure and intubated secondary to
CO2 retention when given oxygen at the outside hospital. She
was subsequently sent to their Intensive Care Unit and
extubated, at which point she was found to have an infection
of her sternotomy wound. She was placed on vancomycin
Proteus sensitive to the vancomycin. She was also in mild
renal failure during her hospitalization which was resolving
upon transfer.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft x4
2. Hypertension
3. Chronic obstructive pulmonary disease
4. Status post knee replacement
5. Aortic stenosis
6. Hiatal hernia
7. Depression
8. Status post cholecystectomy
9. Status post appendectomy
10. Status post carpal tunnel release surgery
ALLERGIES: She had no known drug allergies.
ADMISSION MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Zantac 150 mg p.o. b.i.d.
3. Colace 100 mg p.o. b.i.d.
4. Lasix 20 mg p.o. b.i.d.
5. K-Dur 20 milliequivalents p.o. b.i.d.
6. Lopressor 100 mg p.o. b.i.d.
7. Atrovent and albuterol metered dose inhaler 2 puffs 4x
per day
SOCIAL HISTORY: Significant for ex-smoker who stopped seven
years ago. She had a 60 pack year history of smoking.
PHYSICAL EXAM ON ADMISSION:
VITAL SIGNS: She was afebrile with a pulse in the high 90s
and a blood pressure in the high 180s/90s. She was
saturating 96% on 2 liters nasal cannula.
HEART: She was in regular rate and rhythm.
CHEST: Crackles bilaterally halfway up the lung fields and
she had a dressing placed over her sternotomy with purulent
exudate on the inferior portion.
ADMISSION LABS: White count of 6.9, hematocrit of 25.4. BUN
and creatinine of 40/0.8. Gram stain of the wound
demonstrated gram positive cocci in pairs, chains and
clusters. Given these findings, the patient was continued on
his vancomycin 1 gm intravenous q 12 hours and ciprofloxacin
500 mg b.i.d. was added for gram negative coverage.
Cardiothoracic surgery was consulted to come and evaluate the
patient.
HOSPITAL COURSE: After consultation with cardiac surgery,
the patient was taken to the Operating Room on [**8-25**]
where a radical sternal debridement and open packing of the
wound were performed for a sternal wound infection with
associated sternal osteomyelitis. This was performed by Dr.
[**Last Name (STitle) **], assisted by Dr. [**Last Name (STitle) 11743**]. An infectious disease consult
was also requested which also recommended continuing of the
vancomycin, ciprofloxacin as it appeared to be adequate
coverage for the patient's infections. The cultures obtained
from the sternal swab in the Emergency Room had demonstrated
coagulase positive Staphylococcus aureus, probable
Enterococcus and Proteus.
The patient remained in the Intensive Care Unit and a plastic
surgery consult was requested for possible flap closure of
his sternum. The plastic surgeons recommended flap closure
of the wound and the patient was taken to the Operating Room
once again on [**8-29**] where an omental flap closure of
his sternal wound was performed by Dr. [**First Name (STitle) **], assisted by
Dr. [**Last Name (STitle) **]. Postoperatively, the patient was continued on
his vancomycin and ciprofloxacin and was doing well,
transferred to the floor. The patient's creatinine was
noted, however, to double on postoperative day #2, climbing
from 0.7 to 1.4 and peaking over the next couple days at 2.
Given the development of acute renal failure, the patient's
antibiotics were changed to renal doses. The patient's urine
sediment was examined and did not demonstrate any evidence
ATN. The FENa was not less than 1% and there was no evidence
of acute interstitial nephritis at the time.
Over the next couple of days, the renal failure began to
resolve with a decrease in the creatinine to 1.9 and then 1.8
respectively. The patient was making good urine and remained
afebrile with stable vital signs. Given the fact that her
sternotomy was healing very well with no erythema, edema,
induration or drainage and the abdominal incision that was
used for a flap was well healed with any erythema, edema,
induration or drainage and that the patient had a PICC line
placed and was capable of having intravenous antibiotics at a
rehabilitation facility, it was felt that she was stable for
transfer. She was transferred on a regular diet.
DISCHARGE MEDICATIONS;
1. Colace 100 mg p.o. b.i.d.
2. Zantac 150 mg p.o. b.i.d.
3. Aspirin 81 mg p.o. q.d.
4. Heparin subcutaneous 5000 units subcutaneous b.i.d.
5. Albuterol/Atrovent metered dose inhaler 4 puffs q4h
6. Zestril 10 mg p.o. q.d.
7. Vitamin C 500 mg p.o. b.i.d.
8. Zinc sulfate 220 mg p.o. q.d.
9. Lopressor 75 mg p.o. b.i.d.
10. Zoloft 50 mg p.o. q.d.
11. Vancomycin 1 gm intravenous q 24 hours for 32 days
12. Ciprofloxacin 500 mg p.o. q.d. for 30 days
13. Percocet 1 to 2 p.o. q 4 to 6 hours prn with a request
that vancomycin peak and trough levels be checked after the
first dose given at the rehabilitation center.
DISCHARGE DIAGNOSES:
1. Sternal wound infection with sternal osteomyelitis,
status post operative debridement with flap closure
2. Coronary artery disease, status post coronary artery
bypass grafting x4 in [**2109-7-10**]
3. Hypertension
4. Chronic obstructive pulmonary disease
5. Aortic stenosis
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-641
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2109-9-5**] 09:13
T: [**2109-9-5**] 10:10
JOB#: [**Job Number 35719**]
ICD9 Codes: 5849, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4156
} | Medical Text: Admission Date: [**2115-12-26**] Discharge Date: [**2116-1-3**]
Date of Birth: [**2032-5-26**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7733**]
Chief Complaint:
squamous cell carcinoma of scalp eroding through cranium to the
dura
Major Surgical or Invasive Procedure:
1. wide-excision of squamous cell carcinoma of scalp
2. craniotomy
3. dural excision and dural replacement using anterior rectus
fascia
4. free right rectus muscle flap to cranium using superficial
temporal vessels on the right
5. split-thickness skin graft to vascularized muscle flap
6. mesh closure of abdomen
7. excision of squamous cell carcinoma of the right helical rim
of ear (3 x 1 cm)
8. plastic closure of the ear excision site
History of Present Illness:
83 year old male who has been followed initially in [**State 1727**] over
the past decade for multiple basal cells and squamous cells
involving the head and neck region. He has had multiple
previous procedures. We first met him with a radiation related
problem[**Name (NI) 115**] nonhealing ulcer on the nose with recurrent tumor.
This was eventually widely excised and he is now missing the
right half of his nose. He does not wished to have any
reconstruction for this. Problem[**Name (NI) 115**] over the past year has
been an erosive ulcer involving the dome of
the cranium. This has been open for least 4-6 months. MRI was
obtained that showed erosion through the outer and inner table
of the skull just to the right of the superior sagittal sinus in
the upper parietotemporal region with accumulation of tissue on
the dura.
Past Medical History:
1. Dyslipidemia
2. Hypertension
3. Non-Hodgkin's lymphoma(dx 6-7yrs ago-in remission per
hospital
notes)
4. Melanoma to cheek, s/p resection & STSG [**2110**]
5. s/p LLL lobectomy [**3-/2115**](also w/known mediastinal and
axillary
lesions)-Path per hospital records Stge IB Non-small cell lung
cancer
6. Small cell carcinoma to right head, s/p STSG [**10/2115**]
7. s/p Left THR [**2111**]
8. s/p Right Knee arthroscopy
Social History:
resides at home in [**State 1727**], capable of self-care, lives
independently
tobacco: 40pack-year history, quit 40 years ago
EtOH: occasional alcohol use
denies ilicit drug use
Family History:
father and sister with cancer diagnosis (nonspecific details)
Physical Exam:
upon admission:
General: alert and oriented x3
HEENT: wide surgical excision of right nose, skin lesion right
scalp
Chest: clear to auscultation on right, coarse breath sounds on
left
CV: RRR
Abdomen: soft, nontender, nondistended
Ext: no BLE edema appreciated
Pertinent Results:
[**2115-12-26**] 05:57PM TYPE-ART PO2-384* PCO2-36 PH-7.46* TOTAL
CO2-26 BASE XS-2
[**2115-12-26**] 05:57PM freeCa-1.10*
[**2115-12-26**] 05:40PM GLUCOSE-138* UREA N-18 CREAT-0.9 SODIUM-141
POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-22 ANION GAP-11
[**2115-12-26**] 05:40PM estGFR-Using this
[**2115-12-26**] 05:40PM CALCIUM-7.9* PHOSPHATE-2.7 MAGNESIUM-1.3*
[**2115-12-26**] 05:40PM WBC-8.4 RBC-3.36*# HGB-10.5*# HCT-30.2*#
MCV-90 MCH-31.3 MCHC-34.9 RDW-13.1
[**2115-12-26**] 05:40PM PLT COUNT-204
[**2115-12-26**] 03:13PM PO2-172* PCO2-42 PH-7.40 TOTAL CO2-27 BASE
XS-1
[**2115-12-26**] 03:13PM GLUCOSE-107* LACTATE-0.7 NA+-140 K+-3.7
CL--110
[**2115-12-26**] 03:13PM HGB-10.5* calcHCT-32
[**2115-12-26**] 03:13PM freeCa-1.11*
[**2115-12-26**] 10:28AM TYPE-ART PO2-116* PCO2-43 PH-7.41 TOTAL
CO2-28 BASE XS-2
[**2115-12-26**] 10:28AM GLUCOSE-105 LACTATE-0.8 NA+-140 K+-3.6
CL--111
[**2115-12-26**] 10:28AM HGB-11.0* calcHCT-33 O2 SAT-98
[**2115-12-26**] 10:28AM freeCa-1.10*
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
[**2115-12-26**] and had a wide-excision of squamous cell carcinoma of
scalp, craniotomy, dural excision and dural replacement using
anterior rectus fascia, free right rectus muscle flap to cranium
using superficial temporal vessels on the right, split-thickness
skin graft to vascularized muscle flap, mesh closure of abdomen,
excision of squamous cell carcinoma of the right helical rim of
ear (3 x 1 cm), plastic closure of the ear excision site, the
patient tolerated the procedure well and was admitted to the
SICU post-operatively.
Neuro: Post-operatively, the patient received morphine IV and
percocet with good effect and adequate pain control. Upon
transfer to the inpatient floor, patient experienced significant
delirium and agitation with worsening symptoms at night.
Patient was noted to have had a paucity of uninterrupted sleep
post-operatively in the SICU. Patient was closely monitored by
the primary team, nursing, and family and effort was made to
provide a dark, quiet environment to facilitate rest. The
following day, he showed marked improvement in symptoms and his
delirium did not return for the remainder of this admission.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate
and was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. The foley catheter was removed on
[**12-30**]. Intake and output were closely monitored.
ID: Post-operatively, the patient was started on IV cefazolin,
then switched to PO cephalexin on POD#2 until discharge. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient was provided with pneumatic boots and
encouraged to get up and ambulate as early as possible.
At the time of discharge on POD#8, the patient, rectus flap, and
surgical sites were doing well, afebrile with stable vital
signs, tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled.
Medications on Admission:
aspirin
atenolol
atorvastatin
amlodipine
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*20 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
southern [**Hospital **] medical center VNA,
Discharge Diagnosis:
squamous cell carcinoma of scalp eroding through cranium to the
dura
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
- Avoid caps, stockings, or other headwear that place pressure
on your graft site
- Keep your skin graft donor site clean and dry at all times
- You may clean around the area of your head flap with normal
saline
- You may shower but avoid direct waterfall onto your head flap
and keep a tegederm over the skin graft donor site on your leg
- Do not remove the steristrips on your abdominal incision, you
may trim them at the edges when there lose adherence to the
skin. The steristrips will fall off on its own in [**1-18**] weeks.
Call Dr[**Name (NI) 23346**] office or return to the ER if:
* You notice significant changes in your flap, surgical incision
site, or skin graft site - to include color, swelling, drainage,
and pain
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
please call Dr[**Name (NI) 23346**] office at [**0-0-**] to schedule a
follow-up visit
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]
Completed by:[**2116-1-3**]
ICD9 Codes: 2930, 2749, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4157
} | Medical Text: Admission Date: [**2128-1-26**] Discharge Date: [**2128-1-31**]
Date of Birth: [**2052-12-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2128-1-26**] 1. Coronary artery bypass grafting x2, left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft to the right coronary artery. 2. Aortic
valve replacement, [**Street Address(2) 11688**]. [**Hospital 923**] Medical Biocor tissue.
History of Present Illness:
74 yo male followed for several years with serial
echocardiograms for aortic stenosis. He has slowly developed
some dyspnea on exertion. Most recent echocardiogram showed
confirmed aortic stenosis. He underwent a cardiac cath in
preparation for aortic valve surgery which revealed two vessel
disease.
Past Medical History:
Aortic stenosis
History of transient Atrial fibrillation (not on Coumadin)
Hypertension
History of Pericarditis [**2110**]
Cataract Surgery
Social History:
Race: Caucasian
Last Dental Exam: 6 months ago
Lives with: Wife
Occupation: Retired
Tobacco: Quit at age 27
ETOH: 1 beer/night
Family History:
Non-contributory
Physical Exam:
Pulse: 51 Resp: 18 O2 sat: 98%
B/P Right: 128/71 Left: 132/69
Height: 6'0" Weight: 195 lbs
General: Well-developed male in no acute distress
Skin: Warm[X] Dry [X] intact [X]
HEENT: NCAT[X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur 3/6 systolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema - trace
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: trans murmur
Pertinent Results:
[**2128-1-26**] Echo Prebypass: No spontaneous echo contrast is seen in
the body of the left atrium or left atrial appendage. No
mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild left ventricular hypertrophy.The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Mild to moderate ([**1-18**]+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of
the results on [**2128-1-26**] at 900am.
Post bypass: Patient is A paced and receiving an infusion of
phenylephrine. Biventricular systolic function is unchanged.
Bioprosthetic valve seen in the aortic position. It appears well
seated. The mean gradient across the valve is 15 mm Hg. Mild
mitral regurgitation persists. Cannot visualize aortic contours
very well post bypass.
Brief Hospital Course:
Mr. [**Known lastname 88403**] was a same day admit and on [**1-26**] was brought to the
operating room where he underwent a coronary artery bypass graft
x 2 and aortic valve replacement. Please see operative report
for surgical details. Following surgery he was transferred to
the CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one he was started on
beta-blockers and diuretics and diuresed towards his pre-op
weight. He went into atrial fibrillation post-operatively and
was started on Amiodarone and given additional beta-blockers.
Coumadin was eventually started for a goal INR of [**2-18**].5. On
post-op day one he was transferred to the stepdown floor for
further care. Chest tubes and epicardial pacing wires were
removed per protocol. During his post-op course he worked with
physical therapy for strength and mobility. Except for his
atrial fibrillation he made good progress and was ready for
discharge home with VNA services on post-op day five with the
appropriate medications and follow-up appointments. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4129**] will advise pt on Coumadin dose following INR draw on
Sunday [**2-1**]. Then his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 11270**] will follow his Coumadin
and INR. [**First Name9 (NamePattern2) 88404**] [**Last Name (un) **] PA-C who works with Dr. [**First Name (STitle) 11270**] stated
there office will contact Mr. [**Known lastname 88403**] for Coumadin follow-up.
Medications on Admission:
Triamterene 37.5 mg/HCTZ 25 mg daily
ECASA 81 mg daily
Norvasc 5 mg daily
Atenolol 50 mg daily
Simvastatin 40 mg QHS
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take 400 mg twice daily x 5 days, then 200 mg
twice daily x 7 days. And finally 200 mg daily until stopped by
cardiologist.
Disp:*60 Tablet(s)* Refills:*2*
7. warfarin 1 mg Tablet Sig: as directed Tablet PO once a day:
Please take zero tablets on [**1-31**]. VNA to draw INR on [**2-1**] with
results to be called to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] at [**Telephone/Fax (3) **]. In future,
your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 11270**] is following your Coumadin and INR and will
advise on dosage. Goal INR 2-2.5.
Disp:*90 Tablet(s)* Refills:*2*
8. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease/Aoritc Stenosis s/p Coronary Artery
Bypass Graft x 2 and Aortic valve replacement
Past medical history:
History of transient Atrial fibrillation (not on Coumadin)
Hypertension
History of Pericarditis [**2110**]
Cataract Surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2-19**] at 1:15pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8421**] on [**3-1**] at 2:15pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) 11270**] in [**4-20**] 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: Sunday [**2128-2-1**] with results to be phoned to [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4129**] at [**Telephone/Fax (1) 170**].
Then next draw on Tuesday [**2-3**] and every Monday, Wednesday,
Friday.
All these results to phone: Dr. [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) 11270**] will follow and
his office will contact Mr. [**Known lastname 88403**] regarding f/u but results
should be called into [**Telephone/Fax (1) 79695**] unless otherwise noted by Dr.
[**First Name (STitle) 11270**].
Completed by:[**2128-1-31**]
ICD9 Codes: 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4158
} | Medical Text: Admission Date: [**2130-5-16**] Discharge Date: [**2130-5-27**]
Date of Birth: [**2050-4-5**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
SAH
Major Surgical or Invasive Procedure:
Right Extenral Ventricular drain
History of Present Illness:
Patient is an 80 yo F with hx of HTN/HL who presents with
headache as transfer from OSH with SAH. Per patient, yesterday
she had the abrupt onset of posterior/occipital HA at around 5pm
that lasted 30 minutes and then resolved on own. No associated
neurological changes with headache. Today, at around 4pm she
had
again the sudden onset of posterior/occipital HA with radiation
down neck. This time the headache was much more severe and
associated with a worsening of her baseline tinnitus. No N/V.
No weakness or numbness sensation. No visual changes. She was
taken to an OSH where a CT head was performed which showed a SAH
in the basal cistern without hydrocephalus. She was transferred
to [**Hospital1 18**] for Neurosurgical evaluation. Neuro exam at OSH on
presentation intact with baseline L facial droop.
Past Medical History:
Past Medical History:
hypertension
hypercholesterolemia
asthma on advair
history of GI bleed felt likely [**1-4**] ischemic colitis per [**2126**] DC
summary from [**Location (un) **]
depression (on bupropion)
T10 left discectomy on [**9-6**].
Social History:
Lives at home alone without services. She has 5 children,
several
grandchildren and 8 great grandchildren. Retired behavioral
optometry assistant. Never smoked. Rare etoh
Family History:
Noncontributory
Physical Exam:
On admission:
PHYSICAL EXAM:
GCS E: 4 V: 5 Motor 6. Hunt and [**Doctor Last Name 9381**] 2. [**Doctor Last Name 957**] 2
O: T: 97.4 BP: 152/71 HR: 92 R 15 O2Sats 98%2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: R surgical 4-3 L [**2-1**] EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: mildly sleepy but appropriate 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, R pupil surgical
but reactive 4-3mm, L 3-2mm. Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: L facial droop (baseline)
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 [**4-6**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Pa Ac
Right 2 2 2 2
Left 2 2 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Upon discharge:
Expired
Pertinent Results:
[**2130-5-16**] CTA Head/Neck:
1. Hemorrhage in the collicular cister with extension into the
ventricles is likely secondary to ruptured AVM in the cerebellar
vermis.
2. 17-mm x 11 mm arteriovenous malformation with high-flow
feeding from the bilateral posterior cerebral and superior
cerebellar arteries and draining into the deep cerebral venous
system.
3. 2-mm left cavernous ICA aneurysm.
4. No evidence of an acute infarction.
[**2130-5-17**] CT Head:
No evidence for hydrocephalus, with grossly stable
intraventricular and small subarachnoid hemorrhage.
[**5-17**] Cerebral Angiogram - 1. Mrs. [**Known lastname 8029**] underwent diagnostic
cerebral angiogram which demonstrates an arteriovenous
malformation within the anterior superior cerebellum
predominantly supplied by the bilateral superior cerebellar
arteries and to a lesser extent the right PICA and left
AICA-PICA complex. There may be a questionable 1.5- 2mm aneurysm
at the anterior aspect of the arteriovenous malformation
immediately adjacent to the nidus. Venous drainage is central,
to the straight sinus without stenosis or aneurysm. No active
extravasation of contrast demonstrated.
2. 3-mm broad-based aneurysm along the posterior wall of the
proximal
cavernous left internal carotid artery.
3. Short segment of corrugated appearance of the left distal
cervical
internal carotid artery wall without flow-limiting stenosis may
represent a short segment of fibromuscular dysplasia.
4. Severe tortuosity of the cervical vessels noted. This anatomy
may
complicate future intervention.
[**2130-5-18**] CT head:
1. New focus of left parietal subarachnoid hyperdensity and
increased
hyperdense material layering in the left occipital [**Doctor Last Name 534**], which
may represent redistribution of blood products, but slight new
hemorrhage cannot be excluded.
2. Evolving blood products in the third and fourth ventricles,
aqueduct and foramina of Luschka without evidence for
hydrocephalus.
[**5-18**] CT Head repeat - 1. Interval development of hydrocephalus
compared to seven hours prior, with new dilation of the lateral
and third ventricles, likely secondary to hemorrhage within the
fourth ventricle.
2. No definite evidence of new intracranial hemorrhage. Some
redistribution of blood products into the right occipital [**Doctor Last Name 534**]
is noted.
[**5-19**] CT Head - no change
[**5-20**] Ct head - no change
MR HEAD W & W/O CONTRAST [**2130-5-23**]
1. Multiple areas of small acute infarctions involving the left
centrum
semiovale, parasagittal frontal cortex, splenium of corpus
callosum, and
posterior midbrain.
2. Interval reduction in the size of ventricles and stable
position of the
right transfrontal ventriculostomy catheter.
3. Hemorrhage in the superior vermis with blood products from
ruptured AVM
Brief Hospital Course:
80F who presented after a sudden onset of headache, CT revealed
a SAH at the OSH and she was transferred to [**Hospital1 18**]. A CTA was
performed which showed a question of a venous anomaly in the
cerebellar vermis. She was admitted to the Neuro ICU under
Neurosurgery. She was started on Nimodipine and Keppra. She was
monitored closely overnight, as patient was becoming more
lethargic. The family had expressed that if she decompensated,
they did not want to intubate and would want DNR/DNI.
A repeat head CT was done on [**5-17**] which showed no evidence for
hydrocephalus, with grossly stable intraventricular and small
subarachnoid hemorrhage. An Angiogram was recommended and they
reversed the DNI order for procedures. She was intubated for an
angiogram with Dr. [**Last Name (STitle) **]. and this showed an AVM possibly being
fed by left SCA aneurysm. She was not able to be extubated and
she was trasnfered to the SICU intubated. On [**5-18**] she was
following commands and opening eyes. The SICU felt that her left
side was weaker and she had a CT which was stable. Her exam did
not improve however and an EVD was placed.
On, [**5-19**] CT of the head showed that the lateral ventreicles were
slightly smaller and the EVD was lowered to 10 and pulled back
2cm. She had some decreased Sats to 90 with decreased breathe
sounds at the right anterior lung base with suggestion of right
middle lobe consolidation on CXR. She also had some thick
secretions and sputum cultures were sent. She required Lasix
20mg. CPAP was increased. Her PICC line was malpositioned
ordered IR
to reposition, will do monday so PICC used as mid-line for now.
pt became oliguric in afternoon and required IVF bolus, started
LR @ 75 w/ good response
On [**5-18**] pt had a brief rise in ICP to 28 after turning and
repeat CT showed no new hemorrhage. A CXR on [**5-21**] RLL
infiltrate and a Bronchoscopy was performed w/ no secretions for
BAl, and results came back + for MRSA. On [**5-22**], Vancomycin
started for MRSA in sputum/VAP. Rhythmic twitching of LUE noted,
concerning for seizure. Resolved w/ ativan 2mg IV. Neuro
consulted and they recommended starting Keppra and titrating
accordingly. EEG was obtained which showed PLEDS and dilantin
was started per Neurology. She had an MRI on [**5-23**] which showed a
brainstem infarct. Her exam worsened and she did not open her
eyes. She only WD to deep noxious.
On [**5-24**] exam worsened, her dilantin level was 12.8 and patient
recieved ativan for pled. [**5-25**], no changes were seen in exam. On
[**5-26**], a family meeting was held to discuss goals of care. Since
patient's exam has not improved, the family has decided to make
patient CMO. Her EVD was removed and she was extubated. On
[**2130-5-27**] at 0602 she expired.
Medications on Admission:
Lipitor 10mg'
Advair 250/50 1puff daily
Senna 8.6mg [**Hospital1 **]
Cartia XT 120mg q24
Calcium 500mg [**Hospital1 **]
Cyclobenzaprine 10mg TID
Colace 100mg po BID
oxycodone 5mg po q4prn
Aleve 220mg po PRN
Gabapentin 400mg TID
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Subarachnoid hemorrhage
Intraventricula hemorrhage
AV Malformation
cavernous left internal carotid artery aneurysm
Hydrocephalus
Respiratory failure
LLL Pneumonia
MRSA - sputum culture
Malnutrition
Seizures
Brainstem infarct
Discharge Condition:
expired
Discharge Instructions:
Expired
Followup Instructions:
EXPIRED
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2130-5-27**]
ICD9 Codes: 431, 4019, 2724, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4159
} | Medical Text: Admission Date: [**2183-3-18**] Discharge Date: [**2183-4-7**]
Date of Birth: [**2124-12-30**] Sex: F
Service: CSU
CHIEF COMPLAINT: Increasing chest tightness with shortness
of breath and dyspnea on exertion during rest.
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
woman first told that she had a murmur 15 years ago following
a dental visit and was found to have endocarditis and a
pericardial effusion. She had pericardiocentesis at that
time followed by serial echocardiograms.
She underwent cardiac catheterization on [**2183-3-4**]. At
that time, cardiac catheterization showed an ejection
fraction of 50 percent, left main with 60 percent ostial
stenosis, left anterior descending coronary artery with 50
percent midvessel stenosis, and mild luminal irregularity,
circumflex with a 60 percent ostial stenosis, and right
coronary artery with mild luminal irregularities, and a
distal 50-60 percent lesion at the origin of the .
Th[**Last Name (STitle) 1050**] was ultimately discharged to home following
cardiac catheterization and referred to Cardiac Surgery. She
was seen by Dr. [**Last Name (Prefixes) **] and accepted for aortic valve
replacement and scheduled as an outpatient admission.
The patient was admitted to [**Hospital6 2018**] on [**3-18**] to have her surgery; however, this had to be
postponed due to an emergency with another patient, and she
was therefore rescheduled to undergo aortic valve replacement
on [**3-19**].
PAST MEDICAL HISTORY: Endocarditis with pericardial
effusion. Aortic stenosis. Congestive heart failure.
Noninsulin dependent diabetes mellitus.
Hypercholesterolemia. Anemia. Peripheral neuropathy.
Chronic low back pain. Bilateral lower extremity
varicosities.
PAST SURGICAL HISTORY: Cesarean section times four.
Laparoscopic cholecystectomy.
MEDICATIONS PRIOR TO ADMISSION: Procrit once a week,
Glyburide 10 mg b.i.d., Aspirin 325 q.d., Atenolol 25 b.i.d.,
Imdur 60 q.d., Lipitor 20 q.d., Lisinopril 5 q.d., Metformin
1000 b.i.d., Centrum Silver 1 q.d., Calcium Carbonate no dose
provided, Betacarotene, Vitamin B12 no dose provided, Folic
Acid 1 mg q.d., Lasix no dose provided.
ALLERGIES: Felpine causes acute shortness of breath.
FAMILY HISTORY: Mother is alive at 83 with anemia and
congestive heart failure. Father died at 77 of an myocardial
infarction.
SOCIAL HISTORY: The patient lives with her husband and four
children. She has a remote tobacco history; quit in [**2172**].
Rare alcohol, only on social occasions. She denied any other
drug use.
REVIEW OF SYMPTOMS: Angina with activity, no palpitations or
syncope. Shortness of breath at rest and with activity.
Positive paroxysmal nocturnal dyspnea. Positive PNA. No
asthma. Positive bronchitis. Positive congestive heart
failure. Positive constipation. No melena. Positive
claudication and bilateral varicosities. Positive peripheral
neuropathy of the hands and legs. Positive diabetes. No
thyroid problems. Positive anemia.
PHYSICAL EXAMINATION: Vital signs: Heart rate 72 and
regular, blood pressure 142/68, respirations 20, height 5 ft
0 in, weight 207 lbs. General: The patient was very obese.
Skin: Birth mark of the right face and tongue. HEENT:
Normal mucosa. Nonicteric. Neck: Supple. No jugular
venous distension. Murmur radiating bilaterally to the
carotids. Chest: Clear to auscultation bilaterally. Heart:
Regular rate and rhythm. S1 and S2. There was a 4/6
systolic ejection murmur throughout. Abdomen: Soft and
nontender. No CVA tenderness. Extremities: Warm and well
perfused. No clubbing or cyanosis. There was 1+ bilateral
edema. There were bilateral varicosities of the right thigh
greater than left thigh, left calf greater than the right
calf. Neurologic: Cranial nerves II-XII grossly intact.
Nonfocal examination. She had 4/5 strength in all four
extremities. Pulses: Femoral 2+ bilaterally, dorsalis pedis
2+ bilaterally, posterior tibial 2+ bilaterally, radial 2+
bilaterally.
LABORATORY DATA: White count 6.8, hematocrit 36.2, platelet
count 175; sodium 136, potassium 4.4, chloride 108, CO2 22,
BUN 28, creatinine 12.1, glucose 129.
Chest x-ray showed no congestive heart failure or pneumonia,
positive cardiomegaly.
Electrocardiogram was in sinus rhythm with a rate of 67 beats
per minute, nonspecific ST wave changes.
Carotid ultrasound showed scattered areas of focal calcific
plague at the origin of the left right coronary artery and
beyond the origin of the right internal carotid artery.
There was normal antegrade flow within both vertebral
arteries, no associated significant internal carotid artery
or common carotid artery stenosis.
HOSPITAL COURSE: On [**3-19**], the patient was brought to the
Operating Room at which time she underwent an aortic valve
replacement with a number 19 St. [**Male First Name (un) 923**] mechanical valve.
Please see the operative report for full details.
In summary, the patient had an aortic valve replacement. She
tolerated the operation well. Her bypass time was 122 min
with a cross-clamp time of 66 min. She was transferred from
the Operating Room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient was in sinus rhythm at a
rate of 81 beats per minute. Her mean arterial pressure was
70 with a CVP of 15 and PAD of 24. She had Dopamine at 2.5
mcg/kg/min, Propofol at 10 mcg/kg/min, and Nitroglycerin at
0.3 mcg/kg/min.
The patient remained hemodynamically stable in the immediate
postoperative period. An initial attempt to awaken and wean
the patient from the ventilator was unsuccessful. She was
therefore resedated and remained sedated throughout the night
of the operative day.
On postoperative day 1, the patient's Dobutamine infusion was
weaned to off, which she tolerated well. An additional
attempt was made to wean and extubate the patient from the
vent; however, she became increasingly dyspneic and had mild
respiratory acidosis. She therefore remained on the
ventilator following which a bronchoscopy was done which
showed minimal secretions and generally clear airway.
On postoperative day 2, the patient was again weaned from the
ventilator and successfully extubated. Additionally, she
remained hemodynamically stable and was weaned from her Neo-
Synephrine infusion.
On postoperative day 3, the patient continued to make slow
progress. She remained extubated; however, her creatinine
had begun to rise. Attempts were made to diurese with both
Lasix and Diuril. The patient's temporary pacing wires were
removed, and the patient was begun on a heparin infusion.
On postoperative day 4, the patient continued to be
hemodynamically stable. She was begun on Coumadin, and was
transfused with 1 U packed red blood cells for a hematocrit
of 24.
On postoperative day 5, the patient continued to make slow
progress. A sputum culture from prior bronchoscopy showed
Staphylococcus aureus, and she was begun on Levaquin and
transferred to FAR2 for continuing postoperative care and
cardiac rehabilitation.
Once on the floor, the patient made extremely slow progress
in her physical activity. Her Coumadin doses were adjusted
to a target INR of 2.5-3.0, at which time her heparin
infusion was weaned to off.
On postoperative day 10, the patient complained of blurred
vision with diplopia at that time. The Ophthalmology Service
was consulted which reported horizontal diplopia with mild
distant vision disturbances that they felt were due likely to
small microvascular infarcts which would resolve with time.
The patient was informed to schedule an outpatient clinic
appointment with the Ophthalmology Department.
On postoperative day 12, the patient remained hemodynamically
stable. Her creatinine remained in the 1.3-1.5 range;
however, she seemed to be having less response to her
diuresis. She was therefore started on Natrecor drip at that
time with good affect. Additionally, the patient continued
to have mildly elevated blood glucose levels, and the [**Last Name (un) **]
was consulted to assist with glucose control.
Over the next several days, the patient remained
hemodynamically stable. She continued to have good diuresis
to the Natrecor infusion. She continued to make exceedingly
slow progress in advancing her physical activity. On
postoperative day 6, the Natrecor infusion was discontinued.
She was again maintained with Lasix for diuresis.
She was monitored for three additional days to be sure that
she would not have an increase4 in her creatinine and that
her fluid balance would remain stable, and on postoperative
day 18, it was decided that the patient was stable and ready
to be discharged to home.
DISCHARGE PHYSICAL EXAM: Vital signs: Temperature 98.1,
heart rate 77 in sinus rhythm, blood pressure 122/60,
respirations 18, oxygen saturation 96 percent on room air,
weight preoperatively 207 lbs, on discharge 195 lbs.
General: She was alert and oriented times three. She moves
all extremities. She follows commands. Respiratory:
Bibasilar crackles. Cardiovascular: Regular rate and rhythm
with mechanical click. Sternum stable. Incision open to
air, clean and dry. Abdomen: Soft, nontender, nondistended.
Positive bowel sounds. Extremities: Warm and well perfused.
She had [**11-15**]+ edema bilaterally, right greater than left.
Lower extremity incision open to air, clean and dry.
DISCHARGE MEDICATIONS: Aspirin 81 mg q.d., Glyburide 10 mg
b.i.d., Prilosec 40 mg q.d., Folate 1 mg q.d., Ferrous
Sulfate 325 mg q.d., Vitamin C 500 mg b.i.d., Metoprolol 50
mg b.i.d., Furosemide 20 mg b.i.d., Insulin Lantus 13 U
q.p.m., regular Insulin sliding scale, Lipitor 20 mg q.d.,
Warfarin as directed, the patient is to receive 1 mg on the
day of discharge, she is to have an INR check on [**4-8**] with
the results called to Dr. [**Last Name (STitle) 38610**] in [**Hospital1 3597**], [**Location (un) 3844**].
Additionally, the patient is to receive Dilaudid 1-2 mg q.4-6
hours p.r.n.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: She is to be discharged to home with VNA.
FO[**Last Name (STitle) 996**]P: She is to follow-up with Dr. [**Last Name (STitle) 38610**] in one week,
follow-up with Dr. [**Last Name (Prefixes) **] in four weeks, follow-up with
Dr. [**Last Name (STitle) 410**] in [**12-17**] weeks, follow-up with Ophthalmology six
weeks following discharge; the patient is to make an
appointment in the outpatient clinic.
DISCHARGE DIAGNOSIS:
1. Aortic stenosis status post aortic valve replacement with
a 19 St. [**Male First Name (un) 923**] mechanical valve.
2. Obesity.
3. Noninsulin dependent diabetes mellitus.
4. Hypercholesterolemia.
5. Anemia.
6. Chronic low back pain.
7. Bilateral varicosities.
8. Peripheral neuropathy.
9. Status post cesarean section times four.
10. Status post laparoscopic cholecystectomy.
DISCHARGE LABORATORY DATA: Hematocrit 35; PT 18, PTT 2.2;
sodium 136, potassium 4.4, chloride 100, CO2 29, BUN 23,
creatinine 1.0, glucose 164.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2183-4-8**] 09:03:31
T: [**2183-4-8**] 10:13:34
Job#: [**Job Number 38611**]
ICD9 Codes: 4241, 4280, 2762, 4168, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4160
} | Medical Text: Admission Date: [**2115-8-2**] Discharge Date: [**2115-8-10**]
Date of Birth: [**2054-6-13**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Lipitor
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
# SOB
Major Surgical or Invasive Procedure:
Hemodialysis x4
History of Present Illness:
61F ESRD s/p L arm HD fistula placement ([**2115-5-29**]), pending
possible HD initiation (not anuric), admitted with increasing
SOB and BLE edema x 3-4d. On the night of admission, pt had
called EMS after noting increasing SOB while lying in bed. Per
report, pt's initial BP=226/94, with SaO2 100/CPAP. Of note, pt
had been recently admitted [**3-25**] with RLL MSSA PNA c/b MSSA
bacteremia.
.
ED course:
# Meds: Nitroglycerin gtt, furosemide 100mg IV x 1, levofloxacin
PO x 1 dose
# Studies: CXR demonstrated edema and ?LLL PNA
# Clinical: Weaned from CPAP to 3L
# Consults: Renal indicated no acute indication for HD.
.
ROS on admission:
(+) As above
(-) Dietary indiscretion, medication non-compliance, UOP decline
.
ROS on floor transfer: Pt stated that she felt "good."
(-) SOB, abdominal pain, chest pain
Past Medical History:
# CV
-CAD s/p cath ([**8-24**]): Mild epicardial disease, collalateral
flow to distal inferior wall, no intervention
-HTN
-Hyperlipidemia
.
# Endo
-DM2
--Neuropathy
--Nephropathy
--Retinopathy
.
# GU
-Chronic kidney disease (stage IV)
.
# Neuro
-Stroke
-Impaired memory s/p MVA
.
# Heme
-Anemia
Social History:
# Alcohol: Never
# Tobacco: Never
# Recreational drugs: Never
Family History:
# F, d70s: Heart disease
# Siblings (two sisters): DM2
Physical Exam:
PE on MICU admission:
.
VS: T 97.1, BP 184/72, HR 85, R 21, SaO2 98/3L
GEN: NAD
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD, no
carotid bruits. 8-10 cm JVD.
CV: Regular, nl s1, s2, no m/r, +s4.
PULM: Crackles bilaterally, no r/w.
ABD: Soft, NT, ND, + BS, no HSM. well healed midline gallston
scar.
EXT: Warm, 2+ DP/radial pulses BL, 1+ B LE edema. L UE fistula
+thrill.
NEURO: Alert & oriented x 3, CN II-XII grossly intact. [**3-23**]
strength symmetric @ triceps, biceps, delts, hip flexion,
dorsoflexion, plantarflexion. Sensation grossly intact.
.
PE on floor transfer:
VS: Tm 97, Tc 97, HR 68-76, BP 139-163/47-74, R 13-21, SpO2
98/RA-100/RA
.
Gen: Sleeping, NAD
HEENT: NCAT, no LAD, no JVD, CN II-XII grossly intact
CV: RRR, S1S2, no m/r/g noted
Chest: CTAB
Abd: Soft, NTND, BS+, large pannus
Ext: No c/c/e
Neuro: Nonfocal
Pertinent Results:
Admission labs of note:
.
[**2115-8-2**] 04:50AM GLUCOSE-351* UREA N-60* CREAT-4.3* SODIUM-134
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-19* ANION GAP-19
[**2115-8-2**] 04:56AM LACTATE-1.0
[**2115-8-2**] 09:11AM CK-MB-5 cTropnT-0.03*
[**2115-8-2**] 09:11AM CK(CPK)-179*
[**2115-8-2**] 11:15AM %HbA1c-8.5*
[**2115-8-2**] 04:50AM WBC-10.0 RBC-4.12* HGB-12.2 HCT-37.4 MCV-91
MCH-29.6 MCHC-32.7 RDW-13.9
.
=========================================
Studies of note:
.
# CHEST (PA & LAT) [**2115-8-2**] 1:31 PM
1. Interval improvement of bilateral pleural effusions, now
moderate to large on left and moderate on right.
2. Interval progression of congestive heart failure.
.
# CHEST (PORTABLE AP) [**2115-8-2**] 4:26 AM
1. Probably large, layering bilateral pleural effusions with
upper zone vascular redistribution suggestive of pulmonary
edema.
2. Dense opacification of the retrocardiac left lower lobe.
While this could represent atelectasis in the context of pleural
effusion, pneumonia cannot be excluded.
.
# ECG Study Date of [**2115-8-2**] 4:38:22 AM
Sinus rhythm. Within normal limits. Compared to the previous
tracing of [**2115-5-27**] no significant diagnostic change.
.
# CHEST (PORTABLE AP) [**2115-8-3**] 3:34 AM
IMPRESSION: Improving interstitial pulmonary edema with
persistent bilateral pleural effusions.
Brief Hospital Course:
61F h/o ESRD [**12-21**] DM2 not yet on HD, presented with increased
SOB, BLE edema, and hypertensive urgency [**12-21**] CHF.
.
# SOB: Pt's SOB was considered likely [**12-21**] either to pulmonary
edema [**12-21**] either ESRD vs PNA per CXR. After receiving one
empirically dose of levofloxacin, pt was diuresed in the ED with
furosemide 100mg IV, leading to UOP 650cc and marked improvement
of SOB. Levofloxacin was stopped and pt was continued on
furosemide 100mg IV PRN for a diuresis goal of 2L in the MICU.
Upon transfer to the floor, pt had SpO2=100/RA and continued to
be monitored for respiratory status. Pt was changed to
furosemide PO. After starting HD, pt was d/c'd without
furosemide and had ambulatory SaO2 = 97%.
.
# HTN: Pt reported baseline SBP=170s, but was found to have
SBP=240s on admit. Pt was therefore placed on a nitroglycerin
gtt, with Toprol XL increased to 300mg daily and amlodipine
increased to 10mg PO daily. As volume overload was considered
the likely primary cause of pt's HTN, pt was diuresed with
furosemide IV with good effect. Pt was also started on
minoxidil 5 mg PO daily for improved SBP control. Upon transfer
to the floor, pt had SBP=139-163, and continued to be monitored
for BP control. After beginning HD, however, pt's BPs
normalized and she was discharged with only Toprol XL 150mg
daily.
.
# ESRD: Pt had ESRD but had not been started on HD. Renal was
consulted and initially determined there was no acute indication
for HD. Pt was therefore continued on her home regimen of
calcitriol and darbepoetin alfa. However, pt was noted to have
persistent nausea and vomiting from uremia, and therefore was
ultimately started on HD. Pt was discharged with sevelamer
800mg TID with meals and nephrocaps 1 cap daily.
.
# DM2: On admission, pt did not know her home insulin regimen,
and HbA1c = 8.5%. The insulin regimen from pt's prior discharge
summary was therefore applied, using insulin 70/30 29 units QAM,
10 units QPM, and HISS. While on this previous fixed dose
regimen, however, pt experienced one episode of hypoglycemia
while on the floor, with BG to 40s. Pt's insulin needs were
therefore calculated after placing her only on humalog sliding
scale, and pt was discharged on NPH 10 units at breakfast and
NPH 6 units at dinner.
.
# CAD: Pt ruled out for MI, with negative CE x3 and EKG
demonstrating no acute changes. Pt was continued on her home
regimen of ASA. Toprol XL was increased from her original home
regimen of 200mg daily to 300mg daily, with improved SBP
control. After beginning HD, pt was discharged on a reduced
dose of Toprol XL 150mg daily.
.
# LFTs: To be screened for outpatient HD placement, laboratories
were drawn to assess LFTs and hepatitis serologies. Pt was
negative for HBV and HCV infection, but ALT and alk phos were
found to be slightly elevated. This could be due to congestive
hepatopathy. Pt was informed that it may be useful to follow up
on these LFTs (if they persist to be abnormal) by liver
ultrasound as an outpatient.
# Full code
Medications on Admission:
# Amlodipine 10mg PO daily
# Calcitriol 0.25mg QOD/ 0.50mg QOD
# Toprol XL 200mg PO daily
# Insulin: Pt did not know regimen
# ASA 325mg po qdaily
# Darbepoetin alfa 25mcg/0.42ml Syringe, 1 injection daily
# Tums
# MVI
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Humalog insulin sliding scale
121-160mg/dL: Breakfast 2 Units; Lunch 2 Units; Dinner 2 Units;
Bedtime 2 Units
161-200mg/dL: Breakfast 4 Units; Lunch 4 Units; Dinner 4
Units; Bedtime 4 Units
201-240mg/dL: Breakfast 6 Units; Lunch 6 Units; Dinner 6 Units;
Bedtime 6 Units
241-280mg/dL: Breakfast 8 Units; Lunch 8 Units; Dinner 8 Units;
Bedtime 8 Units
281-320mg/dL: Breakfast 10 Units; Lunch 10 Units; Dinner 10
Units; Bedtime 10 Units
321-360mg/dL: Breakfast 12 Units; Lunch 12 Units; Dinner 12
Units; Bedtime 12 Units
361-400mg/dL: Breakfast 14 Units; Lunch 14 Units; Dinner 14
Units; Bedtime 14 Units
>400mg/dL: CALL YOUR PRIMARY CARE DOCTOR AND GO TO THE EMERGENCY
[**Apartment Address(1) 65274**]. Outpatient Lab Work
Please check chem 10 on [**Last Name (LF) 2974**], [**8-16**], and fax to Dr. [**Name (NI) 12492**] office at fax [**Telephone/Fax (1) 434**]
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
9. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: One (1) bottle Subcutaneous as directed: please inject 10
units at breakfast and 6 units at dinner time. .
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis
# Congestive heart failure [**12-21**] pulmonary hypertension
# Hypertensive, malignant
# Diabetes mellitus type 2, with complications uncontrolled.
# Chronic kidney disease stage 5
# Initiation of hemodialysis
.
Secondary diagnosis
# Hyperlipidemia
# Coronary artery disease
Discharge Condition:
Stable
Discharge Instructions:
You came to the hospital because you were short of breath. We
found that you had too much fluid in your body, you had very
high blood sugars and you had a very high blood pressure. We
gave you medications to make you urinate, we gave you blood
pressure medications, and we gave you insulin.
.
We ***CHANGED*** your medications:
.
THIS IS THE NEW INSULIN YOU SHOULD TAKE:
# For your blood sugar:
---Insulin 70/30 10 units when you are eating breakfast
---Insulin 70/30 6 units when you are eating dinner
---WRITE DOWN YOUR SUGARS EVERY FOUR HOURS. BRING THIS TO YOUR
APPOINTMENT WITH DR.[**Doctor Last Name **] OFFICE on MONDAY!
-Please follow the insulin sliding scale attached
.
# For your kidney
---Nephrocaps 1 capsule daily
---Sevelamer 800 mg three times daily with meals
.
For your blood pressure:
-Toprol XL 150mg daily
You should no longer take the amlodipine that you were taking
before you came into the hospital.
Please take the rest of your medications as usual until you see
your primary care doctor.
.
You have several follow-up appointments. See below.
.
If you have fevers, chills, nausea, vomiting, chest pain, or
shortness of breath, call your primary care doctor immediately
and go to the emergency room.
Followup Instructions:
You have the following appointments:
.
YOUR KIDNEY (Nurse [**Last Name (un) **] is part of Dr.[**Name (NI) 9920**] nephrology
team): THIS IS VERY IMPORTANT!
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2115-8-12**] 5:00
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2115-8-15**] 10:00
.
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2115-10-23**] 11:00
Completed by:[**2115-8-19**]
ICD9 Codes: 4280, 5849, 4168, 2724, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4161
} | Medical Text: Admission Date: [**2143-6-17**] Discharge Date: [**2143-6-30**]
Date of Birth: [**2086-2-20**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
weakness, inability to speak
Major Surgical or Invasive Procedure:
IV tPA
Cerebral angiogram with attempted clot extraction
Trach placement
PEG
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 1 minutes (I was near the room already when "Code
stroke"
was paged, and at bedside in less than a minute)
Time (and date) the patient was last known well: 11:42am
NIH Stroke Scale Score: 18
t-[**MD Number(3) 6360**]: YES
Time t-PA was given 13:00 (24h clock)
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
NIH Stroke Scale score was 18:
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 0
2. Best gaze: 1
3. Visual fields: 0
4. Facial palsy: 3
5a. Motor arm, left: 0
5b. Motor arm, right: 2
6a. Motor leg, left: 2
6b. Motor leg, right: 3
7. Limb Ataxia: 1
8. Sensory: 0
9. Language: 2
10. Dysarthria: 2
11. Extinction and Neglect: 0
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 57 year-old man who was BIBA for weakness
and inability to speak. A code stroke was called on arrival, and
I was in the room in time to hear report from EMS. Later, his
brother provided some collateral information. He was reportedly
in his USOH earlier today, except for an intermittent headache
over the past few days.
EMS reports they were called to the walkway around [**Country **] Pond
because Mr. [**Known lastname **] was slumping to the left with "right eye
droop," non-verbal on their arrival. They received the call at
11:42am. He had been seen at [**Hospital 882**] Hospital 2wks prior after
falling on his head; two sutures to a forehead laceration; Head
CT
reportedly normal at that time. He presented to [**Hospital3 **]
a
few days ago with concern for neurologic symptoms possibly
seizure, but the details are unknown. He has c/o [**5-30**] headache
for the past few days. His brother [**Name (NI) 892**] ([**Telephone/Fax (1) 10786**]) [**Name2 (NI) 10787**]ed
and clarified that he had just dropped off the pt at J.Pond to
walk. He was driving away when pt. called him and said that his
side was weak. He came back and called the ambulance. tPA
contraindications were reviewed with the brother (none were
identified), and bleeding risk were explained. Regarding the
fall
2wks ago, [**5-21**] clinic note says that pt. had a "bruise around
right orbit. Fell getting out of a car, lost balance; no LOC."
and that "alcohol was involved."
Review of Systems: via nods and head-shakes, pt denies headache.
endorses diplopia. cannot speak.
Past Medical History:
Depression/Anxiety/Panic Attacks; [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]=Psychiatry; SSRI
Insomnia (on trazodone)
Bladder Obstruction
Plantar Fascia Release
"LOW NORMAL" VITAMIN B12
COLONOSCOPY [**2140**], INCONPLETE PREP: NEEDS REPEAT
HERNIATED DISC: NECK (C56/67 disc bulge, contacting the ventral
cord on prior imaging)
ALCOHOL ABUSE: RECOVERING
HYPERLIPIDEMIA (on statin)
HEPATITIS C TREATED
Chest pain
Chronic foot pain with plantar fasciitis
Borderline hypertension
GERD on PPI, H2 blocker found ineffective
Social History:
unemployed: custodian (brother says he is living on disability
payments at present). four brothers and one sister and he lives
with brother. unmarried: no children. Brother says pt used to
run
marathons (years ago).
- never smoked.
- h/o Alcohol abuse in recovery: Formerly six to eight drinks at
a time one day a week. 9 years sober in the past, recently
started drinking again per brother.
- denies history of substance abuse / IVDU
Family History:
mother died: 92 respiratory problems,had an MI in her 70s
father died at age 72 throat cancer, long history of smoking
brother: heart attack: age of 57
no family history of sudden cardiac death
Brother denies FH of Neurologic disease.
Physical Exam:
Physical Examination on Admission:
General: Lying in ED stretcher, appears anxious. Breathing
somewhat irregularly, puffing air through flaccid right side of
lips.
HEENT: Normocephalic. Mucous membranes are moist. Facemask O2
Neck: Supple. No carotid bruits I can appreciate. No LAD.
Pulmonary: Lungs CTA anteriorly. Non-labored.
Cardiac: Regular, bradycardic (50), normal S1/S2.
Abdomen: Soft, non-tender, and non-distended. Mildly obese.
Extremities: Warm and well-perfused. 2+ radial, DP pulses.
Skin: no gross rashes or lesions noted.
Neurologic examination:
Mental Status:
Eyes open, alert, follows commands with head and LUE;
comprehension seems intact. No speech.
-Cranial Nerves:
II: PERRL, 3.5 to 2mm and brisk. Does not reliably blink to
threat on either side. Seems distressed by prolonged fixation or
eye opening (shuts eyes frequently).
III, IV, VI: EOM conjugate at rest, lying perhaps 10 deg off the
midline to the right. On attempted Rightward gaze, the left eye
does not adduct fully and the right eye beats (fast-phase) to
the
left). On attempted Leftward gaze, the left eye does not abduct
more than a few degrees past midline. Does not look up/down for
me on command.
V: Facial sensation intact (patient nods) to pin bilaterally.
VII: No ptosis. Left NLF and lips flaccid (pt huffs breaths
through unsealed lips). Smile is assymetric (L-facial droop).
Brows and eye-closure appear strong.
VIII: Hearing grossly intact.
IX, X, XII: Does not open mouth or protrude tongue on command.
[**Doctor First Name 81**]: Does not lift R trap (Left full).
-Motor:
Right arm only slight movement at the fingers, which are
hypertonic (flexed) and not flaccid. At one time, however, he
lifted the arm in a flexed position with gross ataxia
(subsequently unable). LUE full at the delt, tri/[**Hospital1 **], WE/FE/grip,
no pronator drift of LUE. Can move toes of both legs R>L. At one
point lifts LLE AG, not right. Legs tone is increased
bilaterally.
-Sensory: nods intact to LT/pin in all four extremities.
-Reflexes (left; right): pathologically brisk in both patellars,
with few beats of clonus bilaterally and briskly upgoing toes.
-Coordination: No ataxia of LUE on FNF; gross ataxia of RUE the
one time he was able to lift it AG.
-Gait: unable
Physical Exam on Discharge:
General: awake and alert, NAD
HEENT: NCAT. Trach in place, c/d/i. Tongue with dark red
scabbing over R side.
Pulmonary: Lungs CTAB, coarse breath sounds
Cardiac: RRR, no m/r/g.
Abdomen: Soft, non-tender, and non-distended.
Extremities: Warm and well-perfused
Skin: no rashes or lesions noted
Neurologic examination:
Mental Status: Awake and alert, able to follow commands and
answer yes/no questions appropriately by blinking eyes/nodding
head.
-Cranial Nerves:
PERRL 3 to 2mm. Eyes deviated slightly toward R at baseline.
Able to look toward right somewhat with left-beating nystagmus.
Unable to look toward left. Preserved vertical eye movements.
Minimal voluntary mouth movement but able to yawn.
-Motor: Spastic quadriplegia, more hypertonic in legs than arms.
Intermittent low-amplitude tremors of all extremities.
-Sensory: reports sensation to light touch in all extremities
-Reflexes: brisk b/l, both toes upgoing
-Coordination: unable to assess
-Gait: unable to assess
Pertinent Results:
[**2143-6-17**] 08:01PM HCT-35.5*
[**2143-6-17**] 07:08PM TYPE-ART PO2-200* PCO2-45 PH-7.35 TOTAL
CO2-26 BASE XS-0
[**2143-6-17**] 07:00PM PT-13.0* PTT-26.3 INR(PT)-1.2*
[**2143-6-17**] 01:15PM URINE HOURS-RANDOM
[**2143-6-17**] 01:15PM URINE GR HOLD-HOLD
[**2143-6-17**] 01:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.037*
[**2143-6-17**] 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2143-6-17**] 12:30PM UREA N-15
[**2143-6-17**] 12:30PM LIPASE-35
[**2143-6-17**] 12:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-6-17**] 12:30PM WBC-5.9 RBC-4.43* HGB-13.8* HCT-41.2 MCV-93
MCH-31.1 MCHC-33.4 RDW-13.1
[**2143-6-17**] 12:30PM PT-10.6 PTT-23.4* INR(PT)-1.0
[**2143-6-17**] 12:30PM PLT COUNT-321
[**2143-6-17**] 12:30PM FIBRINOGE-292
[**2143-6-17**] 12:28PM CREAT-0.9
[**2143-6-17**] 12:28PM estGFR-Using this
[**2143-6-17**] 12:27PM COMMENTS-GREEN TOP
[**2143-6-17**] 12:27PM GLUCOSE-120* NA+-138 K+-3.8 CL--104 TCO2-24
ECG: Sinus bradycardia, rate 50. Otherwise, no abnormalities
CT/CTA/CTP [**6-17**]:
IMPRESSION:
1. Occlusion of the right vertebral artery from its origin to
the C6 level. Occlusion of the distal cervical right vertebral
artery and of the basilar artery. These findings may represent
proximal dissection with distal thromboembolism, or proximal
thrombosis with distal embolism.
2. No evidence of acute intracranial abnormalities on
non-contrast head CT. MRI would be more sensitive for an acute
infarction.
3. The CT perfusion study is limited by artifacts. Ischemia in
the posterior fossa cannot be excluded.
Cerebral angiogram [**6-17**]:
IMPRESSION: [**Known firstname **] [**Known lastname **] underwent cerebral angiography which
revealed
occlusion of the right vertebral artery with thrombus in the
basilar artery. An attempt to recanalize the right vertebral
artery with the intention of stenting it was unsuccessful.
Transthoracic echo [**6-18**]:
IMPRESSION: No ASD or PFO seen. Normal global and regional
biventricular systolic function. No pulmonary hypertension or
clinically-significant valvular disease seen.
MRI/A [**6-18**]:
IMPRESSION:
1. Bilateral pontine infarctions, worse on the left. Caudal
midbrain is also involved.
2. Occlusion of the right vertebral artery and the left
vertebral artery
distal to PICA. No flow detected in the proximal basilar
artery.
3. No hemorrhage or mass effect.
MRI [**6-22**]:
IMPRESSION: Brainstem infarct is again identified and may
slightly more
superior extension or unchanged due to differences in slice
selection. Small other infarcts are again seen as noted before.
No change in mass effect is seen. Flow void is now visualized
in the distal right vertebral artery, which may indicate
recanalization.
CXR [**6-27**]:
FINDINGS: Compared to the previous radiograph, the monitoring
and support devices, including the tracheostomy tube, are
unchanged. The lung volumes have slightly decreased. Increase
in extent of a pre-existing retrocardiac atelectasis.
Otherwise, unchanged appearance of the lung parenchyma and the
cardiac silhouette.
Brief Hospital Course:
57y man with hx of borderline HTN, hyperlipidemia, and prior
ETOH abuse who initially presented as a code stroke with right
sided weakness and inability to speak. CT head was negative; CTA
revealed absence of flow in the basilar, with proximal occlusion
of the dominant right vert and distal ?occlusion of the (left
post-PICA). He was taken to [**Doctor First Name 10788**] but access to the right
vertebral could not be obtained. Post-procedure course was
complicated by failed angioseal X 2 with bleeding from R femoral
artery which required cisatricurium paralysis overnight (to
limit movement and rebleeding). Heparin gtt was stopped given
these complications but was subsequently restarted considering
the tight stenotic basilar.
.
ICU course ([**2143-6-18**] - [**2143-6-29**]):
.
# Neuro:
Cisatricurium was stopped and patient was maintained sedated on
propofol. He was started on Neosynephrine with BP goal 140-180.
Heparin was eventually restarted with PTT goal 50-70 after 48hrs
once bleeding in b/l groins had stopped in the hopes of
maintaining flow through the basilar.
.
He was weaned off propofol and extubated on [**2143-6-19**] which was
noted to be difficult, requiring CPAP mask and concern for
airway protection/lack of gag. However overnight on [**2143-6-20**] he
was noted to have b/l rigidity and myoclonic jerking. His
respiratory status subsequently deteriorated and he was
reintubated and restarted on propofol.
.
Given that extubation seemed unlikely in the near future, a
trach was placed on [**6-22**] after discussion with his family.
.
On [**6-22**] his exam was noted to have worsened with decreased
movement of his left side. He was also noted to have
intermittent rigidity with tonic stiffening and shaking of his
limbs. A repeat MRI confirmed extension of pontine infarct.
Heparin gtt was switched to aspirin, BP allowed to autoregulate.
.
Currently he is plegic other than preserved blinking, vertical
eye movements, and some minimal head movements consistent with
locked in syndrome. He is awake and alert and able to follow
commands and answer yes/no questions appropriately. Speech
therapy has been consulted for asssistance with communication
techniques, and PT and OT are involved as well. He is on aspirin
325mg and pravastatin 80mg. He was started on clonazepam 1mg TID
on [**6-24**] for rigidity with some improvement. He was subsequently
started on baclofen 10mg TID on [**6-27**].
.
# CV:
He was maintained on telemetry monitoring. BP was allowed to
autoregulate with hydralazine prn SBP > 180.
.
# Pulm:
He was initially extubated on [**6-19**] and maintained on CPAP.
However he decompensated with difficulty managing his secretions
and desaturation and later that night and was reintubated. A
trach was placed on [**6-22**]. He remained stable on CPAP and
subsequently was weaned to trach mask, on which he has been
stable since [**6-26**].
.
# ID:
He began to spike fevers and was initially started on Vancomycin
on [**6-21**] for empiric coverage. CXR showed pulmonary effusions but
no clear infiltrate. Sputum cx from [**6-19**] showed MSSA and his
antibiotics were narrowed to Nafcillin on [**6-24**]. He continued to
spike intermittent fevers. Repeat sputum cx from [**6-23**] grew MSSA
as well as serratia. Abx were broadened to Cefepime on [**6-24**] and
subsequently changed to Vanc/Cipro on [**6-25**] (to be continued for
10 days through [**7-5**]). UA's and cultures have been negative and
blood cultures are negative to date.
.
# Gastrointestinal / Nutrition:
NGT was placed and tube feeds were started on [**2143-6-19**]. PEG
placement was discussed with the patient and his family who are
all in agreement with proceeding. ACS was consulted and peg was
placed. He was continued on his home protonix.
.
# Consults:
PT/OT were consulted for range of motion exercises. Speech
therapy was consulted to help with communication techniques.
.
# Code status: FULL code, confirmed with family. Family and
patient in favor of PEG placement.
.
He was transferred to the step-down unit on [**2143-6-29**]. Placement
was found at a facility on [**2143-6-30**]
[ AHA/ASA Core Measures for Ischemic Stroke ]
1. Dysphagia screening before any PO intake? (X) Yes - () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? () Yes - (X) No - TG 492, unable to calculate
5. Intensive statin therapy administered? (for LDL > 100) (X)
Yes - () No
6. Smoking cessation counseling given? () Yes - (X) No (Reason
(X) non-smoker - () unable to participate)
7. Stroke education given? () Yes - () No
8. Assessment for rehabilitation? () Yes - () No
9. Discharged on statin therapy? (X) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on anti-thrombotic therapy? (X) Yes (Type: (X)
Antiplatelet - aspirin 325mg () Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (X) No - n/a
Medications on Admission:
1. CITALOPRAM 40mg daily (confirmed by brother)
2. ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 40mg EC daily (brother
said
"Prilosec").
3. PRAVASTATIN - 20mg daily (confirmed by brother)
4. ASPIRIN - 81mg daily (confirmed by brother)
5. TRAZODONE 300mg qhs (confirmed by brother)
6. (per OMR) DICLOFENAC SODIUM - 50 mg Tablet, Delayed Release
(E.C.) - 1 Tablet(s) by mouth twice a day
7. MELATONIN - (Prescribed by Other Provider) - 3 mg Tablet -
1
Tablet(s) by mouth bedtime
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
4. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q8H (every 8 hours) as needed for pain.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q4H (every 4
hours) as needed for pain: hold for rr less than 12 .
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
12. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO DAILY (Daily) as needed for constipation.
13. baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
14. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
15. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four
Hundred (400) mg Intravenous Q8H (every 8 hours): Through [**7-5**].
16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000)
mg Intravenous Q 8H (Every 8 Hours): Through [**7-5**].
17. hydromorphone 2 mg/mL Syringe Sig: 0.5-1.5 mg Injection Q3H
(every 3 hours) as needed for pain: hold for over-sedation .
18. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten
(10) ML Intravenous PRN (as needed) as needed for line flush:
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
19. insulin regular human 100 unit/mL Solution Sig: Sliding
Scale Injection ASDIR (AS DIRECTED).
20. hydromorphone 2 mg/mL Syringe Sig: 0.5-1.5 Injection Q3H
(every 3 hours) as needed for pain.
21. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Bilateral pontine infarcts
Right vertebral/basilar occlusion
Hypertriglyceridemia
Discharge Condition:
Mental Status: Awake and alert.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic exam: Awake and alert, able to follow commands and
communicate by blinking eyes. No spontaneous movement except
blinking/vertical eye movements and slight head nodding/turning.
Eyes deviated somewhat to R with horizontal nystagmus. Able to
look toward right minimally, unable to look to left. Hypertonic
throughout (LE>UE) with intermittent tremors/myoclonus of all
extremities.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 69**] on [**6-17**], [**2143**] due to right sided weakness and inability to speak. You
were found to have a stroke in the left side of your brainstem.
You received IV tPA and were subsequently taken for a cerebral
angiogram which showed blockage of one of the arteries in your
neck leading to a major artery in your brain. The blockage was
unfortunately not able to be removed. You were admitted to the
neuro ICU for close monitoring. Over the next few days your
stroke worsened to involve both sides of your brainstem. You had
a tracheostomy tube placed to help protect your airway and a
gastrostomy tube placed to give you nutrition.
We made the following changes to your medications:
Increased aspirin to 325mg daily
Increased pravastatin to 80mg daily
Started Vancomycin and Ciprofloxacin to treat your pneumonia
(will finish [**7-5**])
Started clonazepam 1mg three times a day and baclofen 10mg three
times a day to help with the stiffness and pain in your arms and
legs
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
Please return to the neurology clinic in 6 weeks.
Dr. [**First Name (STitle) **]
Office Phone: ([**Telephone/Fax (1) 7394**]
Office Location: [**Location (un) **] 127
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2143-6-30**]
ICD9 Codes: 5070, 2859, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4162
} | Medical Text: Admission Date: [**2115-1-28**] Discharge Date: [**2115-2-5**]
Date of Birth: [**2051-5-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
sigmoid carcinoma, umbo hernia
Major Surgical or Invasive Procedure:
1. Laparoscopy.
2. Flexible sigmoidoscopy and tattooing of tumor.
3. Laparoscopic sigmoidectomy with #31 stapled
coloproctostomy.
4. Incarcerated umbilical hernia repair
History of Present Illness:
The patient is a morbidly obese gentleman with multiple medical
problems who was diagnosed with sigmoid colon cancer. After
cardiac clearance, and no
evidence of metastatic disease by CT scan, he was taken to the
operating room for definitive resection.
Past Medical History:
DM2, HTN, hyperchol, anxiety
Social History:
quit tobacco > 20 years ago, drinks 4-6 beers daily, retired
from [**Last Name (un) **] [**Doctor Last Name 20728**]. Married, wife recently broke ankle.
Family History:
His family history is negative for cancer. There is no family
history of premature coronary artery disease, unexplained heart
failure, or sudden death.
Father died in his 70's, had Parkinson disease.
Physical Exam:
At time of dscharge:
Tm:98.1 Tc: 98.1 P76 BP:138/73 RR:20 SaO2:98% at 4L
Gen: NAD
Card: RRR No M/R/G
Lung: CTAB with distant breath sounds
Abd: +BS, soft, obese, nontender, nondistended, no reboung or
guarding
Wound: C/D/I
Ext: pedal edema
Pertinent Results:
[**2115-2-2**] 01:10PM BLOOD WBC-15.1* RBC-3.81* Hgb-12.0* Hct-37.7*
MCV-99* MCH-31.5 MCHC-31.7 RDW-14.2 Plt Ct-384
[**2115-1-31**] 04:12AM BLOOD Neuts-90* Bands-1 Lymphs-3* Monos-3 Eos-2
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2115-1-31**] 04:12AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL
[**2115-2-2**] 01:10PM BLOOD PT-13.8* PTT-22.0 INR(PT)-1.2*
[**2115-2-5**] 06:50AM BLOOD Creat-1.5* K-4.5
[**2115-2-4**] 07:20AM BLOOD Creat-1.5* K-4.0
[**2115-2-3**] 07:25AM BLOOD Creat-1.2 K-3.4
[**2115-1-29**] 07:40AM BLOOD Glucose-138* UreaN-13 Creat-0.9 Na-135
K-4.6 Cl-103 HCO3-29 AnGap-8
[**2115-1-30**] 05:37AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-1129*
[**2115-2-5**] 06:50AM BLOOD Mg-2.1
[**2115-1-28**] 05:18PM URINE Hours-RANDOM Creat-573 Na-27
.
MRSA SCREEN (Final [**2115-2-1**]): No MRSA isolated
.
Path:Primary Tumor: pT3: Tumor invades through the muscularis
propria into the subserosa or the nonperitonealized pericolic or
perirectal soft tissues.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 14.
Number involved: 0.
.
STUDIES:
[**1-29**] ECHO: LA normal in size. LV wall thickness, cavity size,
global [**Month/Year (2) 16631**] function normal (LVEF>55%). RV chamber size,
free wall motion normal. AV not well seen. No AR. MV not well
seen. No MR. [**First Name (Titles) **] [**Last Name (Titles) 16631**] pressure not determined. anterior space
which most likely represents a prominent fat pad.
.
[**1-30**] CTA: No evidence of PE. B/L ground-glass opacities with
central distribution, sparing the lung bases, no intralobular
septal thickening (aspiration pneumonia >> fluid overload). Mild
dilatation of the main pulmonary artery suggestive of PA HTN.
B/L small pleural effusions (L > R). Gallstones, no
cholecystitis.
.
Brief Hospital Course:
Mr. [**Known lastname 8071**] is a 63-year-old man who underwent a screening
colonoscopy and was found to have several polyps and a mass at
25 cm. This was biopsied positive for moderately differentiated
adenocarcinoma. He underwent a CT scan of the abdomen, which
showed no evidence of metastatic disease. He had no GI symptoms
referable to the colon cancer. After cardiac clearance, and no
evidence of metastatic disease by CT scan, he was taken to the
operating room for definitive resection. Patient underwent
laparoscopic sigmoidectomy with stapled coloproctostomy and
umbilical hernia repair.
.
He returned to [**Location **] 5 from the PACU. He was made NPO and had
IV hydration, IV medications, foley and oxygen via NC. He
started to show evidence of fluid overload, initially O2 sats's
the mid 90s on 5L NC, but had desated to mid 80s requiring NRB.
A CTA was done - negative for PE. He also had an ECHO, which
showed a normal EF. He had been persistently hypertensive and
tachycardic despite hydralazine IV and metoprolol IV. After
stabilizing diurisis and blood pressure control in the ICU, he
returned to the surgical floor requiring oxygen by nasal
cannula.
.
The patient's serum creatinine increased from 0.9 to 1.5 his PO
lasix will be held for a total of 3 days. The pt will follow up
with his PCP [**Last Name (NamePattern4) **] [**2115-2-7**]. Prior to his visit the VNA will draw a
serum creatinine and fax to PCP [**Name Initial (PRE) 3726**]. A discharge summary was
faxed to the office.
.
The pt's blood sugar was 50 on [**2115-2-5**] without any signs or
symptoms of hypoglycemia. This was treated and the pt was
educated on the s/s of hypoglycemia. He was advised to check his
blood sugar before meals and at bedtime and to continue with his
oral diabetic medications. He was advised to call his PCP if his
blood sugar is less than 90 or more than 250. The patient's
staples were removed and steri strips were applied.
.
The patient is currently on home oxygen 2L via NC. He will
continue with this at home. He was evaluated per Physical
Therapy, and cleared for home with oxygen. He was able to
ambulate up and down stairs in hospital prior to discharge with
sats remaining over 95% on 2 liters with minimal assist. It was
recommended he be discharged to a rehabilitation facility
secondary to his acute renal failure and hypoglycemia, but he
refused this. The risks of this were explained to the patient.
Discharge paperwork was reviewed with the patient and he will
follow up with Dr. [**Last Name (STitle) 1120**] in [**1-22**] weeks and his PCP [**Last Name (NamePattern4) **] [**2115-2-7**]
.
Medications on Admission:
lisinopril 40 mg, Lasix 80 mg, Toprol XL 50 mg,
metformin 1000 mg [**Hospital1 **], glyburide 5 mg [**Hospital1 **], Zoloft 40 mg, Xanax
0.5 mg TID PRN, Zocor 80 mg, Betoptics drops [**Hospital1 **]
Discharge Medications:
1. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for 2 weeks.
Disp:*45 Tablet(s)* Refills:*0*
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
10. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for anxiety.
11. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Sertraline 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Trusopt 2 % Drops Sig: One (1) Ophthalmic twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary:
Sigmoid colon cancer
Incarcerated umbilical hernia.
Post-op Hypoxia secondary to fluid over load
Hypercarbia
Post op ventricular tachycardia
Hypertension
Acute renal failure
.
Secondary:
DM2, HTN, hyperchol, anxiety
Discharge Condition:
Stable
Tolerating regular diet
Pain well controlled with oral medicaitons
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your 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.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Oxygen:
-Please continue with your home oxygen therapy. Titrate oxygen
to maintain resting saturations over 93%.
.
Medications:
Lasix:
-Please continue to hold your lasix until your follow up your
PCP [**Last Name (NamePattern4) **] [**2115-2-7**].
.
Blood sugars:
-Please continue to check your blood sugars before meals and at
bedtime.
-Please call your PCP if your blood sugars are under 90 and over
250.
-Continue your metformin and glyburide unless otherwise
instructed per yor PCP.
Followup Instructions:
1) Please call Dr.[**Name (NI) 77999**] office for a followup appointment in
[**12-21**] weeks ([**Telephone/Fax (1) 3378**]
2. A follow up appointment was made for you at your PCP's
office, [**Last Name (un) **],[**Doctor Last Name **] M. [**Telephone/Fax (1) 27541**], on [**2115-2-7**] at 11:00
AM. Please call if you can not make this appointment. It is very
important for you to keep this appaointment to follow up with
your lab results.
NEITHER DICTATED NOR READY BY ME
Completed by:[**2115-2-5**]
ICD9 Codes: 5849, 5180, 9971, 4280, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4163
} | Medical Text: Admission Date: [**2143-4-11**] Discharge Date: [**2143-4-15**]
Date of Birth: [**2090-5-29**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Gemfibrozil / Zosyn
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Fever and Hypotension
Major Surgical or Invasive Procedure:
Central Line placement
Left Nephrostogram
History of Present Illness:
52M with h/o BPH, markedly elevated PSA (>200) and outlet
obstruction, presents with fever and hypotension. He presented
to the ED with confusion, fever and abdominal pain on [**4-11**]. In
the ED, he was found to have a positive UA with CT Abdomen
revealing bilateral hydronephrosis with pyeloneprhosis. He was
hypotensive requiring vaspressors 5L NS. Foley was placed and he
was initially treated with levofloxacin.
.
On admission to the MICU he was treated with vancomycin and
zosyn with vasopressors weaned off on day of admission. On [**4-12**]
urine culture grew enterococcus so Linezolid was started for
concern for VRE. Due to concern of ureteral obstruction as well
as bladder outlet obstruction, IR atempted placement left perc
nephrostomy tube, but ureterogram did not reveal obstruction or
hydroureter and therefore no tube placed. On [**4-13**] he developed
acute SOB and CT chest/abd showed small RP bleed at site of
prior procedure with no PE. There was concern for anaphylaxis
to zosyn (as SOB was temporally related to infusion) so he was
given steroids, Epi, H1 and H2 blockers.
.
[**Hospital **] transferred to floor for further care.
Past Medical History:
1. S/P hemorrhagic CVA [**2127**] with residual partial right
hemiparesis, homonymous hemianopsia and partial aphasia.
Etiology of CVA thought to be thrombotic; MRA at that time
showed
no vascular abnormality. High homocysteine resolved with B
complex.
2. Reactive depression, never suicidal, improved.
3. GERD, nearly resolved after rx for H. pylori, now uses
ranitidine only prn.
4. Hypertension.
5. Chronic headaches, improved.
5. Hyperlipidemia / hyperuricemia. Triglycerides greatly
improved with strict diet but then patient regained weight.
6. Abnormal lfts - noted [**6-/2140**]; unclear if related to lipitor
or hyperlipidemia or other etiology, resolved. Hepatitis A Ab+,
Hepatitis B and C neg.
7. Sexual dysfunction. did not try cialis and is not currently
having sexual relations.
8. HTN
9. left hydronephrosis
.
PAST SURGICAL HISTORY:
1. S/P circumcision
2. S/P shrapnel wound upper back.
3. s/p ccy [**10/2142**]
Social History:
Cambodian immigrant (came to US at age 27).
Disabled. Lives with wife and 2 daughters. Resumed smoking up to
1 PPD, no alcohol, no history drug abuse.
Family History:
Resumed smoking up to 1 PPD, no alcohol, no history drug abuse.
Physical Exam:
T 97.1 HR 70 RR 34 BP 118/70 99%% on RA (on floor)
Gen: NAD
HEENT: PERRLA, OP clear
Neck: R IJ in place.
Lung: crackles at bases, no wheeze
Cor: RRR, nml S1S2 no MRG
Abd: NABS, soft NT, mod distended, no CVA tenderness
Ext: trace bilat LE edema, contracted on the R upper ext.
Back: mild Left CVA tenderness
Pertinent Results:
[**2143-4-11**] CT ABD: 1. Perinephric stranding with thickening of
Gerota's fascia on the left not identified on previous study
dated [**2143-2-18**]. The differential includes an
inflammatory process versus a slow forniceal leak. The renal
parenchyma cannot be well evaluated given lack of IV contrast
administration. No stones are identified within the
genitourinary system. There is mild increase in left hydroureter
since previous study.
2. There is a suggestion of a small bladder diverticulum at the
insertion of the left ureter. No definite bladder mass
identified to explain hematuria, although full evaluation is
limited secondary to lack of IV contrast administration.
3. Bibasilar airspace opacity representing either atelectasis or
pneumonia.
4. Trace bilateral pleural effusions, greater on the left.
5. Diffuse fatty infiltration of the liver.
.
[**2143-4-12**] NEPHROSTOGRAM: Uncomplicated ultrasound and
fluoroscopically-guided left nephrostogram. No evidence of left
hydronephrosis or hydroureter or urinary obstruction.
.
[**2143-4-13**] CT PELVIS/ABD/CHEST: 1. New high-density material
surrounding the left ureter and tracking within the
retroperitoneum consistent with hemorrhage.
2. Abnormal perfusion of the left kidney, most severe at the
upper pole. Findings are consistent with pyelonephritis. Edema
and abnormal perfusion at the upper pole and interpolar region
medially with multiple peripheral hypoenhancing wedge- shaped
regions likely represent ischemia and a component of infarction.
3. Limited examination for pulmonary embolism due to suboptimal
contrast bolus with no large central embolus seen. Evaluation of
distal segmental and subsegmental branches is limited.
4. Small bilateral layering pleural effusions with associated
compressive atelectasis. Patchy predominantly ground-glass
opacities in both lower lobes, left worse than right could
represent pneumonia or pneumonitis.
5. 5mm cystic lesion in the head of the pancreas. Recommend 1
year follow up.
.
[**2143-4-13**] CXR: Questionable small right pleural effusion, vague
indistinct linear opacity in the right infrahilar region, likely
atelectasis.
.
[**2143-4-11**] 05:01AM BLOOD Lactate-4.3*
[**2143-4-11**] 08:54PM BLOOD Lactate-1.6
[**2143-4-10**] 08:35PM BLOOD CRP-118.7*
[**2143-4-11**] 01:58PM BLOOD Cortsol-32.8*
[**2143-4-11**] 02:43AM BLOOD CK-MB-5 cTropnT-<0.01
[**2143-4-13**] 01:46PM BLOOD cTropnT-0.07*
[**2143-4-11**] 02:43AM BLOOD CK(CPK)-548*
[**2143-4-13**] 01:46PM BLOOD ALT-20 AST-18 CK(CPK)-139 AlkPhos-78
[**2143-4-14**] 04:12AM BLOOD ALT-18 AST-17 LD(LDH)-243 AlkPhos-71
Amylase-56 TotBili-0.8
[**2143-4-10**] 08:35PM BLOOD Glucose-116* UreaN-20 Creat-1.9* Na-133
K-3.5 Cl-96 HCO3-22 AnGap-19
[**2143-4-15**] 05:00AM BLOOD Glucose-222* UreaN-23* Creat-1.1 Na-141
K-3.6 Cl-109* HCO3-23 AnGap-13
[**2143-4-10**] 08:35PM BLOOD Neuts-88* Bands-4 Lymphs-2* Monos-5 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2143-4-11**] 05:05AM BLOOD Neuts-71.0* Bands-16.0* Lymphs-1.0*
Monos-2.0 Eos-0 Baso-0 Metas-9.0* Myelos-1.0*
[**2143-4-13**] 05:25AM BLOOD Neuts-76* Bands-9* Lymphs-9* Monos-2
Eos-1 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2143-4-10**] 08:35PM BLOOD WBC-17.3*# RBC-5.55# Hgb-15.3# Hct-45.3#
MCV-82 MCH-27.5 MCHC-33.6 RDW-13.7 Plt Ct-202
[**2143-4-15**] 05:00AM BLOOD WBC-12.9* RBC-3.96* Hgb-10.8* Hct-32.0*
MCV-81* MCH-27.2 MCHC-33.6 RDW-14.0 Plt Ct-218
.
URINE CULTURE (Final [**2143-4-12**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
Brief Hospital Course:
#Enterococcus Pyelonephritis/Urosepsis: initially treated with
Vanco/Zosyn---> Linezolid. Enterococcus isolate pan-S; pt
switched to Doxycycline on discharge given concern for ?Zosyn
allergy. Will complete a total of 14 days of abx. Lopressor
and Flomax held on d/c until pt follows up with PCP.
.
#?Anaphylaxis to Zosyn: episode of acute SOB in ICU that was
thought to be temporally related to Zosyn. Resolved with
treatment for anaphylaxis. CTA negative for large PE, CXR
without overt volume overload. Will complete a total of 4 days
of steroids to prevent possible late anaphylaxis. 02 sats/Lung
exam normal on floor.
.
#Enlarged Prostate, ?Prostate Cancer: to f/u with urology as an
outpatient for bx.
.
#Urinary Retention: No Hydronephrosis noted on Nephrostogram
(after Foley placed). Per Urology, pt to leave Foley catheter
in place until f/u as outpatient.
.
#Acute Renal Failure: resolved after IVF. Likely secondary to
prerenal causes/sepsis.
.
#Retroperitoneal Bleed: likely secondary to Nephrostogram (IR
procedure). Serial HCTs stable.
.
#5mm cystic lesion in the head of the pancreas: Noted on
imaging. Per radiology, needs 1 year follow up.
Medications on Admission:
1. FLOMAX 0.4 mg--2 capsule(s) by mouth at bedtime
2. METOPROLOL TARTRATE 25 mg--1 tablet(s) by mouth twice a day -
blood pressure
3. OMEPRAZOLE 20 mg--1 capsule(s) by mouth once a day - reflux,
gastritis
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 1 days.
Disp:*3 Tablet(s)* Refills:*0*
2. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
twice a day for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day. Capsule, Delayed
Release(E.C.)(s)
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
1. Enterococcus Pyelonephritis/Urosepsis
2. ?Anaphylaxis to Zosyn
3. Enlarged Prostate, ?Prostate Cancer
4. Urinary Retention/Hydronephrosis secondary to above
5. Acute Renal Failure, resolved
6. Retroperitoneal Bleed, likely secondary to Nephrostogram
Discharge Condition:
stable
Discharge Instructions:
Please come back to the emergency room should you develop any
fevers, chills, sweats, nausea, vomiting, diarrhea, burning with
urination, or any other complaints.
Do not take your "Flomax" or "Metoprolol" medications until you
see Dr. [**Last Name (STitle) 1683**].
Followup Instructions:
Please call to make an appoinment with Dr. [**Last Name (STitle) 770**] in two weeks
([**Telephone/Fax (1) 5727**]).
Please call to be seen by Dr. [**Last Name (STitle) 1683**] within 1-2 weeks.
ICD9 Codes: 0389, 5849, 2762, 486, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4164
} | Medical Text: Admission Date: [**2192-4-18**] Discharge Date: [**2192-4-26**]
Date of Birth: [**2134-12-9**] Sex: M
Service: [**Last Name (un) **]
ADMITTING DIAGNOSIS: Post necrotic cirrhosis/hepatitis C
virus waiting for liver transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
male with a history of hepatitis A and B, end-stage liver
disease secondary to hepatitis C virus and alcohol abuse (the
patient treated with Rebetol). Also a history of
hepatopulmonary syndrome and with MELD score of 27. The
patient has been to [**Hospital1 69**] 2
times prior to this admission for potential liver transplant
surgery. History of ascites and encephalopathy.
He has had no recent fevers or infections. No major weight
loss or gain. He denies any shortness of breath or chest
pain. No change in urinary or bowel movements.
He has abstained from drugs/alcohol x 33 to 35 years. He is
currently employed as a substance abuse counselor and remains
active with AA and NA.
The patient has been waiting for a liver transplant on the
last 2 admissions, but the donated liver was not acceptable
and had to be discharged home.
PAST MEDICAL HISTORY: History of end-stage liver disease
secondary to hepatitis C and alcohol abuse. Also a history of
hepatitis A and B, history of stab wounds, history of sleep
apnea, hypertension, rheumatoid arthritis, GERD, history of
multi substance abuse, history of pneumothorax. No diabetes.
No history of MI. No history of lower extremity blood clots.
No history of asthma or emphysema.
PAST SURGICAL HISTORY: Status post appendectomy. Status post
right knee arthroscopy x 2. History of "blood clot" at the
age of 5.
ALLERGIES: TETANUS - reaction unknown.
MEDICATIONS ON ADMISSION: Nadolol 60 mg daily, Prevacid 20
mg daily, spironolactone 50 daily, lactulose, Caltrate 600
b.i.d., nicotine patch 14 mg daily.
SOCIAL HISTORY: Single. Lives alone. Patient has a
girlfriend. Stopped tobacco 1 month ago; 2 packs per day x 48
years. Stopped alcohol abuse in [**2176**]. He drank for 36 years.
Multiple drugs; stopped in [**2176**], abuse x 33 years.
PHYSICAL EXAMINATION: The patient is an overweight friendly
male in no acute distress. Temperature of 97.6, BP of 120/79,
heart rate of 62, respirations of 18, 97% on room air. Skin
with multiple well-healed lacerations on body. Warm to touch.
HEENT is atraumatic except for a right facial well-healed
laceration. Eyes reveal pupils equal, round, and reactive to
light. EOMs are full. Tongue is midline. No exudates. The
neck is supple with no palpable nodes. No thyromegaly. No
carotid bruits. Lungs are clear to auscultation and
percussion sitting erect bilaterally. CV with a regular rate
and rhythm, normal S1 and S2 without murmurs or rubs. Abdomen
is obese, distended, slight bowel sounds, soft, nontender,
hepatomegaly. No splenomegaly. No flank pain bilaterally.
Extremities: No C/C/E. ________________ dorsalis pedis.
Cranial nerves II through XII intact. Motor in upper and
lower are [**5-10**] bilaterally. No drift bilaterally. No asterixis
bilaterally.
LABORATORY DATA ON ADMISSION: WBC of 15.0, hematocrit of
30.3, platelets of 85. Sodium of 140, potassium of 3.9,
chloride of 112, bicarbonate of 23, BUN of 15, and creatinine
of 1.0. AST of 366, ALT of 209, alkaline phosphatase of 58,
total bilirubin of 2.7
RADIOLOGIC STUDIES: The patient had a previous chest x-ray
on [**4-13**] demonstrating no acute cardiopulmonary process.
HOSPITAL COURSE: The patient went to the OR on [**2192-4-18**]. The patient went to the ICU postoperatively. The
patient was kept intubated. Afebrile. Vital signs stable. The
patient was placed on tacrolimus 2 and 2. The patient was put
on morphine, ganciclovir, Bactrim. His LFTs were decreasing
in number. On [**4-19**], postoperative day, the patient had an
ultrasound of his liver, demonstrating widely patent hepatic
artery and branches. Portal and hepatic veins were also
patent. The patient had insertion of an internal jugular
catheter on [**2192-4-20**] for IV access. On postoperative
day 2, the patient was on tacrolimus 2 and 2. [**Last Name (un) **] was
consulted. The wound was clean, dry, and intact. The patient
had 2 JP drains in place. The patient had _________ written
for. Cholangiogram was performed on [**2192-4-24**]
demonstrating a nondilated intrahepatic and extrahepatic
biliary ducts with the passage of contrast into the Roux-en-Y
limb. There was no evidence of stricture or leak within the
biliary tree. There was no retrograde opacification of the
cystic duct along with the pancreatic duct.
On [**4-24**] WBC was 10.9, 37.4, platelet count was 95, PT of
14.0, PTT of 43.7, INR of 1.2, sodium of 134, potassium of
4.4, chloride of 106, bicarbonate of 19, BUN and creatinine
of 52 and 1.7, ALT of 117, AST of 164, alkaline phosphatase
of 55, total bilirubin of 0.8. On the 15th tacrolimus was
13.7. He has been doing well since then. Diet was advanced.
Foley was discontinued. Physical therapy evaluated the
patient on the 19th and felt that he was able to go home
without services. The day the patient was leaving, [**2192-4-26**], the right IJ was removed. Remaining JP drain was
removed. The patient has been eating well and urinating well
without difficulty, and patient is going home with VNA
services. Tacrolimus level on [**2192-4-26**] was 8.2, so
tacrolimus was increased from 0.5 b.i.d. to 1 mg daily. The
patient is going to be leaving on the following medications.
MEDICATIONS ON DISCHARGE: Fluconazole 400 mg q.24h., Bactrim
SS 1 tablet daily, Percocet 1 to 2 tablets q.4-6h. p.r.n.,
Protonix 40 mg daily, MMF 1000 b.i.d., prednisone 20 mg
daily, trazodone 50 mg p.o. at bedtime p.r.n., calcium
carbonate 500 mg 1 tablet daily, vitamin D3 one tablet daily,
Lopressor 100 mg daily, Valcyte 450 mg daily, tacrolimus 1 mg
b.i.d., and Lasix 20 mg b.i.d.
DISCHARGE FOLLOWUP:
1. The patient has a MRI appointment on [**2192-4-30**] at
12:30 p.m.
2. Also, the patient has an appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**2192-5-3**] at 10:10 a.m., and also another
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2192-5-10**] at 9:30
a.m.
DISCHARGE INSTRUCTIONS:
1. The patient is to have laboratories every Monday and
Thursday in which a CBC, Chem-7, AST, ALT, alkaline
phosphatase, total bilirubin, albumin, and a Prograf level
to be obtained. Please fax the results to [**Telephone/Fax (1) 697**].
2. The patient should call the transplant team office at [**Telephone/Fax (1) 32749**] if there are any fevers, nausea, vomiting, any
abdominal pain, any discharge from the drain sites, and
difficulty urinating or with bowel movements, any
lethargy, inability to tolerate p.o. foods.
FINAL DIAGNOSES: Post necrotic cirrhosis/hepatitis C virus;
status post liver transplant.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2192-4-26**] 14:17:31
T: [**2192-4-26**] 15:31:29
Job#: [**Job Number 32750**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4165
} | Medical Text: Admission Date: [**2187-8-13**] Discharge Date: [**2187-8-19**]
Date of Birth: [**2160-6-24**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 27 year old female
with a history of asthma whose last asthma flareup was in
[**2186-1-30**]. Prior to admission she woke up around
3:00 a.m. with worsening shortness of breath. She used her
inhaler/nebulizer and was able to go back to sleep. When she
woke up she got short of breath and progressively worsened
over the morning. She took prednisone 40 mg and began using
her inhaler from every four hours to every one hour. She
then came to the emergency department. She denied fever,
chills. She did have a cough with rare sputum production.
She denied nausea, vomiting, abdominal pain, dysuria. She
claimed that this was very similar to her previous episodes,
but does not know of any symptoms or triggers for this
attack.
PHYSICAL EXAMINATION: Vitals on exam 98.8, rate 117, blood
pressure 143/84, respiratory rate 20, 93% in room air, 98%
post nebs. Pertinent physical findings included diffuse
bilateral expiratory wheezing, good air movement. She was
tachycardiac, no murmurs. Skin was without rashes.
PAST MEDICAL HISTORY: Asthma with 64 PICU stays, multiple
MICU admissions, no previous intubations. She has chronic
sinusitis with nasal polyps, status post seven polypectomies.
She has a history of hypokalemia.
MEDICATIONS: Serevent two puffs b.i.d., Flovent 110 mcg two
puffs b.i.d., albuterol MDI p.r.n., Accolate 20 mg p.o.
b.i.d., Nasonex, Zoloft 100 q.d., Ortho Tri-Cyclen.
ALLERGIES: Include penicillin, sulfa, metabisulfites
(preservatives in medications such as epinephrine), latex.
HOSPITAL COURSE: After arriving in the emergency department
on [**8-13**], she proceeded to have worsening shortness of breath.
She received q.four hour nebs, IV steroids in the emergency
department and then was transferred to the floor. After a
few hours her requirements increased to q.one hour nebs and
closer observation, thus she was transferred to the MICU
later that evening. A Z-Pak was added to the regimen. In
the MICU the frequent nebulizer treatments and steroids were
continued, but she received elective intubation on [**8-13**] for
better ventilation due to increased difficulty breathing
regardless of the continued nebulizer treatments. She was
extubated on [**8-14**] without difficulty and was stable to
transfer to the floor the following day, but they decided to
watch her for a few more days while on greater than or equal
to q.three hour nebs.
On [**8-16**] she was started on IV aminophylline which was
switched to p.o. theophylline on [**8-17**]. She was transferred
to the general medicine floor on [**8-18**]. Patient was wheezing
upon auscultation, but patient stated she was feeling better.
Patient states her peak flow personal best is approximately
400, on the 17th she was 285, the following day she was in
the 250s to 260s. On the floor she continued with q.four to
six hour nebulizer treatments as needed. On the 20th patient
was started on her home regimen with nebulizers p.r.n. On
the 20th patient ambulated with physical therapy. O2 sats
upon ambulation were 92% to 93%. Her peak flow was found to
be 350. On physical exam she has good air movement and
decreased wheezing bilaterally. Thus, it was determined it
was safe to be discharged home that afternoon.
DISCHARGE STATUS: To home with followup at [**State **]Hospital on [**10-3**] at 2:45 p.m. with Dr. [**First Name4 (NamePattern1) 13624**] [**Last Name (NamePattern1) 108763**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS: Asthma exacerbation.
DISCHARGE MEDICATIONS:
1. Albuterol MDI.
2. Serevent.
3. Flovent.
4. Accolate.
5. Ortho Tri-Cyclen.
6. Zoloft.
7. Nasonex.
8. Three albuterol and ............. nebulizer solutions.
9. Prednisone taper beginning with 60 mg q.d. times three
days, then 50 times three days, then 40 times three days,
then 30 times three days, then 20 times three days, then 10
times three days.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Male First Name (un) 32816**]
MEDQUIST36
D: [**2187-8-20**] 19:21
T: [**2187-8-24**] 18:40
JOB#: [**Job Number 108764**]
ICD9 Codes: 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4166
} | Medical Text: Admission Date: [**2193-9-19**] Discharge Date: [**2193-9-25**]
Date of Birth: [**2124-5-26**] Sex: M
Service: SURGERY
Allergies:
lobster
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Abdominal Aortic Aneurysm
Major Surgical or Invasive Procedure:
PROCEDURE: Resection of juxtarenal aortic aneurysm.
History of Present Illness:
The patient is a 69-year-old male with an identified 5.7-cm
juxtarenal aortic aneurysm extending down just to the aortic
bifurcation.
Past Medical History:
PMHx:
-DJD spine
-CAD
-HTN- checks BP at home and states, SBP ~110/60 consistently
-Hyperlipidemia
-AAA, which was followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**]
-Trigger finger
-GERD - controlled with omeprazole
-Raynaud's
-bilateral cataracts
.
PSH:
-CABG x 4 vessel ([**2176**])
-tonsilectomy and adenoidectomy
-Left inguinal hernia repair approximately 10 years ago
Social History:
Smoke: 1.5 ppd (previously 2ppd) x 50 years
EtOH: daily glass of wine most nights; occassionally more on
social occassions, no recent episode of binge drinking
Drugs: none
Lives: [**Location (un) **], lives alone with cat, works as quality
technician
Family History:
No family history of GI issues or malignancies
FHx of heart disease, HTN, CAD
Physical Exam:
PHYSICAL EXAMINATION
Vitals: T: 99.7 HR 65 BP 107/48 96% on RA.
Gen: Pleasant, NAD, AOx3
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No carotid bruits.
CV: RRR, normal S1,S2. No murmurs, rubs, clicks, or [**Last Name (un) 549**]
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM. No palpable mass. Incision
c/d/i.
EXT: MAE, warm to touch. No c/c/e.
PULSE: Femoral palpable, DP and PT dopplerable bilaterally
Pertinent Results:
[**2193-9-24**] 06:58AM BLOOD WBC-5.8 RBC-3.52* Hgb-11.5* Hct-34.0*
MCV-97 MCH-32.6* MCHC-33.8 RDW-14.2 Plt Ct-150
[**2193-9-21**] 03:26AM BLOOD WBC-8.8 RBC-3.10* Hgb-10.3* Hct-29.3*
MCV-95 MCH-33.1* MCHC-35.0 RDW-15.1 Plt Ct-70*
[**2193-9-20**] 02:09AM BLOOD WBC-8.5 RBC-3.76* Hgb-12.2* Hct-35.3*
MCV-94 MCH-32.5* MCHC-34.5 RDW-15.4 Plt Ct-115*
[**2193-9-20**] 02:09AM BLOOD WBC-8.5 RBC-3.76* Hgb-12.2* Hct-35.3*
MCV-94 MCH-32.5* MCHC-34.5 RDW-15.4 Plt Ct-115*
[**2193-9-19**] 11:23AM BLOOD Hct-42.0 Plt Ct-135*
[**2193-9-23**] 03:00AM BLOOD PT-12.2 PTT-24.9 INR(PT)-1.0
[**2193-9-19**] 03:09PM BLOOD PT-15.1* PTT-32.9 INR(PT)-1.3*
[**2193-9-19**] 11:23AM BLOOD PT-14.8* PTT-31.9 INR(PT)-1.3*
[**2193-9-24**] 06:58AM BLOOD Glucose-109* UreaN-26* Creat-1.2 Na-142
K-3.7 Cl-105 HCO3-29 AnGap-12
[**2193-9-21**] 03:26AM BLOOD Glucose-117* UreaN-24* Creat-1.7* Na-135
K-4.5 Cl-104 HCO3-24 AnGap-12
[**2193-9-19**] 11:23AM BLOOD Glucose-142* UreaN-26* Creat-1.3* Na-141
K-5.6* Cl-114* HCO3-21* AnGap-12
[**2193-9-22**] 04:17AM BLOOD CK(CPK)-499*
[**2193-9-21**] 01:27PM BLOOD CK(CPK)-1074*
[**2193-9-21**] 09:58AM BLOOD CK(CPK)-1066*
[**2193-9-20**] 02:09AM BLOOD ALT-13 AST-34 LD(LDH)-350* AlkPhos-53
Amylase-32 TotBili-0.4
[**2193-9-19**] 11:23AM BLOOD ALT-10 AST-17 AlkPhos-68 TotBili-0.4
[**2193-9-22**] 01:22AM BLOOD CK-MB-2 cTropnT-<0.01
[**2193-9-21**] 01:27PM BLOOD CK-MB-3 cTropnT-<0.01
[**2193-9-21**] 09:58AM BLOOD CK-MB-3 cTropnT-<0.01
[**2193-9-19**] 11:23AM BLOOD CK-MB-3 cTropnT-<0.01
[**2193-9-23**] 03:00AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.2
[**2193-9-21**] 01:27PM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
[**2193-9-19**] 11:23AM BLOOD Albumin-2.8* Calcium-7.0* Phos-4.6*#
Mg-1.8
[**2193-9-20**] 02:05PM BLOOD Lactate-1.3
[**2193-9-19**] 09:16PM BLOOD Glucose-135* K-4.7
[**2193-9-19**] 09:16PM BLOOD freeCa-1.18
[**2193-9-19**] 10:30AM BLOOD freeCa-1.01*
CXR:
IMPRESSION:
1. Interval removal of the right internal jugular Swan-Ganz
catheter with the introducer remaining in place and having its
tip in the proximal SVC. Stable cardiac and mediastinal contours
in this patient status post median sternotomy for CABG. Patchy
bibasilar opacities, left greater than right in the setting of
low lung volumes most likely represents bibasilar atelectasis.
Small left pleural effusion. Low lung volumes with crowding of
the pulmonary vascularity and no overt pulmonary edema. No
pneumothorax.
Brief Hospital Course:
VASCULAR: The patient was admitted to the Vascular Surgery
Service on [**9-19**] and had a Juxta renal resection of AAA.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. EBL was roughly 2L and patient
received 3 units of RPBCs and 900cc of cell [**Doctor Last Name 10105**]
intraoperatively in addition to IVF. He tolerated the procedure
well without any difficulty or complication (reader referred to
operative note for details).
Post-operatively, he was transferred to the CVICU for further
stabilization and monitoring. He received 500cc of albumin and
IVF fluid for resuscitation but was otherwise hemodynamically
stable. He was kept in CV ICU for close monitoring with A-line,
PA Catheter, Foley, and Telemetry to monitor him during his
resuscitation and for fluid shifts.
He was then transferred to the VICU for further recovery. While
in the VICU he received monitored care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabilized from the acute setting of post operative care,
he was transferred to floor status
On the floor, he remained hemodynamically stable with his pain
controlled. Staples were removed on POD 7 and replaced with
steri-strips. Incision remained c/d/i. He progressed with
physical therapy to improve her strength and mobility. He
continues to make steady progress without any incidents. He was
discharged home with VNA in stable condition.
Neuro: Pre - pt received a epidural catheter infusing the APS
solution. This was removed POD # 3. After removal the patient
received Dilaudid IV/PCA with good effect and adequate pain
control. When tolerating oral intake, the patient was transition
to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. Pt did have a new RBBB. A
cardiology consult was obtained. The RBBB was thought to be
caused by the PA catheter. After this was removed. Pt HR
returned to NSR. There is no sequelae for the event.
Pulmonary: Post operatively the patient required 02 via nasal
canula and face tent to provide adequate oxygenation. Patient
was actively diuresed and given nebulizers and the breathing
improved. At time of discharge, he was breathing on room air
without respiratory distress.
GI: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Before DC he is taking PO and had a
bowel movement.
GU: Foley was removed on POD#3. Intake and output were closely
monitored. Pt is urinating on DC.
ID: Pt received perioperative antibiotics. The patient's
temperature was closely watched for signs of infection. Sputum
culture revealed normal respiratory flora.
Heme: The patient received subcutaneous heparin during this
stay, This was stopped because of platelet drop to 70. A HIT was
sent this was negative. He was begun on aspirin before
discharge.
Prophylaxis: Pt was put on Pneumo Boots because of the
aforementioned platelet drop. He was encouraged to get up and
ambulate as early as possible.
At the time of discharge on POD#7, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
ATORVASTATIN [LIPITOR] - 80 '; BUPROPION HCL - 150
ER';LISINOPRIL 10' METOPROLOL SUCCINATE - 50 ER'; OMEPRAZOLE
20'; ASPIRIN -325'; NIACIN 500'
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 10 days: prn for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule,
Extended Release PO HS (at bedtime).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual x 3: with chest pain, call PCP if pain persists.
14. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]vna
Discharge Diagnosis:
juxtarenal aortic aneurysm.
CAD ; HTN ; Hyperlipidemia; GERD; Raynaud's ; diverticulosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**4-24**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**12-20**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8244**], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:[**2193-12-12**]
1:00
Call Dr [**Last Name (STitle) 11918**] office and schedule an appointment for 2
weeks. [**Telephone/Fax (1) 1393**]
ICD9 Codes: 2762, 412, 5859, 2724, 311, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4167
} | Medical Text: Admission Date: [**2149-6-28**] Discharge Date: [**2149-7-6**]
Date of Birth: [**2083-9-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
lethargy, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 yo f w/ h/o bipolar d/o, dementia, and COPD (91% RA) who
initially presented to the ED from Rehab after she was noted to
be lethargic, w/ SaO2 on RA of 78%, initially 7.28/67/80 on 4L
NC. LIJ was placed. Pt started on vancomycin for b/l
cellulitis and levofloxacin for UTI. CT head showing old
lacunar infarcts. CXR (-). Started on solumedrol/nebs for
presumed COPD flair. Admitted to [**Hospital Unit Name 153**] for further monitoring.
.
In the [**Hospital Unit Name 153**], it was felt that the patient's low oxygen
saturation and lethargy were due to sedating meds, and her
mental status has subsequently cleared. Steroids were not
continued. Urine cultures grew out Proteus, R to levofloxacin
so patient was switched to CTX. Surgery debrided R anterior
tibial eschar.
Past Medical History:
MRSA
Osteoarthritis
COPD
CAD/MI
Depression
Opiod dependence
Social History:
Lives in [**Hospital 100**] Rehab. Has a daughter, chart says she "doesn't
want to be called unless the situation is life-threatening."
Substance Abuse Hx: Pt carries a diagnosis of opiate dependence,
and Heb Reb notes make reference to med-seeking behavior. The
extent of this is unknown. No known alcohol use.
Family History:
Non contributory
Physical Exam:
From when patient transferred to floor from [**Hospital Unit Name 153**]
98.5/ 91-110 / 90-160/69-95 / 17-19 / 93% ra
well appearing obese female in nad, found resting in bed, w/
mild paradoxical abdominal respiration while sleeping.
PERRL. anicteric. conjunctiva clear
OP clr.
no cervical cervical/sm/sc LAD. former LIJ side c/d/i w/ small
scab at site. thyroid not appreciated. JVP not appreciated [**1-16**]
body habitus.
regular, s1,s2. no m/r/g
poor air entry. lca b/l
+bs. soft. nt. nd.
b/l le edema. erythema extending to 2/3 up anterior tibia,
anterior wounds b/l, R now s/p escharotomy.
Pertinent Results:
[**2149-6-28**] 11:56PM LACTATE-2.4*
[**2149-6-28**] 12:00AM WBC-10.4 RBC-3.98* HGB-12.5 HCT-37.5 MCV-94
MCH-31.5 MCHC-33.4 RDW-16.1*
[**2149-6-28**] 12:00AM proBNP-340
[**2149-6-28**] 12:00AM GLUCOSE-81 UREA N-49* CREAT-1.4* SODIUM-133
POTASSIUM-7.1* CHLORIDE-98 TOTAL CO2-20* ANION GAP-22*
[**2149-6-28**] 12:11AM LACTATE-1.3 K+-5.8*
[**2149-6-28**] 12:58AM TYPE-ART O2 FLOW-4 PO2-80* PCO2-67* PH-7.28*
TOTAL CO2-33* BASE XS-2 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**]
[**2149-6-28**] 05:30AM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2149-6-28**] 05:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**6-27**] Head CT non contrast negative
[**6-28**] CXR IMPRESSION: Limited study. Low lung volumes and likely
left lower lobe atelectasis vs early left base infiltrate.
Urine cx: proteus mirabalis sensitive to ceftriaxone
Would cx: MRSA positive, 1+ PMN
Brief Hospital Course:
65 yo f w/ h/o copd a/w hypoxia and lethargy, found to have UTI
and b/l cellulitis. Was in [**Hospital Unit Name 153**] for 4 days and became more
alert with antibiotic treatment.
.
1) Hypoxia with hypercapnia- now at baseline O2 sat. Likely was
combination oversedation and mild COPD flare. Pt received a few
days doses of prednisone (4) and covered on antibiotics for
flare. No clear indication of PNA. Continue outpatient advair
and albuterol prn for treatment of COPD. Attempt to avoid
oversedation with pain medications.
.
2) UTI- Proteus mirabalis with resistance. Has received 6 days
of appropriate antibiotics and would benefit from a full 10 days
course. Foley has been left in as patient having difficulty
getting to bathroom and wanted to avoid contaminating leg
wounds.
-remove foley on return to [**Hospital1 1501**]
-finish cefpodoxime course
.
3) B/l cellulitis- likely [**1-16**] anterior tibial wounds. S/p R
debridement. Wound cx grew MRSA. Pt initially received
vancomycin, then transitioned to linezolid. Finish 14 days
course total of antibiotics (today is day 9). No recent fevers
or chills.
.
4) [**Name (NI) 3674**] unclear etiology. No evidence of blood loss or Fe
defiency. Follow up as outpatient.
.
5) HTN-Elevated by end of this admission. Made medication
adjustments to attempt better control.
-cont amlodipine 10mg po qd, imdur 60mg po qd, atenolol 100mg po
qd
-pt appeared volume contracted so stopped lasix. [**Month (only) 116**] need to
restart as outpatient.
.
6) Hyperlipidemia- cont simvastatin
.
7) [**Name (NI) 13338**] Pt with low potassium here. Have repleted.
Most recent repeat K is 4. Would recheck in 4 days and consider
restarting standing potassium if needed. Off lasix now so
unclear if will be as potassium wasting.
.
8) Pain management- Seen by psychiatry who felt patient was on
confusing pain and psych regimen and did not require as many
medications. Have made adjustments and patient to get followed
in [**Hospital1 1501**].
-changed to risperdal 1mg qhs with 1mg [**Hospital1 **] prn anxiety/agitation
-ultram 25mg tid with morphine SR 10-20mg q6hours prn pain
.
DNR/DNI
Medications on Admission:
combivent inh 1 puff [**Hospital1 **]
alendronate tablet 70 mg qsunday
amlodipine 10 pg qd
atenolol 50 mg qd
bisacodyl 5 mg qd
bupropion SR 150 mg [**Hospital1 **]
buspirone 20 mg po tid
cyclobenzaprine 10mg [**Hospital1 **]
docusate 200mg qhs
fluticasone/salmeterol 100/50 1 puff [**Hospital1 **]
furosemide 40mg [**Hospital1 **]
gabapentin 600mg tid
isosorbide mononitrate 30mg qd
pantoprazole 40 mg qd
kcl 20 meq once daily
simvastatin 20 mg qd
tramadol 100mg qid
methadone 10 mg po tid
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Neurontin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QDAY ().
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day).
12. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 days.
13. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days.
14. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
15. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
16. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety/agitation.
17. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
18. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
20. Outpatient Lab Work
Please get repeat chem 7 and Mg and Phos on [**2149-7-10**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Proteus urinary tract infection
MRSA cellulitis
COPD exacerbation
oversedation from medications
Discharge Condition:
Good
Discharge Instructions:
Follow for improvement of lower extremity cellulitis. Try to
avoid oversedation with pain medications.
Followup Instructions:
She should follow up with Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 6193**] in the next [**12-16**]
weeks. [**Telephone/Fax (1) 62610**]
ICD9 Codes: 5990, 496, 5849, 4280, 2760, 2859, 4019, 2724, 412, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4168
} | Medical Text: Admission Date: [**2191-3-3**] Discharge Date: [**2191-3-28**]
Date of Birth: [**2124-4-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
1. endotracheal intubation
2. bronchoalveolar lavage
3. placement of OG tube
4. placement of R internal jugular venous catheter
5. placement of R subclavian venous catheter
6. thoracentesis
7. lumbar puncture
History of Present Illness:
66 yo M with h/o CLL and follicular lymphoma currently receiving
chemotherapy, myasthenia [**Last Name (un) 2902**] (Dx [**2185**]; last flare [**2187**]), and
h/o recent pneumonia, who presented on [**2191-3-3**] with 1 week of
URI sxs, fevers, and worsening SOB. Patient had "pneumonia" in
early [**Month (only) 956**] and was treated with Ceftriaxone and
Levofloxacin. He finished a 10 day course of Azithro yesterday
for URI sx. Yesterday the patient had worsening SOB and cough
productive of clear sputum associated with low grade fevers to
99. Pt reported no chest pain other than pressure with cough, +
chronic back pain, no abdominal pain, no diarrhea or
constipation, no headache. EMS was called this AM and he was
noted to be 87% on RA.
.
In ED T 101.8, respiratory distress, improved to 100% on 100%
NRB. An initial ABG showed 7.44/46/126 on NRB. He received
Cefepime for essential neutropenia, Tylenol, and ativan 1 mg.
.
A CTA was negative for PE but showed diffuse centrilobular
nodules b/l and some consolidation in the RML and LL b/l, c/w
infection or mets.
Pt was improving in terms of oxygenation and weaned to nasal
cannula, but started to have increased tachypnea and tachycardia
and with concern for fatigue in setting of myasthenia [**Last Name (un) 2902**],
NIF was checked and found to be -22 and Vital capacity of 1.2L.
Was intubated for impending respiratory fatigue.
Pt underwent bronch on [**3-3**] with positive AFB smear; no evidence
PCP.
Neurology was consulted with concearn for flare-up of his
Myasthenia [**Last Name (un) **]; Tensilon test was positive; neurology
recommended increase Mestinon from 60TID to 80TID and no
indication for IVIG or plasmaphoresis.
Pt was transferred to [**Hospital Unit Name 153**] per onc attending request.
Past Medical History:
1. CLL diagnosed [**2179**], received chemo and was in remission
until [**2189**] when he had recurrence and now on his 4th regimen of
chemotherapy, s/p fludarabine, CPR x4 cycles, Campath
[**Date range (1) 55712**], now on CEPP (cytoxan, etoposide, procarbazine,
prednisone)
2. myasthenia [**Last Name (un) 2902**], on IVIG for the past 3 years
3. anxiety
4. hypertension, now off meds after weight loss
5. BPH
6. h/o grade III internal hemorrhoids
Social History:
Retired science teacher, lives at home w/ wife and son, hx of
tobacco 3 ppd x 20 years, now dc'ed x 34 years, prev 2 ETOH/day,
now dc'ed x 2 years, no IVDU, no illicit drug use
Family History:
Breast cancer in sister, suicide at 67; brother died of lung
cancer at 60; o/w no FH ca, DM2, HTN, CAD
Physical Exam:
VS: 101.0 108/68 136 33 100% NRB
Gen: appears uncomfortable, tachypneic
HEENT: Sclerae anicteric. PERRLA. No oral lesions. Tongue is
well papillated. Shotty cervical and supraclavicular adenopathy.
Large seven by eight centimeter left axillary node is nontender.
NECK: Shotty right axillary adenopathy.
Pulm: + crackles at RLL, no wheezes
CV: tachycardic, regular, nl S1/S2, no murmurs
ABDOMEN: soft, NT/ND, good bowel sounds, spleen is palpable two
centimeters below
the left costal margin, liver edge palpable about 2cm below
costal margin.
EXTREMITIES: Bilateral shotty femoral adenopathy, no edema, 2+
distal pulses.
Pertinent Results:
Admission labs:
[**2191-3-3**] 08:20AM WBC-1.4*# RBC-3.22* HGB-9.8* HCT-27.9* MCV-87
MCH-30.5 MCHC-35.1* RDW-19.0*
[**2191-3-3**] 08:20AM PLT COUNT-119*
[**2191-3-3**] 08:20AM GRAN CT-680*
[**2191-3-3**] 08:20AM GLUCOSE-99 UREA N-21* CREAT-0.6 SODIUM-137
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-30* ANION GAP-13
[**2191-3-3**] 08:20AM ALT(SGPT)-35 AST(SGOT)-35 CK(CPK)-15* ALK
PHOS-71 AMYLASE-57 TOT BILI-1.4
[**2191-3-3**] 08:20AM PT-12.4 PTT-29.1 INR(PT)-1.0
[**2191-3-3**] 08:41AM LACTATE-1.4
[**2191-3-3**] 09:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2191-3-3**] 09:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2191-3-3**] 09:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-RARE
EPI-0-2
[**2191-3-3**] 09:00AM URINE HYALINE-0-2
[**2191-3-3**] 09:46AM TYPE-ART TEMP-38.3 PO2-126* PCO2-46* PH-7.44
TOTAL CO2-32* BASE XS-6 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2191-3-3**] 09:19PM TYPE-ART O2-100 PO2-506* PCO2-44 PH-7.39
TOTAL CO2-28 BASE XS-1 AADO2-173 REQ O2-38 -ASSIST/CON
INTUBATED-INTUBATED
Imaging:
CXR [**3-3**]:
IMPRESSION:
1) Left lower lobe opacity consistent with pneumonia.
2) Proper placement of the NG tube.
CT angio [**3-3**]:
IMPRESSION:
1) No CT evidence of pulmonary embolism.
2) Interval development of innumerable, diffuse, ill-defined
nodules which appear to be in a centrilobular pattern, some of
which are arranged in a tree and [**Male First Name (un) 239**] pattern. These findings are
most suggestive of a small airways atypical infection, such as
fungal, mycobacterial, or mycoplasma.
3) Multifocal areas of consolidation within the right middle
lobe, right lower lobe, left lower lobe, findings which may
represent atelectasis or multifocal infectious process.
4) Slight interval decrease in size of the right middle lobe
pulmonary mass.
5) Stable appearance of bulky axillary, hilar, or mediastinal
lymphadenopathy.
6) Interval resolution of previously seen effusions.
CT head [**3-15**] (noncontrast):
IMPRESSION: No intracranial hemorrhage or mass effect.
EEG [**3-16**]:
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized
background and bursts of generalized slowing. These findings
indicate a
widespread encephalopathic condition affecting both cortical and
subcortical structures. Medications, metabolic disturbances, and
infection are among the most common causes. There were no areas
of
prominent focal slowing, but encephalopathies may obscure focal
findings. There were no epileptiform features. A tachycardia was
noted.
Brief Hospital Course:
1. Respiratory failure - etiology was multifactorial, due to a
multifocal pneumonia, RSV bronchiolitis, and myasthenia crisis.
Neurology was consulted early, and a tensilon test could not
rule out myasthenia crisis. Pt was therefore treated with 5
days of IVIG. In addition, BAL on [**3-3**] eventually revealed RSV,
which was consistent with the tree-in-[**First Name5 (NamePattern1) 239**] [**Last Name (NamePattern1) 55713**] picture
on chest CT. He was therefore treated with a 5-day course of
ribavirin, as well as Synagis. Further, due to his neutropenia,
pt was placed on broad spectrum antibiotics (cefepime as
febrile/neutropenic, doxycycline for atypicals, and vanco for
possibility of MRSA)for his presumed multifocal pneumonia. On
BAL [**3-3**], a few AFB were noted on concentrated smear; this
proved to be MAC and not thought to be a major player in pt's
respiratory failure. Pt was intubated in the ED and ventilated;
Over the first 2 weeks of his hospitalization, as the above
treatments proceeded, pt required decreasing amounts of
ventilatory support. His NIF was measured daily, and increased
to about -27 without increased effort. Eventually, his mental
status (as detailed below) and ability to manage secretions were
thought to be the major impediments to extubation, he had a
trach placed on [**2191-3-20**]. He did well for a few days off any
ventilatory support, and then on [**2191-3-28**] became hypotensive and
went into hypercarbic respiratory failure.
.
2. Mental status - After propofol was weaned, pt did not clear
his mental status as predicted: he had intact brainstem function
but could not follow commands and did not move his extremities
spontaneously. A head CT did not reveal any acute intracranial
process. An EEG showed changes consistent with encephalopathy,
thought to be due to metabolic causes. An LP was eventually
performed to rule out a meningitis, which was negative. Pt's
mental status continued to improve gradually, but waxed and
waned.
.
3. tachycardia - Pt was noted to be tachycardic, between the
90s-120s during most of his hospitalization. There was no clear
etiology; pt's EKG was consistent with sinus tachycardia. There
was a loose association between his fevers and tachycardia, but
pt remained on the tachycardic side whether or not he was
febrile.
.
4. anemia - Pt's baseline Hct was around 28-30. However, his
Hct dropped to 22-24 during the first few days of
hospitalization. GI was consulted and it was thought that if he
had a true GI bleed, pt would have melena or BRBPR, neither of
which he had. He was transfused and his Hct responded
appropriately. However, later on, around 2 weeks into his
hospitalization, his Hct again dropped to about 26. He was
transfused 2 units again, without significant response
(increased to 29 from 26). Hemolysis and DIC labs were
negative. A reticulocyte count was 1.8%, which pointed to an
underproduction/bone [**Last Name 15482**] problem. Pt was guaiac positive but
not frankly melenic or with BRBPR; this was thought to be due to
the small amount of oral bleeding pt demonstrated in the context
of gum disease.
.
6. myasthenia [**Last Name (un) 2902**] - Due to an equivocal tensilon test, pt
was treated with 5 days of IVIG. He was continued on his
pyridostigmine, which was initially increased to 80mg po tid.
While pt was receiving IVIG and his secretions were increased,
this was lowered to 40mg po tid, and then uptitrated to 60mg po
tid with resolution of these symptoms, after the IVIG was
completed. He was maintained on the pyrdidostigmine throughout
his course and it was felt the myasthenia contributed to his
poor respiratory status.
.
7. fevers - Pt was consistently febrile throughout his
hospitalization. Low-grade fevers were thought to be consistent
with pt's underlying CLL and were consistent with his low-grade
fevers at home. However, he had multiple fever spikes, to the
102s. Blood cultures were repeatedly negative, with the
exception of a myco/lytic blood culture bottle ([**12-27**] blood
cultures from that day, [**3-11**]) grew Enterococcus faecium, which
was sensitive to vancomycin. Pt was therefore placed on
vancomycin for a 2 week course. Pt's sputum cultures did not
grow any bacteria; however, repeated nasopharyngeal aspirates
were positive for RSV antigen and he was treated with ribavirin
and palivizumab x 2. Urine cultures were repeatedly negative.
Pt's nasopharyngeal aspirates grew HSV-1 on viral culture, but
this was not thought to be a pathogenic source. He was treated
with acyclovir for his HSV infection as he had oral ulcers. Pt
developed increasing bilateral pleural effusions. He was covered
with meropenum for possible VAP on [**2191-3-28**].
.
8. adrenal insufficiency - Pt'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim was borderline
positive, thought likely in the context of sepsis. He was
placed on stress dose steroids, which ere weaned to his
outpatient prednisone dose.
.
9. CLL - pt is s/p recent CEPP chemotherapy, the last dose
being on [**2-28**]. He was pancytopenic as a result, but his ANC
recovered within the first few days, by [**3-8**]. G-CSF and
neutropenic cautions were stopped. Daily ANC revealed a
down-trend, though not to neutropenic levels, but he was felt to
be functionally neutropenic. Pt was also thrombocytopenic and
anemic, thought to be due to his recent chemotherapy. He did
require transfusions of platelets and PRBC.
.
10. FEN - Pt was maintained on tube feeds. He had increased
insensible losses, particularly during the time of ribavirin
treatment due to the tent in place, as well as in the context of
his fevers. He became transiently hypernatremic in this
setting, but this resolved with free water flushes. In
addition, pt was maintained with tight glycemic control (goal
<120) with fingersticks four times daily and an inuslin sliding
scale.
.
11. Goals of care: HIs clinical picture worsened on [**2191-3-28**] when
he became hypotensive and had acute repsiratory failure.
Multiple family meetings were had to discuss his code status and
to discuss goals of care. He was made comfort measures only and
passed away comfortably with his family at his side on [**2191-3-28**].
Medications on Admission:
senna
protonix 40mg po daily
folate 1mg po daily
allopurinol 300mg po daily
acyclovir 800mg po daily
iron sulfate 650mg po daily
bactrim DS MWF
prednisone 50mg po daily
flomax 0.4mg po daily
oxycontin 20mg po bid
restoril 45mg po q4h
CEPP
rituxan weekly
IVIG monthly
albuterol/atrovent nebs
pyridostigmine 180mg po qHS
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
CLL, repsiratory failure, sepsis
Discharge Condition:
Expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5849, 2762, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4169
} | Medical Text: Admission Date: [**2151-5-19**] Discharge Date: [**2151-6-7**]
Date of Birth: [**2081-11-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Diarrhea, Weakness, Anemia
Major Surgical or Invasive Procedure:
Port-a-cath placement.
History of Present Illness:
69 yo F with h/o Anaplastic large cell lymphoma and granuloma
annulare who presents with fatigue and weakness x 2-3 days. Pt
is poor historian but notes weakness x 2-3 days. She also notes
loose stools over this time period. She denies fevers, chills,
night sweats. She denies chest pain, shortness of breath, cough.
She denies melena, hematochezia, brbpr. She denies dysruia. Per
the patient's son, she has had no PO intake and has not got OOB
x 2 weeks. She also has occcassional urinary/fecal incontinence.
In the am of admission, she slipped and fell on leg. No LOC,
head trauma.
In [**Name (NI) **], pt was found to have diarrhea and poor rectal tone, neuro
consulted.
--CT head-multiple lytic lesions seen in the right parietal and
both occipital bones.
--CT C-spine - Multiple lytic lesions seen in the occipital
bones bilaterally and lateral mass of C1
--MRI L-spine - Degenerative changes seen in the lower lumbar
spine with no evidence of nerve root compression. Diffuse
mottled appearance seen within the vertebral bodies, the sacrum,
and both iliac bones is nonspecific in etiology. This can be
seen in diffuse osteopenia, myeloproliferative or lymphomatous
involvement of the osseous structures.
She also had a hematocrit of 19 and then 15 with fluids with LDH
380, I. Bili 1.3, INR 1.6. The patient was transfused 1 U PRBC.
She also had elevated LFTs:
--RUQ US - Multiple ill-defined small hypoechoic lesions
throughout the right lobe of the liver and surrounding the
gallbladder fossa.
--CT ABD - Diffuse stranding in the mesentery, which could
suggest infiltration by neoplastic process or fluid. Progressive
retroperitoneal and inguinal lymphadenopathy.
.
Pt admitted to MICU for ? cord compression and hypotension with
anemia. Found to be OB neg, received 4 units PRBC and ruled out
for cord compression. Transfered to medical floor once HD
stable. In addition, pt found to have PNA with hx of exposure to
Pertussis.
Past Medical History:
HTN
Anxiety
No Hx of skin sensitivity to sun or creams.
Granuloma Annulare
Social History:
Smokes [**12-20**] ppd x 60 years
No Etoh
Lives at home with son
Family History:
Mother died of ruptured appendix
Father died of EToh abuse
No hx of CA in family
Physical Exam:
Vitals: T99.8, BP: 130/50, HR: 107, RR: 26, O2 98% RA.
GEN: Moderately ill appearing female in NAD, mildly tachypneic,
no use of accessory muscles, speaking in full sentences.
HEENT: Pupils equal and reactive, MM dry, neck is supple with no
LAD.
CV: Tachy, reg, 1/6 SEM at axilla.
CHEST: Decreased BS at b/l bases. No rales or wheezes
appreciated.
ABD: NDNT, normoactive BS, soft. No masses appreciated.
EXT: trace pedal edema, warm and well perfused. L inguinal LAD
with skin changes. 4-5 cm ulcerative lesion on R calf with
surrounding erythema and lichenifcation of skin. Pt also has
mult areas on both upper ext with scaly lesions.
Neuro: A&Ox3 and appropriate. Moving all ext with normal
strength.
Pertinent Results:
CXR [**2151-5-20**]: FINDINGS: There is interval increase in the left
retrocardiac opacity with associated left pleural effusion. This
is consistent with an evolving pneumonia. There is prominence of
the pulmonary vasculature, suggestive of mild CHF. The soft
tissue and osseous structures are unchanged. No pneumothorax is
seen.
IMPRESSION: Left retrocardiac opacity and associated left
pleural effusion, which is increased in comparison to the prior
study, likely representing an evolving pneumonia. There is mild
prominence of the pulmonary vasculature, suggestive of
associated mild CHF.
.
.
CT Head: FINDINGS: No previous examination available for
comparison.
White and [**Doctor Last Name 352**] matter differentiation is preserved. No
intracranial masses effect and no hemorrhage is seen. Midline
structures are normal in position. Ventricles and subarachnoid
spaces are within normal limits. No findings to suggest an acute
territorial infarction are noted. MRI is more sensitive to
detect acute infarction, consider this if clinically indicated.
Bone windows demonstrated lytic lesion seen in the left parietal
skull measuring approximately 1 cm in diameter. Multiple
additional lytic lesions are seen in the occipital bones
bilaterally. Clinical correlation is necessary..
.
.
RUQ ultrasound: IMPRESSION:
1) No evidence of cholecystitis, cholelithiasis, or
choledocholithiasis. Tiny comet tail artifact likely secondary
to an adherent crystal versus a small cholesterol polyp.
2) Multiple ill-defined small hypoechoic lesions throughout the
right lobe of the liver and surrounding the gallbladder fossa.
These may be secondary to focal fatty sparing, however, given
the history of lymphoma a CT or MRI is recommended for
definitive characterization.
.
.
CT pelvis:
IMPRESSION:
1) No evidence of retroperitoneal hematoma.
2) Diffuse stranding, likely related to third-spacing.
3) Progressive retroperitoneal and right inguinal
lymphadenopathy, concerning for relapsed lymphoma; slight
improvement in size of left inguinal adenopathy. This unexpected
finding was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the morning of [**5-20**], [**2150**].
4) Diverticulosis.
5) Similar appearance of left adnexal cyst.
6) Liver lesions not assessed without intravenous contrast.
Mild mucosal thickening is seen involving both posterior ethmoid
sinuses. Small fluid level is seen within the left sphenoid
sinus and inferior left maxillary sinus.
INTERPRETATION:
1) No acute intracranial abnormalities.
2) Multiple lytic lesions seen in the right parietal and both
occipital bones, clinical correlation is necessary.
.
.
[**2151-5-21**] 04:39AM BLOOD WBC-14.2* RBC-3.07* Hgb-9.4* Hct-28.7*
MCV-93 MCH-30.5 MCHC-32.6 RDW-18.7* Plt Ct-492*
[**2151-5-21**] 04:39AM BLOOD Neuts-92.6* Bands-0 Lymphs-2.8* Monos-2.3
Eos-2.1 Baso-0.1
[**2151-5-21**] 04:39AM BLOOD Glucose-105 UreaN-13 Creat-0.6 Na-136
K-3.8 Cl-106 HCO3-23 AnGap-11
[**2151-5-21**] 04:39AM BLOOD ALT-34 AST-41* LD(LDH)-164 AlkPhos-122*
TotBili-1.7*
[**2151-5-20**] 02:59AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
.
.
Pelvic U/S:
Transabdominal ultrasound demonstrates a uterus measuring 5.7 x
3.1 x 5.7 cm. No fibroids are identified. The endometrium is
heterogeneous and thickened as it is seen transabdominally,
measuring 1.4 cm. There are echogenic foci within the
myometrium. The right ovary is not identified. A rounded left
adnexal cyst is seen, measuring approximately 2.4 cm in
diameter. This corresponds to a left adnexal cyst seen on the
recent CT exam. The left ovary itself is not clearly identified.
Transvaginal examination was declined by the patient.
IMPRESSION:
1. Thickened heterogeneous endometrium. The differential
diagnosis includes endometrial hyperplasia, carcinoma,
adenomyosis, or polyp. Further evaluation with MRI could be
considered. This exam is limited as the patient declined
transvaginal exam.
2. Left adnexal cyst. The ovaries are not clearly identified
Brief Hospital Course:
A 69-year-old female with past medical history significant for
anaplastic large cell lymphoma, granuloma annulare, who
presented with weakness, anemia, and hypertension.
.
BRIEF HOSPITAL COURSE BY PROBLEM:
.
1. Anaplastic large cell lymphoma: The patient has been
treated in the past with methotrexate successfully. During this
admission, she was found to have a white blood cell count that
was consistently trending upwards, even with broad-spectrum
antibiotics. After the patient had received approximately 14
days of broad-spectrum antibiotics, it was felt that this rising
white blood count was likely secondary to reactive leukocytosis.
The patient did not have any abnormal cells on blood smear;
however, it was noted that she had new lymphadenopathy on the
right side in the inguinal region per pelvic CT. In addition,
progression of her left-sided inguinal adenopathy was noted as
the patient developed open draining sores, which she had had on
prior admissions prior to treatment with methotrexate. It was,
therefore, felt that the patient's rising white blood counts and
symptoms were likely secondary to reactive leukocytosis from her
underlying lymphoma. The patient was, therefore, started on
CHOP chemotherapy on [**2151-6-1**], after placement of a right
subclavian Port-A-Cath. The patient successfully received 5
days of CHOP chemotherapy. She had some nausea and vomiting on
the first day, which was treated with antiemetics. The patient
did not receive any further hydration during this chemotherapy
as she was already quite anasarcous. After treatment with CHOP
chemotherapy, her white blood cell count begin to trend down
from 55 and is now at 16 after chemotherapy. The plan will
continue with CHOP chemotherapy as the patient will be unable to
take methotrexate with pleural effusion seen on CT scan. The
plan for the next dose of chemotherapy will be [**2151-5-31**]. Pt
with need twice weekly CBC and chem 7 during rehab admission as
Nadir will likely be around [**2151-6-23**]. Pt will follow-up with Dr.
[**Last Name (STitle) **] prior to next dose of chemo. Please communicate lab values
to Dr. [**Last Name (STitle) **].
.
2. Fevers: The patient was transferred to the medicine floor
and subsequently developed fevers up to 101. The patient's
symptoms included tachypnea without shortness of breath. She
denied nausea, vomiting, abdominal pain, lightheadedness,
dizziness, or headache. The patient also had a rising white
blood cell count associated with fevers with a maximum while
blood cell count of 55,000. The patient was initially started
on Levaquin, Flagyl and azithromycin while in MICU. She was
started on the azithromycin for an exposure to pertussis per the
patient's son. When the patient spiked again, she was started
on vancomycin. There was also a ? of asp pna due to altered MS
on admission. The patient did continue to spike through these
antibiotics. Infectious disease was consulted at this point.
The patient was persistently febrile through these
broad-spectrum antibiotics. They recommended coverage for
Pseudomonas, which would be the only thing that was not covered.
The patient was, therefore, started on Zosyn. The patient
developed diarrhea. Her stools were cultured and all cultures
were negative. All blood cultures, sputum cultures, and urine
cultures were negative. However, on hospital day 10, the
patient was found to have white blood cells in her urine and
grew out yeast. The patient was started on a 7-day course of
fluconazole. In addition to this, Histoplasma, Brucella, and
Bartonella were all sent per recommendation by the ID team. A CT
scan was performed which showed bilateral large pleural
effusions. It was felt that the left-sided pleural effusion
should be tapped to rule out empyema. A thoracentesis was
performed and the fluid was a transudate with no bacteria seen
on Gram stain and no growth on culture. Wound cultures were
also performed on the draining wounds in her left groin. These
grew out both yeast and staph, coagulase negative. However, it
was felt that these were likely secondary to normal skin flora.
The patient's fevers defervesced and all antibiotics were
discontinued after a full 14-day course for suspected pneumonia.
The patient remained afebrile and at the time of dictation,
both Brucella and Bartonella results were negative. Histoplasma
was still pending. The patient was also ruled out for pertussis
by PCR and cultures. After fevers defervesced, the patient's
white blood cell count continued trending up. Therefore, it was
felt that her fevers and leukocytosis were secondary to a
reactive leukocytosis from her lymphoma. The patient was
afebrile after her CHOP chemotherapy and white blood cell count
trended down.
.
3. Neuro: On admission, the patient was felt to be weak and
there was a question of cauda equina syndrome. The patient was
assessed by neurology who felt that her symptoms of weakness and
fatigue were likely associated with infection versus metabolic
dysfunction. The patient was found to have a hematocrit of 15
at the time of admission, and after transfusions and treatment
with broad-spectrum antibiotics, the patient's symptoms
resolved. The patient had an MRI as above which showed no
evidence of compression. Neurology signed off as they felt that
the patient's symptoms were not secondary to neurologic
dysfunction. The patient was seen and evaluated by physical
therapy. They felt that her weakness is secondary to
deconditioning. The patient will need aggressive physical
therapy and rehabilitation after discharge.
.
4. Anemia: Most likely secondary to inflammatory process with a
background of lymphoma. The patient had no clear source of
bleeding initially on admission as well as stools were guaiac
negative. DIC labs were sent and were negative. Haptoglobin
was normal on admission. Hematocrit was stable after receiving
4 units of PRBCs on admission. The patient received 2
additional transfusions after CHOP chemotherapy for hematocrit
less than 25. Pt found to have vaginal bleeding on [**6-4**]. HCT
remained stable. See below for details.
.
5. Vaginal bleeding: The patient was noted to have small
amounts of vaginal bleeding after the CHOP chemotherapy. The
patient is postmenopausal and has never had the symptoms before.
She denied pain. She was afebrile. A transvaginal ultrasound
was ordered; however, the patient refused this ultrasound. She
did allow a pelvic ultrasound, which showed a thickened
heterogeneous endometrium and a left adnexal cyst was also
noted. The ovaries were not clearly identified. OB/GYN was
consulted, but the patient refused a pelvic exam and refused
further workup at this time. The patient stated that she wanted
to discuss the issue with her family members. The patient was
educated and counseled about the risks of possible endometrial
cancer. She felt that she did not want any further intervention
at this time. After further discussion with the patient she
agreed to had biopsy and further work-up as an outpatient. GYN
agreed to this plan and an appointment was scheduled for [**6-30**], [**2150**].
.
6. Tachycardia: The patient was found to be tachycardic between
100 and 120 during the entire admission. Old records were
reviewed which showed that her heart rate had been in this range
since her first admission in 11/[**2149**]. It was noted in her prior
records that the patient had been on both beta-blockers and
calcium channel blockers in the past; however, her granuloma
annulare seemed to worsen with these medications and they were
therefore stopped. An Pt has a normal EF, but did have an
element of diastolic dysfunction. The patient received Lasix
with transfusions and her heart rate did improve to between 80
and 90 after chemotherapy and decrease in white blood cell
count. The patient should be started on a beta-blocker or
calcium channel blocker for another trial after her lymphoma is
stabilized.
.
7. Pneumonia: It was felt that the patient had a pneumonia on
initial admission to the MICU. She was started on antibiotics
as described above. The patient's respiratory status improved
after pleural effusion tapped on the left. Sputum cultures were
negative. Pertussis PCR neg. It is likely that her bilateral
pleural effusions were secondary to volume overload as the
patient was anasarcic after fluid resuscitation and
transfusions. The patient's respiratory status was back to
baseline at the time of discharge.
.
8. Diarrhea: The patient noted on admission that she was having
frequent loose bowel movements. The patient had C. diff checked
x3 and all were negative. She also had stool cultures sent for
ova and parasites, Salmonella, Cyclospora, and Giardia, all of
which were negative. The patient was on Flagyl for 14 days.
.
9. Nutrition: The patient was found to have an elevated INR on
admission, which was felt to be nutritional. The patient has
had a difficult time with nutrition since her diagnosis. She
states that she is simply not hungry. The patient received subq
vitamin K and oral vitamin K x5 days. Her INR then trended back
down to normal. She was noted to have hypoalbuminemia to 2.
The patient seemed to do well with encouragement while eating.
Nutrition was consulted and added a high-calorie shake to all of
her meals. The patient did well with this plan and was eating
more with encouragement and assistance with eating. The patient
is able to feed herself.
.
10. Anxiety: The patient has a history of anxiety and was
continued on her Valium during this admission.
.
11. FEN. Nutrition as above. Electrolytes: The patient had a
creatinine that was trending up during this admission. Checked
FeNa which was 0.9 suggesting dehydration. The patient received
gentle hydration plus transfusion to increase her forward flow.
She was also encouraged p.o. fluid intake for hydration.
Creatinine trended back down to 0.8. The patient also noted to
have chronic hyponatremia. The highest sodium that had been
documented over the past year was 136. Baseline appears to be
closer to 131. The patient has likely been equilibrated. She
was placed on a fluid restriction initially, which did bring the
sodium back up to the low 130s.
.
12. Prophylaxis. The patient was maintained on subq heparin
and PPI.
.
13: Granuloma Annulare: Pt is being followed by dermatology as
an outpatient. Skin lesions are actually much improved after MTX
treatment. Used to have open draining wounds.
.
Contact: The patient gave her son [**Name (NI) **] at phone number
[**Telephone/Fax (1) 22753**].
.
Code status was full during this admission. The patient states
she would like to talk to her family further about her code
status.
Medications on Admission:
HCTZ (not taking)
Valium 5 qd
Prozac - not taking
Folic Acid
Doxacin - ? taking
Aranesp
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
Disp:*90 ml* Refills:*2*
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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Diazepam 2 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*2 cannisters* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: One (1)
flush Intravenous DAILY (Daily) as needed.
9. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg
Injection every eight (8) hours as needed for nausea.
10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Recurrent lymphoma
Granulomata Annulare
Discharge Condition:
Stable to rehab
Discharge Instructions:
Please return to the hospital if you experience chest pain,
shortness of breath, severe nausea/vomiting or any other severe
symtoms.
1. Please follow-up with your appointments as below
Followup Instructions:
1. Please follow up with Gynecology on [**6-30**] with Dr. [**Last Name (STitle) **] at
2:30; Please go to [**Location (un) **], [**Hospital Ward Name 23**] 8. ([**Telephone/Fax (1) 22754**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/CUT. ONC. DERM. Where: CUTANEOUS ONCOLOGY
Date/Time:[**2151-6-30**] 9:45
ICD9 Codes: 486, 2765, 2761, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4170
} | Medical Text: Admission Date: [**2116-8-20**] Discharge Date: [**2116-8-24**]
Date of Birth: [**2053-4-14**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Lactose
Attending:[**Doctor First Name 1402**]
Chief Complaint:
AFib with RVR
Major Surgical or Invasive Procedure:
Electrical cardioversion x 2 in ED on arrival
History of Present Illness:
Ms. [**Known lastname 101707**] is a 63 yo F with history of liver transplant and
paroxysmal Afib, admitted from the ED with AFib with RVR and
tenuous blood pressure. The patient initialy presented to [**Hospital1 **]
[**Location (un) 620**], where she was unsuccessfully electrically cardioverted
twice (50 J and 100 J with INR 3.4) and given lopressor 5 mg IV
x 1. She was transferred here for further management.
In the ED here, VS were T 101, heart rate of 120-140. She was
given hydrocortisone 100 mg IV (for presumed adrenal
insufficiency with chornic prednisone for liver transplant) as
well as lopressor 5 mg IV and calcium gluconate. Cardioversion
was again attempted with 200 J and then 300 J. Her blood
pressure dropped after a dilt drip was started, and then she was
tried on amio drip which also dropped her pressures. She has
received a total of 6L IVF. She was supposed to go to the CCU,
but they have no beds currently.
She denies preceeding viral symptoms including HA, fever,
chills, myalgias, cough, rhinorrhea. She developed two "spells"
of non-bloody vomiting today and has loose stools, but not frank
diarrhea and no ill contacts. She denies feeling unwell over
the last few days. She reports acute onset of paroxysmal AFib
over the last few weeks, which is worsening of her AFib, and is
scheduled for an ablation at the end of the month with Dr.
[**Last Name (STitle) **].
Past Medical History:
Liver transplant [**2095**], [**1-21**] primary biliary cirrhosis (vs.
atresia-- records contradict)
Paroxysmal Afib
Hypertrophic cardiomyopathy, normal EF
Ascending aortic aneurysm, 4.2 x 4.3 cm in [**3-28**]
Hypertension
Thyroid colloid cyst
Stable Lung nodules
Rosacea
Retroperitoneal adenopathy
Skin cancer
Raynaud's syndrome
Cellulitis of thumb and left lower extremity
Keratosis on Left LE which has tract
Hernia repair
Portal shunt
C-section
Social History:
distant smoker; denies ETOH and IVDU; married with two sons;
elementary school social worker
Family History:
non-contributory
Physical Exam:
GEN: comfortable in bed, NAD
HEENT: JVP8cm H2O, MMM,OP clear, decent dentition
LUNGS: crackles at bases that clear with cough
COR: irreg irregular, tachycardic, no murmurs appreciated
Abd: + Bs, soft, NTND
Ext: No edema, WWP
Pertinent Results:
ADMISSION LABS:
[**2116-8-20**] 01:12PM BLOOD WBC-5.3 RBC-5.17 Hgb-15.7 Hct-46.7 MCV-90
MCH-30.4 MCHC-33.6 RDW-14.7 Plt Ct-92*
[**2116-8-20**] 01:12PM BLOOD Neuts-83.5* Lymphs-8.3* Monos-5.8 Eos-1.6
Baso-0.8
[**2116-8-20**] 01:12PM BLOOD PT-33.2* PTT-33.0 INR(PT)-3.4*
[**2116-8-20**] 01:12PM BLOOD Glucose-103* UreaN-14 Creat-0.6 Na-144
K-3.2* Cl-111* HCO3-24 AnGap-12
[**2116-8-20**] 01:12PM BLOOD CK(CPK)-118
[**2116-8-20**] 01:12PM BLOOD cTropnT-<0.01
[**2116-8-21**] 04:22AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.4
[**2116-8-20**] 01:12PM BLOOD TSH-1.2
[**2116-8-20**] 01:12PM BLOOD TSH-1.2
LABS: notable for K 3.2 (repleted in ED), Cr 0.6 (0.9 at BIDN),
TSH pending, INR 3.4
.
MICROBIOLOGY:
[**2116-8-20**] BCx x 2: pending
[**2116-8-20**] UCx: pending
[**2116-8-20**] UA: neg LE, neg nit, WBC 0-2
.
ADMISSION ECG: atrial fibrillation, LVH, QTc 450ms
.
ADMISISON CXR (at [**Location (un) 620**]):
AP supine view of the chest. Mild cardiomegaly is again seen,
though it is probably exaggerated by supine positioning. The
aorta is calcified and slightly tortuous, as before. There is
no evidence of pulmonary edema, pulmonary consolidation, or
pleural effusion.
.
[**2116-8-20**] CT ABD:
1. No intra-abdominal infectious process is identified.
2. Status post liver transplant with unremarkable appearance of
the liver. Extensive portosystemic collaterals.
3. Multiple renal hypodensities, a few of them have minimally
enlarged since the earlier study, including an uncharacterized
9mm left renal hypodensity. Recommended a non-emergent renal
ultrasound for further assessment of the above lesions. A stable
right renal angiomyolipoma.
4. Uncomplicated fat-containing ventral abdominal wall hernia.
.
cMRI [**2116-7-31**]
Impression:
1. Mildly increased left ventricular cavity size with focal
hypertrophy of the distal third and true apex portions of the
left ventricle with normal regional left ventricular systolic
function. The LVEF was normal at 72%. The effective forward LVEF
was mildly decreased at 43%.
2. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 71%.
3. Mild aortic regurgitation. Moderate to severe mitral
regurgitation. Mild tricuspid regurgitation.
4. The indexed diameter of the ascending aorta was moderately
increased. The indexed diameters of the descending thoracic
aorta and main pulmonary artery diameter index were mildly
increased.
5. Moderate biatrial enlargement.
6. Normal size and orientation of the pulmonary veins without MR
evidence of anomalous pulmonary venous return or pulmonary vein
stenosis.
7. Dilated IVC. Several subcentimeter foci in the right kidney
which probably represents cysts.
.
DISCHARGE LABS:
.
[**2116-8-24**] 09:20AM BLOOD WBC-3.9* RBC-5.02 Hgb-14.9 Hct-46.9
MCV-94 MCH-29.7 MCHC-31.8 RDW-14.7 Plt Ct-122*
[**2116-8-24**] 09:20AM BLOOD Plt Ct-122*
[**2116-8-24**] 09:20AM BLOOD PT-21.0* PTT-29.8 INR(PT)-2.0*
[**2116-8-24**] 09:20AM BLOOD Glucose-99 UreaN-16 Creat-0.7 Na-140
K-3.7 Cl-104 HCO3-28 AnGap-12
[**2116-8-24**] 09:20AM BLOOD ALT-43* AST-53* LD(LDH)-218 AlkPhos-128*
TotBili-1.1
[**2116-8-24**] 09:20AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.7
[**2116-8-24**] 09:20AM BLOOD tacroFK-PND
[**2116-8-21**] 04:22AM BLOOD tacroFK-9.1
.
PENDING:
[**8-24**] Tacro level
Brief Hospital Course:
63 yoF s/p liver transplant with refractory AFib/RVR.
#. ATRIAL FIBRILLATION with RVR: On admission, the patient was
found to be in AFib with RVR. She was given Lopressor in the
ED, and then two attempts at cardioversion were unsucessful.
She was started on a Dilt drop and subsequently amiodarone gtt
and her SBP was in the 80s-90s. She was admitted to the MICU,
where she was continued on an amiodarone gtt and received 6L of
IVFs. She remained stable and was transferred to the floor on
[**2116-8-21**]. Her Disopyramide and amiodarone gtt were discontinued
and she was started on Amiodarone 200 mg TID. Her Atenolol was
also uptitrated to 75 mg daily. She spontaneously converted to
NSR on the evening of [**8-23**] with HRs in the 50s, BPs 120s/70s. EP
saw the patient and determined that her rhythm control regimen
should be amiodarone 200 mg TID x 1 week, 200 [**Hospital1 **] x 1 week, 200
qd thereafter, along with atenolol 50 qd for rate control. She
is scheduled to have a pulmonary vein isolation with Dr.
[**Last Name (STitle) **] on [**9-17**], after which the amiodarone should be
discontinued.
.
# Anticoagulation: Patient's INR supertherpaeutic at 4.8 at time
of admission. Dose was decreased from 4 to 1. INR 2 at time of
discharge. Will d/c patient on 2 mg daily wih instructions to
get INR checked later this week.
.
#. HYPOTENSION: Resolved with volume recuscitation. This was
likley from por CO with RVR and loss of atrial kick. By the
time of discharge, patient's BPs were in the 120s/70s.
.
#. s/p LIVER TRANSPLANT: Primary liver doctor is at [**Hospital 36653**]
Clinic, Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) 13527**]. Her dosing of medications
was confirmed: CellCept [**Pager number **] mg b.i.d.,Prednisone 4 mg daily,
and Prograft 1 mg b.i.d.
- Prograft level on [**8-21**] 9.1, level [**8-24**] pending at time of
discharge
.
#. HTN: Resume ACE-I and atenolol
.
#. HYPERTROPHIC CARDIOMYOPATHY: normal EF; no evidence of CHF
exacerbation noted.
.
#. FULL CODE
Medications on Admission:
Atenolol 50 mg daily
Disopyramide 300 mg b.i.d.
CellCept [**Pager number **] mg b.i.d.
Prednisone 5 mg daily
Quinapril 40 mg b.i.d.
Prograf 1 mg b.i.d.
Coumadin as directed
Vitamin C 500 mg b.i.d.
Colace
Magnesium oxide 400 mg b.i.d.
Multivitamin
Calcium
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
2. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID x 4 days,
[**Hospital1 **] x 7 days, QD thereafter.
Disp:*40 Tablet(s)* Refills:*1*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Quinapril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day. Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
1. Paroxysmal Atrial Fibrillation with RVR
2. Nonobstructive hypertrophic cardiomyopathy
3. Hypertension
4. Primary Biliary Cirrhosis s/p liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
ICD9 Codes: 4254, 4589, 2768, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4171
} | Medical Text: Admission Date: [**2186-2-10**] Discharge Date: [**2186-2-14**]
Date of Birth: [**2130-4-22**] Sex: M
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old man
presented to his primary care provider's office with a
three-month history of external angina and dyspnea on
exertion. He had a positive stress test done on [**2-3**],
and was referred to [**Hospital1 69**] for
cardiac catheterization.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Tobacco use, which is remote. He quit in [**2171**], albeit he
does have 90 pack years.
4. Status post tonsillectomy.
5. History of cervical neck fracture.
6. History of alcohol use up to 30 drinks per week.
ALLERGIES: He states no known allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 q.d.
2. Plavix 75 q.d.
3. Atenolol 50 q.d.
4. Lisinopril 10 q.d.
5. Hydrochlorothiazide 25 q.d.
6. Lipitor 20 q.d.
His catheterization, which was done on [**2-6**] showed
heavily calcified left main, heavily calcified LAD with an
80% lesion and a 95% OM lesion with an EF of 50% and a LVEDP
of 23.
Laboratory data at that time: White count 6.4, hematocrit
40.8, platelets 175. Sodium 139, potassium 3.4, chloride
103, CO2 27, BUN 17, creatinine 0.9, glucose 101. AST 18,
ALT 29, alkaline phosphatase 80, amylase 67, total bilirubin
0.7, albumin 3.8. PT 12.7, PTT 24.1, INR 1.1.
PHYSICAL EXAM: Heart rate 53, sinus bradycardic, blood
pressure 144/65, respiratory rate 14, and O2 saturation is
96% on room air. Neurological: Awake, alert, and oriented
times three. Pupils are equal, round, and reactive to light.
Extraocular movements are intact. Grip and strength, plantar
and dorsiflexion are equal bilaterally. Cardiovascular:
Regular rate and rhythm, distant heart sounds, no murmurs.
Respiratory: Breath sounds clear anteriorly with scattered
rhonchi. GI: Soft, nontender, and nondistended with
positive bowel sounds and no masses. Extremities: Distal
lower extremities are cool, no varicosities, positive spider
veins. Pulses: Femoral 2+ bilaterally, popliteal 2+
bilaterally, dorsalis pedis and posterior tibial 1+
bilaterally. Radial 2+ bilaterally. Carotids are 2+ without
bruits.
Patient was accepted for coronary artery bypass grafting.
Post catheterization, he was discharged home. He returned on
[**2-10**] as a direct admission to the operating room at
which time he underwent coronary artery bypass grafting.
Please see the OR note for full details. In summary, the
patient had a CABG x3 with a LIMA to the LAD, saphenous vein
graft to OM, and saphenous vein graft to the diag. His
bypass time was 73 minutes with a cross-clamp time of 60
minutes. He tolerated the operation well and was transferred
from the operating room to the Cardiothoracic Intensive Care
Unit. At the time of transfer, the patient's mean arterial
pressure was 62 with a CVP of 11. He was A-V paced at 90
beats per minute. At that time, he had propofol infusion at
30 mcg/kg/minute.
Patient did well in the immediate postoperative period. His
anesthesia was reversed. He was successfully weaned from the
ventilator and extubated. He remained hemodynamically stable
requiring Neo-Synephrine at low doses to maintain an adequate
blood pressure.
On postoperative day one, the patient continued to do well.
He remained hemodynamically stable. His Neo-Synephrine
infusion was weaned to off. He was begun on beta-blockers
and diuretics. There were no floor beds available at that
time, and therefore he remained in the Cardiothoracic
Intensive Care Unit on postoperative day two. Patient
remained hemodynamically stable. His diuretics and
beta-blockers were continued. His activity level was
increased with the assistance of the nursing staff. His
Foley catheter and chest tubes were removed, and he was
transferred to the floor for continuing postoperative care
and cardiac rehabilitation.
Over the next two days, the patient had an uneventful
hospitalization. Activity level was increased with the
assistance of the nursing staff and physical therapy staff.
On postoperative day four, it was decided that the patient
was stable and ready to be discharged to home.
At that time, the patient's physical exam was as follows:
vital signs: Temperature 98, heart rate 89 sinus rhythm,
blood pressure 126/74, respiratory rate 18, and O2 saturation
95% on room air, weight preoperatively is 109 kg, at
discharge is 115 kg. Laboratory data: White count 8.9,
hematocrit 31.2, platelets 151. Sodium 141, potassium 3.9,
chloride 101, CO2 31, BUN 16, creatinine 0.8.
Physical exam: Neurologic: Alert and oriented times three,
moves all extremities, and follows commands. Respiratory:
Breath sounds are clear to auscultation bilaterally.
Cardiac: Regular rate and rhythm, S1, S2 with no murmurs.
Sternum is stable. Incision with staples open to air, clean,
and dry. Abdomen is soft, nontender, and nondistended with
normoactive bowel sounds. Extremities are warm and well
perfused with 1+ edema bilaterally. Right lower extremity
saphenous vein graft harvest site with Steri-Strips open to
air clean and dry.
DISCHARGE MEDICATIONS:
1. Enteric-coated aspirin 325 mg q.d.
2. Metoprolol 25 mg b.i.d.
3. Lipitor 20 mg q.d.
4. Lasix 20 mg b.i.d. x2 weeks.
5. Potassium chloride 20 mEq b.i.d. x2 weeks.
6. Percocet 5/325 1-2 tablets q.4-6h. prn.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
grafting x3 with a left internal mammary artery to the left
anterior descending artery, saphenous vein graft to the
obtuse margin, and saphenous vein graft to diag.
2. Hypertension.
3. Hypercholesterolemia.
4. Status post tonsillectomy.
5. History of cervical neck fracture.
DISCHARGE STATUS: He is to be discharged to home.
FOLLOW-UP INSTRUCTIONS: He is to have followup in the [**Hospital 409**]
Clinic in two weeks. Follow up with Dr. [**Last Name (STitle) **] in four
weeks. Follow up with his primary care provider (Dr.
[**Last Name (STitle) 54618**] in [**1-19**] weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2186-2-14**] 08:48
T: [**2186-2-14**] 08:57
JOB#: [**Job Number 54619**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4172
} | Medical Text: Admission Date: [**2159-8-20**] Discharge Date: [**2159-8-29**]
Date of Birth: [**2085-8-27**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Transfer from [**Hospital3 105**] for acute on chronic respiratory
distress.
Major Surgical or Invasive Procedure:
Lumbar puncture on [**8-22**]
History of Present Illness:
Mr. [**Known lastname 19641**] is a 73 yo male with a complicated past medical
history, recently discharged from [**Hospital1 18**] on [**8-8**] following a
prolonged admission for STEMI, respiratory failure felt
secondary to pulmonary edema requiring intubation and subsequent
tracheostomy [**2-28**] failure to wean, sepsis and C.difficile colitis
treated with Vancomycin and Flagyl with a course of Levophed. He
was discharged to [**Hospital3 105**] for continued weaning. Per
[**Hospital3 **], patient remained ventilator dependent,
intermittently on PS 20/5 and back on AC 15/5/500/0.35 on [**8-14**].
At OSH, sputum cultures grew Pseudomonas and MRSA, and he was
restarted on Zosyn ([**8-14**]) and Vancomycin ([**8-15**]). He completed
his course of Vancomycin on [**2159-8-16**].
However, today around 17:45, while being moved by the nursing
staff, Mr. [**Known lastname 19641**] [**Last Name (Titles) 4351**] started coughing. Suctioned X 1,
mucus not cleared. He then became dusky and cyanotic, and
stopped breathing on his own. A code was called, + pulse.
Patient placed on FiO2 100%. Vitals [**Last Name (Titles) 4351**] HR 88-98, BP
150/80. ABG done on FiO2 100% 7.36/66/417/98%. At [**Hospital1 **], BP
dropped to 90, and patient was started on NS IVF, with
improvement in BP. EKG without acute changes. He was transferred
to [**Hospital1 18**] ED for further management on AC, RR 15, PEEP 5, Vt 500,
Fi02 1.0.
In ED, BP 80/60, HR 80. Continued on IVF (received total
2300cc), with improved BP to SBP 105-118. Stool sent for C.diff
and given Flagyl 500 mg PO X 1 dose.
Past Medical History:
1. Non-small cell lung cancer s/p XRT and chemotherapy in
[**Country 532**], s/p right pneumonectomy in [**9-/2158**] for recurrence.
Chronic left pleural effusion.
2. SSS status post PM/ICD placement
3. COPD/bronchiectasis
4. Hypertension
5. CAD, with known TO RCA.
6. CHF with EF 25% on last echo on [**2159-7-25**]
7. BPH
8. Depression
9. Left femoral AV fistula [**2159-4-25**]
10. Recent MRSA pneumonia and sepsis [**7-/2159**], treated with
Vancomycin
11. C. difficile colitis treated with Flagyl (completed [**8-16**])
12. Status post PEG tube placement [**7-/2159**]
13. Status post tracheostomy [**7-/2159**] [**2-28**] failure to wean
14. Status post partial colectomy [**2126**]
Social History:
Son is next of [**Doctor First Name **]. See below for contact information. [**Name2 (NI) **] has
been living at [**Hospital1 **] House since [**2159-8-8**]. Per [**Hospital1 **], at
baseline, patient not interactive. Opens eyes spontaneously,
withdraws to painful stimulus.
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM on admission:
VITALS: BP 90s-118/47-59, HR 80-90s.
Vent: AC, RR 15, PEEP 5, Vt 500cc, FiO2 1.0.
GEN: Intubated, opens eyes, responds to painful stimulus.
HEENT: Pupils minimally reactive. Sclera anicteric.
NECK: Unable to assess JVP.
RESP: Bronchial breathing over right hemithorax. Ronchorous
breath sounds left chest. Limited examination.
CVS: RRR. Normal S1, S2. + S4. No murmur appreciated.
GI: PEG in place, site without drainage. BS present, hypoactive.
Abdomen soft. No grimacing with palpation.
GU: Foley in place.
EXT: 2+ edema both upper extremities, sacral edema. Cool
extremities. Good pedal pulses peripherally.
NEURO: Limited examination. Withdraws to painful stimulus. Moves
all 4 extremities.
Pertinent Results:
LABS:
WBC-4.9 RBC-2.92* HGB-8.8* HCT-26.2* MCV-90 MCH-30.1 MCHC-33.5
RDW-18.5*
NEUTS-86.5* LYMPHS-7.5* MONOS-4.7 EOS-1.2 BASOS-0.1
PLT COUNT-145*
GLUCOSE-91 UREA N-21* CREAT-0.6 SODIUM-143 POTASSIUM-4.2
CHLORIDE-106 TOTAL CO2-32 ANION GAP-9 LACTATE-1.4 K+-3.9
ABG:
[**2159-8-20**] 07:30PM TYPE-ART PO2-468* PCO2-44 PH-7.50* TOTAL
CO2-36* BASE XS-10 INTUBATED-INTUBATED
EKG (at [**Hospital3 105**], 17:11): Atrial fibrillation,
occasional V-paced, rate 74. Normal axis. Old TWI V4-6.
EKG in ED: Afib, occasional V-paced, rate 83 bpm. Normal axis.
Long QT interval (QTc 462 ms). ST depressions V4, 5. Mild ST
elevation in V3. Old TWI V4-6.
****************
IMAGING: [**2159-8-20**] CXR: ETT in correct position. PM wires in good
position. S/p right pneumonectomy. Blunting of left CPA likely
effusion. New lower left lateral CW opacity, likely loculated
pleural fluid.
[**2159-7-25**] ECHO: Left-to-right shunt across the interatrial
septum. LVEF 25%. Resting WMA include mid to distal septal
akinesis, apical akinesis, inferior akinesis/hypokinesis, and
mid to distal anterolateral hypokinesis/akinesis. No definite
apical thrombus seen (cannot exclude). [**1-28**]+ AR. Trivial MR. 1+
TR.
[**2159-8-22**] CT head: New rounded low-density area measuring 2.5 cm
in left basal ganglia, which partially extends to the left
thalamus, probably representing subacute infarction. On this
head CT without contrast, the evaluation is limited.
[**2159-8-22**] CTA chest: No evidence for pulmonary embolism. Findings
consistent with failure or fluid overload. Development of small
loculated pleural fluid collection along the periphery of the
left major fissure or so-called pseudotumor, consistent with the
recent chest x-ray. Unchanged appearance of right pneumonectomy.
[**2159-8-22**] ECHO: The left atrium is normal in size. Overall LVEF
is difficult to assess due to poor echo windows although the
basal LV appeas hyperdynamic without regional contraction
abnormality (suspect significant improvement compared to prior
study dated [**2159-7-24**]). No masses or thrombi are seen in the left
ventricle (due to poor echo windows cannot fully exclude). The
ascending aorta is mildly dilated. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade
[**2159-8-23**] EEG: Markedly abnormal portable EEG due to the voltage
suppression over the left hemisphere and due to the bursts of
generalized slowing and right hemisphere slowing. The first
abnormality raises the possibility of material (such as subdural
fluid) interposed between the brain and recording electrodes or
widespread cortical dysfunction on that side. Anatomic
correlation would be of interest if clinically indicated. The
generalized slowing indicates a non specific dysfunction in
midline structures. There was also evidence of subcortical
dysfunction on the right side. No epileptiform features were
seen.
MICRO DATA:
[**2159-8-23**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-PENDING
[**2159-8-22**] CSF;SPINAL FLUID GRAM STAIN-neg FLUID CULTURE-neg;
FUNGAL CULTURE-PENDING; ACID FAST CULTURE-PENDING; VIRAL
CULTURE-PENDING
[**2159-8-21**] SPUTUM CULTURE-PRELIMINARY {PSEUDOMONAS AERUGINOSA}
[**2159-8-21**] BLOOD CULTURE NGTD
[**2159-8-21**] URINE CULTURE-FINAL
[**2159-8-21**] BLOOD CULTURE NGTD
Brief Hospital Course:
Mr. [**Known lastname 19641**] was admitted with respiratory failure, thought to
be related to mucus plugging as well as a pseudomonal pneumonia.
Both of these etiologies were treated, and he continued to
oxygenate and ventilate well on his usual ventilator settings.
However, the issue that dominated the admission was his recent
acute decline in mental status. He was thoroughly evaluated by
neurology and underwent head CT, MRI, LP, and EEG. This work-up
demonstrated a small left basal ganglia infarct, likely
cardioembolic. However, they felt this event could not account
for his new, severe global deficit; this was thought to be
secondary to a more pervasive process, likely anoxic
encephalopathy, for which the prognosis is extremely grim. This
was discussed at length in several family meetings involving the
patient's wife, son, primary care doctor, ICU attending, and
neurology consultant in the presence of a Russian interpreter.
The end result of these discussion was that the patient's wishes
would not be consistent with this new level of functioning from
which he had little hope of recovery; the family decided to make
him comfort measures only. He was disconnected from the
ventilator and all medications beyond a morphine drip were
stopped, and he expired shortly thereafter. The family was
present.
Medications on Admission:
Jevity 1.2 65 mL/hour continuous with water 240 cc q 8 hours
Lasix 40 mg IV QAM (given [**8-20**])
Vancomycin 1gm IV q 36 hours (last dose at [**2154**] on [**8-19**]).
Started on [**8-15**])
ASA 325 mg PO QD
Lansoprazole 30 mg PO QAM
Heparin 5000 units SC TID
Zosyn 4.5 gm IV q 8 hours (last dose on [**8-20**] at 1400), started
[**8-14**].
Metoprolol 37.5mg q 12 hours (last dose 07/25 in AM)
Protein/Soy supplement 2 scoops q 12 hours
Ipratropium/Albuterol inhaler 4 puffs QID
Completed course of Flagyl [**7-31**] -->[**8-16**].
Discharge Disposition:
Expired
Discharge Diagnosis:
Anoxic encephalopathy
Acute respiratory failure
Chronic respiratory failure
Pseudomonal pneumonia
Volume overload
Chronic obstructive pulmonary disease
Bronchiectasis
Hyponatremia
Anemia of chronic disease
Secondary:
1. Non-small cell lung cancer s/p XRT and chemotherapy in
[**Country 532**], s/p right pneumonectomy in [**9-/2158**] for recurrence.
Chronic left pleural effusion.
2. Sick Sinus Syndrome status post PM/ICD placement
3. COPD/bronchiectasis
4. Hypertension
5. CAD, with known TO RCA.
6. CHF with EF 25% on last echo on [**2159-7-25**]
7. BPH
8. Depression
9. Left femoral AV fistula [**2159-4-25**]
10. Recent MRSA pneumonia and sepsis [**7-/2159**], treated with
Vancomycin
11. C. difficile colitis treated with Flagyl (completed [**8-16**])
12. Status post PEG tube placement [**7-/2159**]
13. Status post tracheostomy [**7-/2159**] [**2-28**] failure to wean
14. Status post partial colectomy [**2126**]
Discharge Condition:
Expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 4280, 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4173
} | Medical Text: Admission Date: [**2101-10-5**] Discharge Date: [**2101-10-28**]
Date of Birth: [**2059-9-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
EtOH cirrhosis/jaundice
Major Surgical or Invasive Procedure:
Multiple paracenteses
.
endoscopy
History of Present Illness:
42y/o M w/ a PMH of only HTN who was transferred here after a
1month admission at an OSH for further management of his liver
disease. He was in his USOH until approximately 1 month ago
when, in the context of continued heavy drinking, he developed
tremors of his hands and became unstable with walking. He also
noticed, at this time, abdominal distention and diffuse
abdominal pain. He presented to the the ED at [**Hospital3 **] where he found to be confused and jaundiced and was
admitted for furhter management.
.
While in the OSH, he developed increasing somnolence and
eventually required ICU level care for respiratory protection
(although it does not appear he was ever intubated). He was
noted to have ARF and hyponatremia as well as a ? PNA. His ARF
was thought to be [**1-13**] renal hypoperfusion [**1-13**] diuretic therapy
and poor PO intake but worsened despite IVF support. He was
initially treated with CTX/azithromycin for the suspected PNA
but these were later d/c for unclear reasons. UCX during this
time grew multiple organisms including MRSA and he was treated
with vancomycin by level. Taps of his abdomen were reported to
be c/w SBP but no note of antibiotic therapy is made in the d/c
summary and these results show <10 PMN per tap. He was
eventually transfered her for further management of his medical
conditions.
.
On arrival here, the patient complained only of abdominal
tightness, mild abdominal pain, and decreased appetite but
denied any CP, SOB, N/V, HA, rash, cough, URI symptoms, dysuria,
diarrhea, or constipation.
Past Medical History:
HTN
Social History:
No tobacco/drug use. Married with infant child. Immigrated from
[**Country 11150**]. Drank [**5-18**] glasses of hard liquor a day until his hospital
admission (~1mo ago).
Family History:
No liver/kidney problems. Father w/ CAD s/p CABG.
Physical Exam:
99.2, 121/80, 87, 22, 96%RA
Gen: Jaundiced M lying in bed, slightly uncomfortable
HEENT: + scleral icterus, MMM, O/P clear, no cervical LAD
CV: RRR, 2/6 SEM at the USB w/out radiation
Lungs: L basilar crackles
Abd: Grossly distended and tense, easily appreciable fluid wave
and shifting dullness, distant BS, HSM not able to be assessed,
mild diffuse tenderness, + caput medusa
Ext: 3+ LE pitting edema to the mid thigh, distal pulses
difficult to assess
Neuro: AAO x3, appropriate in conversation per interpreter,
moving all his extremities spontaneously
Skin: Jaundiced
Pertinent Results:
Admission labs:
Na 131, K 4.1, Cl 104, bicarb 16, BUN 45, Cr 2.8, glu 115
Ca 8.1, Mg 3.9, Phos 2.4
tbili 34.1, alk phos 157, Ast 138, ALT 59, INR 1.8, alb 2.9
.
Dispo Labs
tbili 11; Na 141, K 3.7, Cr 1.4
Alb 3.9, INR 1.5
WBC 10, Hct 28.7, plt 177
.
ferritin 619
.
Ceruloplasmin wnl
.
HBV and HCV serologies negative
.
HAV Ab +
.
[**Doctor First Name **], AMA, ANCA negative
.
AFP 1.9
.
OSH Cultures:
[**9-26**] - Ascites: 52WBC (5% pmn) Cx negative
[**9-28**] - Stool: Cdiff negative
[**9-30**] - UCx: enterococcus (2sp) and s aureus
- BCx: NGTD
[**10-4**] - Ascites: 122WBC (3% pmn) Cx NGTD
.
[**9-30**] Renal US: 2 calculi, no obstruction
[**9-16**] abd angiogram: no Portal or hepatic vein obstruction,
recanulized umbilical vein suggestion varices.
.
[**10-6**] paracentesis: no SBP
[**10-6**] RUQ US: normal portal/hepatic vein flow.
[**10-6**] CXR Two PA and two lateral views of the chest show
markedly elevated right hemidiaphragm and bilateral perihilar
and left bibasilar atelectasis. Different technique compared to
study from nine hours earlier makes exact comparison difficult,
but consolidation may have progressed. Pneumonia remains a
possibility, but the appearance could be entirely consistent
with consolidation from atelectasis
.
[**10-7**] CXR:Lung volumes remain quite low, and the right
hemidiaphragm is still markedly elevated, but less so compared
to the prior study. Pulmonary vasculature is congested, but
there is no edema or focal consolidation and no clear evidence
of substantial pleural effusion. No pneumothorax. Heart size is
difficult to assess because of displacement by the elevated
hemidiaphragm, but probably top
normal.
.
endoscopy: no varices. + esophageal candidiasis
Brief Hospital Course:
Mr [**Known lastname **] is a 42y/o M w/ EtOH cirrhosis and alcoholic hepatitis
complicated by renal failure and massive fluid overload/ascites
who was transferred to [**Hospital1 18**] after a 1mo OSH admission for
further management.
.
#. Cirrhosis/alcoholic hepatits: Mr [**Known lastname **] presented with labs
suggestive of alcoholic hepatitis superimposed upon his EtOH
cirrhosis. He was admitted with a discriminant function of 62
and a MELD score of 35 with bili 34, Cr 2.7, INR.1.8, albumin
2.9.
.
He was shortly started on pentoxyphylline for his alcoholic
hepatitis and completed over a 3 wk course in the hospital.
Steroids were not administered b/c of concern over potential
infection. Due to concern over very poor po intake (abt
300kcal/d) A post-pyloric dauboff feeding tube was placed and he
was begun on continuous tube feeds with thiamine, folate, and
multivitamin. He gradually improved with this therapy and his
bilirubin declined from 34 on admission to 11 on discharge. His
INR remained stable around 1.6. His feeding tube was
discontinued after a trial at po with about 1300kcl and 40g
protein daily intake.
.
Mr [**Known lastname **] did have an EGD which revealed no varices. He was
placed on lactulose and rifaxamin due to hepatic encephalopathy
which gradually cleared. He was moderately encephalopathic on
admission with +asterixis and slowed speech, but was without
asterixis and at his mental baseline as per family members.
.
Mr [**Known lastname **] also had significant pruritis presumed to be [**1-13**] bile
acids (also with component of drug rash as below). He improved
with cholestyramine and is dishcarged with this medicine.
.
With regards to further characterization of his
cirrhosis/hepatitis: Clinical hisory and laboratory pattern
(AST/ALT>2) are certainly consistant with alcoholic hepatitis.
HCV and HBV serologies were negative, RUQ US showed patent flow
in hepatic and portal veins, no stones. [**Doctor First Name **] was negative, and
serum ceruloplasm was normal as was ferritin. AFP was 1.9 and
US showed no signs of hepatoma.
.
Mr [**Known lastname **] will eventually need a liver transplantation and the
patient is aware of this, although his true understanding may be
limited. Multiple conversations took place through an
interpreter with the patient and his health care proxy (cousin)
regarding the seriousness of his condition and the need for
alcohol abstinence. He will follow up in the liver clinic with
Dr. [**Last Name (STitle) **] and then be seen in the liver transplant clinic
with Dr. [**Last Name (STitle) 497**]. He will also be set up with the substance abuse
counselors in the transplant center in order to document 6 mos
sobriety.
.
#. Renal failure: Mr [**Known lastname **] Cr was 2.7 on transfer from OSH,
which improved to 2.0 with 1L NS bolus. He was massively
total-body fluid-overloaded with very diminished lung volumes
and pulmonary edema, although oxygenating on room air. He was
unable to be diuresed due to concern over his progressively
rising creatinine. He was started on midodrine, octreotide, and
IV albumin at maximum doses for treatment of presumed
hepatorenal syndrome. At several points in his hospitalization
paracentesis was performed with approx 3-4L off per procedure
(8g albumin/L replaced) and his creatinine would subsuquently
rise and then gradually fall. His highest Cr was 3.5. Renal
was consulted on the patient and felt that he was in a likely
pre-renal state with a component of ATN given his urine Na of 20
and a high urine output. Nevertheless, his renal failure
gradually improved and he tolerated several large volume
paracentesis and was then started on low-dose diuretics (lasix
20, aldactone 50) with large and persistant diuresis. He was
taken off midodrine/octreotide/albumin several days prior to
dishcarge with stable renal function with a cr at 1.2-1.4. He
will continue lasix 20mg/aldactone 50mg daily after discharge.
.
#ID: Mr [**Known lastname **] was admitted with low-grade fevers to 100.7-8,
leukocytosis to 18 (neutrophil predominant, no left shift).
CXR was very difficult to interpret due to his large ascites,
poor lung volumes, and fluid overload. Diagnostic paracentesis
was persistantly negative (despite 1 contaminated specimen + for
enterococcus w/o WBC that was repeated and was negative). Blood
and urine cultures were also negative persistantly as was C
diff. He was treated empirically for several days with CTX; his
low-grade fevers and leukocytosis persisted. CTX was
discontinued without clinical worsening. EGD during his
hospital course revealed esophageal candidiasis and he was
started on fluconazole. Within several days he began having
high fevers up to 103 and was empirically started on CTX and
flagyl to cover empirically for C-diff and SBP or pneumonia. He
subsuquently developed a pruruitic rash and eosinophilia; with
negative cultures and no sympoms to suggest infection all
antibiotics were stopped and his leukocytosis, eosinohpilia, and
fevers resolved prior to discharge. Of note, he did receive 9
days of fluconazole for [**Female First Name (un) **] esophagitis treatment and was
also treated with continued nystatin.
.
#. Immunizations: He was immunized with the first series of HBV;
he was + for HAV Ab; he also received a pneumovax and an
influenza vaccine.
.
#. psychosocial: Mr. [**Known lastname **] seemed quite depressed through much
of his stay with what appeared to be a lack of motivation and a
very blunted affect. I was not in contact with his wife for
much of the hospital stay. Dr. [**Last Name (STitle) **] of psychiatry was very
helpful in evaluating the patient and in discussion issues of
substance abuse. Dr. [**Last Name (STitle) **] felt that Mr. [**Known lastname **] did not meed
criteria for major depression, but rather adjustment disorder.
He was started on Mirtazipine 15mg qhs which seemed to help
quite significantly with insomnia and seemed to improve Mr.
[**Known lastname **] mood. He will continue with Mirtazipine 30mg qhs on
discharge. Mr. [**Known lastname **] will follow with the substance abuse
program throuth the liver transplantation center in the next few
weeks.
Medications on Admission:
1. Protonix
2. Vit B12
3. Folate
4. MVI
5. Diovan 60mg (at home; d/c at OSH)
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day): titrate so that you have at least [**4-16**] bowel
movements per day.
Disp:*1800 ML(s)* Refills:*2*
2. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID
(2 times a day) for 2 weeks: this medication can help with
itching.
Disp:*28 Packet(s)* Refills:*1*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*90 Cap(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day).
Disp:*1 bottle* Refills:*2*
9. 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*
10. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcoholic hepatitis
Alcoholic cirrhosis
acute renal failure
encephalopathy
coagulopathy
Discharge Condition:
fair: Afebrile, VSS, bilirubin 12, Cr 1.2
Discharge Instructions:
Please continue to take the medications we have prescribed for
you. You should come back to [**Hospital1 18**] for an appointment in the
liver clinic as listed below. You will also need to see
substance abuse counselors. It is very important that you do
not drink any alcohol at all. Your liver is very sick and
cannot tolerate it. You should also avoid taking tylenol or any
medications that you have not discussed with your doctor.
.
Please seek medical attention if you notice worsening confusion,
shakiness, fevers, chills, abdominal pain, swelling, yellowness,
or for anything that concerns you.
.
You must refrain from drinking all types of alcohol. You will
likely need a liver transplant in the future. In order to
qualify for this you must enroll in a substance abuse program.
Followup Instructions:
With Dr. [**Last Name (STitle) **] in the Liver Center on [**11-9**] at 2:10.
[**Location (un) **] [**Hospital Unit Name **], [**Doctor First Name **]. ([**Telephone/Fax (1) 1582**]
ICD9 Codes: 5845, 5990, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4174
} | Medical Text: Admission Date: [**2130-4-12**] Discharge Date: [**2130-4-18**]
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
bilateral claudication and rest pain
Major Surgical or Invasive Procedure:
[**2130-4-12**]: B femoral patch endarterectomy, B iliac stents (7
stents)
History of Present Illness:
This elderly lady well known to [**Month/Day/Year 1106**]/Dr. [**Last Name (STitle) **] and has
developed severe disabling claudication progressively worsening
to the point now where she will only walk a few steps without
pain and probably a mild ischemic
rest pain as well. She underwent an MRA because of renal
insufficiency which showed extensive iliac disease bilaterally.
There were high-grade stenoses at the origin of both common
iliac arteries and diffuse disease throughout
both external iliac arteries involving the common femoral
arteries as well with occlusion of her superficial femoral
arteries.
Past Medical History:
1. Coronary artery disease:
- s/p CABG [**2124**] (SVG to OM, SVG to PLV, SVG to LAD)
- Cardiac cath on [**12-13**] showed patent grafts
2. Peripheral [**Month/Year (2) 1106**] disease
3. Diabetes mellitus, type II
4. Hypertension
5. Chronic renal insufficiency (baseline creatinine 1.6-1.9)
6. s/p Right CEA
7. Macular degeneration
8. h/o GI bleed
9. s/p bladder suspension
Social History:
Lives alone. husband died 2 months ago. daughter lives nearby.
activity limited by severe PVD.
Tob: smoked for 30yrs; quit 15yrs ago
EtOH: none
Illicits: none
Family History:
NC
Physical Exam:
VSS: 99.1, 130/80, 86 94%RA
GEN: NAD
CARD: RR, [**2-7**] STEM
Lungs: [**Month/Day (4) **]
EXT: no edema, incisions c/d/i steri-strip
RT DP palp, PT dopp, LT DP/PT dopp
Pertinent Results:
[**2130-4-17**] 06:20AM BLOOD WBC-6.4 RBC-3.23* Hgb-9.5* Hct-27.8*
MCV-86 MCH-29.5 MCHC-34.2 RDW-15.0 Plt Ct-136*
[**2130-4-17**] 06:20AM BLOOD Plt Ct-136*
[**2130-4-17**] 06:20AM BLOOD Glucose-106* UreaN-39* Creat-1.6* Na-138
K-4.3 Cl-103 HCO3-30 AnGap-9
[**2130-4-17**] 06:20AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.6
Brief Hospital Course:
Underwent uneventful bilateral common femoral endarterectomies
and distal external iliac endarterectomies with Dacron patch
angioplasties and balloon angioplasty and stenting of both
common and external iliac arteries. Extubated in OR and
transferred to PACU. B/L DP/PT dopplerable. pain controlled. UO
at 22 cc/hr. BP 125/43, off nitro gtt.
POD1- Hypotension overnight BP 86/42 CVP 3-4. Fluid bolus given
with improvement in BP to 114/48. Second event of hypotension to
SBP 50 HCT 28.4. Received 2 units PRBCs. Non contrast CT
negative for retroperitoneal bleed. Hypertensive meds held.
Dopamine gtt started, 5% albumin given for support. Swan
catheter placed. Denies chest pain, abdominal pain. ECG WNL,
cardiac enzymes cycled. Cardiology consult obtained.
POD2-Intermittent hypotensive events, BP 69-110/32-47. Off
Dopamine. Troponins elevated, likely demand ischemia per
cardiology.
POD3-No overnight events. VSS On heparin gtt. RT DP palp, B/L
DP/PT dop
Cardiology following patient with acute MI:Troponin 0.23, peak
CK 154 with pos MB. Exam negative for CHF.
POD4- No overnight events. OOB to chair. diet advanced to
regular. PA cath discontinued.
POD5- VSS. No overnight events. Cr 1.6. Physical therapy
consulted. transferred from VICU to [**Wardname **] floor bed.
POD6- VSS. No overnight events. Physical therapy cleared for
discharge home with PT/home safety eval. Patient will follow up
with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] next week.
Medications on Admission:
ASA 81', Imdur 30', lisinopril 20", zestoril', metoprolol 50",
MVI' zocor 40, lantus 8hs with Humalog sliding scale
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Lantus 100 unit/mL Solution Sig: 8 units at bedtime
Subcutaneous at bedtime: Follow normal Humalog sliding scale
with meals.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
B/L claudication s/p B femoral patch endarterectomy, B iliac
stents (7 stents)
Elevated Troponin-demand ischemia
PMH: CAD, PVD, IDDM, CRI, HTN, macular degeneration, h/o GI
bleed
PSH: CABG '[**24**] x3, cardiac cath [**12-7**] shows patent grafts, R CEA
'[**27**], bladder suspension
Discharge Condition:
Good. VSS
Cr 1.6
Discharge Instructions:
Division of [**Year (2 digits) **] and Endovascular Surgery
Lower Extremity Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-4**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Call Dr.[**Initials (NamePattern4) 5695**] [**Last Name (NamePattern4) 28043**] at [**Telephone/Fax (1) 3121**] to schedule office
visit to be seen next week.
Call Dr. [**Last Name (STitle) **] (Cardiology) at ([**Telephone/Fax (1) 10085**] to schedule
office visit to be seen next week.
Completed by:[**2130-4-18**]
ICD9 Codes: 5859, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4175
} | Medical Text: Admission Date: [**2161-4-9**] Discharge Date: [**2161-4-14**]
Date of Birth: [**2096-12-10**] Sex: F
Service: PLASTIC
ADMISSION DIAGNOSIS: Excess abdominal pannus.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
female with a history of diabetes, hypertension and coronary
artery disease, who presented to Dr. [**Last Name (STitle) 13797**] with complaint
of excess abdominal pannus and skin. Her excess pannus has
decreased her mobility and ability to arise from a chair and
has generally interfered with her daily activities. She has
elected to undergo a panniculectomy for this admission.
PAST MEDICAL HISTORY:
1. Excess abdominal pannus.
2. Severe lymphedema bilaterally.
3. Bilateral Charcot foot deformities.
4. Diabetes mellitus type 1.
5. Hypertension.
6. Status post MI.
7. Status post CABG times two.
8. Glaucoma.
9. Hypothyroidism.
10. Hyperlipidemia.
11. Gout.
12. Hypercholesterolemia.
13. Status post TAH.
14. CAD.
MEDICATIONS ON ADMISSION:
1. Timoptic eye drops.
2. Rhinocort nasal spray.
3. Humulin 26 units a.m., 16 units p.m.
4. Amaryl 2 mg q.a.m.
5. Actos 45 q. day.
6. Atenolol 50 q. day.
7. Synthroid 75 mcg q. day.
8. Allopurinol 300 mg q. day.
9. Lasix 120 mg b.i.d.
10. Lipitor 20 mg q. day.
11. Detrol 2 mg q.a.m., 2 mg q.p.m.
12. Protonix 40 mg q. day.
13. Lisinopril 10 mg q. day.
14. Omnicef 300 mg b.i.d.
15. Coumadin 5 mg q.h.s., which has been held prior to
admission.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient is an obese, white female
with a height of 5'2", and a weight of 252 lb with clearly
excess abdominal pannus reaching down to the level of her
knees. Her chest was clear to auscultation bilaterally. Her
cardiac exam revealed regular rate and rhythm and normal S1,
S2. Her belly was soft, nondistended and nontender.
HOSPITAL COURSE: The patient was admitted on [**2161-4-9**]
and underwent a panniculectomy performed by Dr. [**Last Name (STitle) 13797**],
which excised a total of 35 lb. The procedure was successful
and there were no immediate postoperative complications.
Please see operative note for further details. Due to her
extensive cardiac and diabetic history, the patient was
admitted to the ICU for overnight observation. The patient
did well on postop day one and was encouraged to get out of
bed, though the patient refused to get out of bed. The
patient was found in the morning not to have pneumatic boots,
and an incident report was filed. Later that afternoon, the
pneumatic boot machine was brought to her bedside.
Her hematocrit on postoperative day zero was 27.9, and she
received one unit of red blood cells. Her hematocrit on
postoperative day one following transfusion was 30.6 and
remained stable throughout the rest of her hospital course.
Her coags were within normal limits during her hospital stay.
She did express a considerable amount of clot material
postoperatively from the wounds, but she did not demonstrate
any persistent bleeding, and by postoperative day three, her
wounds remained dry. On postoperative day three, the patient
was finally transferred out of the unit. Because the patient
did not have any MRSA cultures that were positive in her last
day, her antibiotics were changed from vancomycin to Ancef.
On postoperative day three, her Foley was discontinued and
her IV was heplocked. Her diet was fully advanced which the
patient tolerated. The podiatry team also came by and
recommended that the patient follow up with Dr. [**Last Name (STitle) **]
[**Name (STitle) 3044**]. Wound cultures and x-rays of her feet were
taken during the hospital stay per podiatry. By
postoperative day four, the patient was ambulating and passed
her voiding trial. We felt that the patient would be ready
for discharge home per patient preference. It was
recommended that the patient go to a rehab facility, but the
patient clearly refused this option. Physical therapy also
was consulted and they felt that she would be sufficient with
home P.T.
DISCHARGE STATUS: Home with VNA.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSIS: Excess abdominal pannus, status post
panniculectomy.
DISCHARGE MEDICATION:
1. Colace 100 mg p.o. b.i.d.
2. Percocet 5/325 mg tablets, 1-2 tablets p.o. q4-6h prn for
pain.
3. Keflex 500 mg tablets p.o. q.i.d. times one week.
The patient is to continue all of her home medications except
for Coumadin. This list includes:
1. Allopurinol.
2. Aspirin.
3. Atenolol.
4. Lipitor.
5. Lasix.
6. Insulin.
7. Latanoprost Ophthalmic solution.
8. Synthroid.
9. Lisinopril.
10. Protonix.
11. Timolol Ophthalmic solution.
FOLLOW-UP INSTRUCTIONS: The patient is to follow up with Dr.
[**Last Name (STitle) 13797**] and Dr. [**Last Name (STitle) **] within one week. The patient
should also follow up with cardiology when she restarts her
Coumadin.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19095**], M.D. [**MD Number(1) 19096**]
Dictated By:[**Name8 (MD) 3430**]
MEDQUIST36
D: [**2161-4-14**] 09:34
T: [**2161-4-16**] 07:35
JOB#: [**Job Number 24461**]
ICD9 Codes: 4280, 2851, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4176
} | Medical Text: Admission Date: [**2179-12-20**] Discharge Date: [**2179-12-27**]
Date of Birth: [**2137-8-13**] Sex: F
HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old
woman with a history of schizophrenia who was transferred
from an outside hospital with a report of a right-sided
intracranial lesion.
The patient's mother reports the patient had complaints of a
right-sided headache for three days. Earlier, on the day of
admission, she was found somewhat "out of it." She had
reports of loss of consciousness at her Day Care Center.
Upon arrival at the outside hospital, she had a second
episode of loss of consciousness. The patient reportedly was
hospital. She had a head computed tomography that has been
interpreted as a right parietal/occipital lesion with a
midline shift. She was given 10 mg of Decadron and
transferred to [**Hospital1 69**] for
further management. Her cervical spine was cleared at the
outside hospital.
PAST MEDICAL HISTORY: (Past Medical History includes)
1. Schizophrenia since the age of four.
2. Seizure disorder.
3. Diabetes mellitus.
4. Hypertension.
MEDICATIONS ON ADMISSION:
1. Lisinopril 10 mg p.o. q.d.
2. Glucophage 2.5 mg p.o. q.d.
3. Risperidol one p.o. b.i.d.
4. Cogentin 0.25 mg p.o. q.h.s.
5. Lipitor 10 mg p.o. q.d.
ALLERGIES: The patient has an allergy to ERYTHROMYCIN.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, temperature was 98, heart rate was 102, blood
pressure was 117/94, respiratory rate was 18, oxygen
saturation was 95% on room air. The patient was lying in bed
with her eyes closed, in no acute distress. She opened her
eyes to stimulation and attempts to examine her. She said
her name was [**Known lastname **]. She held her arms up in the air off the
bed with no drift. She followed commands. Pupils revealed
left 5 mm down to 4 mm; right was 4.5 mm down to 3.5 mm.
Brisk withdrawal of lower extremities bilaterally. [**Location (un) 2611**]
Coma Scale score was 10.
RADIOLOGY/IMAGING: A head computed tomography showed a 2-cm
X 1.5-cm isodense area in the right parietal/occipital area
with edema and extending anterolaterally for approximately
6.7 cm with 2 cm of midline shift.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed sodium was 131, potassium was 3.9,
chloride was 92, bicarbonate was 25, blood urea nitrogen was
10, creatinine was 0.6, and blood glucose was 201. White
blood cell count was 13.2, hematocrit was 37.1, and platelets
were 313.
HOSPITAL COURSE: The patient was admitted to the
Neurosurgery Service. She was seen by Dr. [**First Name (STitle) **] in consultation
.
The patient underwent a magnetic resonance imaging scan to
better differentiate the lesion and was taken to the
operating room on [**2179-12-24**] for a right craniotomy for
excision of tumor without intraoperative complications. She
was monitored in the Recovery Room overnight where she
remained neurologically stable; awake, alert and oriented
times three. She moved all extremities with minimal right
drift. Her wound was clean, dry, and intact.
She was transferred to the regular floor on postoperative day
one. She was out of bed ambulating, and tolerating a regular
diet, and voiding spontaneously.
DISCHARGE DISPOSITION: She was cleared for discharge to home
on [**2179-12-27**].
MEDICATIONS ON DISCHARGE:
1. Decadron taper down to 2 mg p.o. b.i.d. over three to
five days.
2. Protonix 40 mg p.o. q.d.
3. Percocet one to two tablets p.o. q.4h. as needed.
4. Lisinopril 10 mg p.o. q.d.
5. Glucophage 2.5 mg p.o. q.d.
6. Risperidol one p.o. b.i.d.
7. Cogentin 0.25 mg p.o. q.h.s.
8. Lipitor 10 mg p.o. q.d.
CONDITION AT DISCHARGE: The patient was in stable condition.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**First Name (STitle) **] in the Brain [**Hospital 341**] Clinic on [**1-10**] and
for staple removal on [**Last Name (LF) 2974**], [**12-31**].
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2179-12-28**] 09:11
T: [**2179-12-28**] 09:26
JOB#: [**Job Number **]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4177
} | Medical Text: Admission Date: [**2187-8-7**] Discharge Date: [**2187-8-13**]
Date of Birth: [**2123-10-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Wide complex tachycardia
Major Surgical or Invasive Procedure:
[**2187-8-9**]: Aortic valve replacement (25 mm tissue)
History of Present Illness:
This is a 63-year-old female with a history of mitral valve
prolapse, hyperlipidemia, palpitations, syncope, ?RBBB at
baseline, and moderate-to-severe aortic stenosis (peak/mean
gradients 58/37 mmHg, [**Location (un) 109**] ~1cm2 on [**2187-7-18**]), no hx of CAD, who
is transferred to the CCU s/p VT ablation with subsequent
pericardial effusion. The patient originally presented to
[**Hospital 1110**] hospital on [**8-5**] with palpations. She reportedly got up
to get dinner out of the oven when she experienced a crushing
chest pain with a twinging sensation in her neck. She was sent
to the ED at [**Location (un) 1110**] and was found to be in a wide complex
tachycardia with LBBB morphology, originally thought to be SVT-
vagal maneuvers were performed which she responded to. 25
minutes later the WCT recurred and was given metoprolol and
amiodarone 150 mg IV. She remained in this rhythm for 45 minutes
and came out and returned to sinus. She then received lidocaine
bolus 100 mg with infusion at 2 mg/min without further
arrhythmia recurrence. The amiodarone was discontinued and
lidocaine continued after discussion with Dr. [**Last Name (STitle) 6254**]. Troponin
T was 0.02-0.04 with no STE noted while in NSR.
She was then referred to [**Hospital1 18**] for further management of this
presumed ventricular tachycaria and surgical intervention on her
aortic valve. Before transfer, she had a coronary
catheterization which was reportedly clean. Lidocaine gtt was
d/ced upon transfer and metolprolol was given.
Patient also reportedly had 2 episodes of syncope which were
evaluated at [**Hospital 1727**] medical center. In both instances patient
describes an aura of "warmth" over her chest and head that
happens from an emotional stimulus (receiving an upsetting phone
call). She also states that she was standing for both episodes
and had decreased PO during the day. Patient elected to leave
[**State 1727**] and come home where she was worked up with a surface
echocardiogram at [**Location (un) 47**]. Moderate to severe AS was found.
She then followed up with her cardiologist who attributed her
symptoms to AS. A referral to cardiac surgery was made.
In the EP lab, a right ventricular focus was mapped. During the
procedure, BP fell from systolic 120 to 100 which was maintained
for 30 minutes. Echo was done immediately after procedure (ICE)
showing developing effusion. Another echo done 45 minutes apart
showed marginal growth. DR.[**Doctor Last Name **] recommended tap due to
involution of RV (tamponade physiology). 280 cc of bloody fluid
was removed and a drain was placed
.
On arrival to the floor, patient was in moderate distress from
pleuritic chest pain. She received up to 1 mg dilaudid IV from
anesthesiology, in addition to fentanyl, versed, ketorolac, and
propofol. The drain was pulled back by Dr. [**Last Name (STitle) **] as it was
thought to be excessively irritating her pericardium.
.
REVIEW OF SYSTEMS
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema
Past Medical History:
--mitral valve prolapse
--hyperlipidemia
--obesity
--aortic stenosis as above
--s/p bladder fistula repair
--s/p uterine curettage for vaginal bleeding 4 years ago
--s/p partial colectomy for fistula
Social History:
She has 3 children. She smoked tobacco many years ago and quit
in the [**2155**]. No alcohol abuse. She has noted a great deal of
stress lately with recent bankruptcy.
Family History:
Per the chart, she has a brother who underwent CABG surgery at
age 51. No other early coronary artery disease or
cerebrovascular disease. No bicuspid aortic valve. No sudden
cardiac death.
Physical Exam:
GENERAL: Obese, in mild distress due to chest pain from
pericardial drain
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Anterior auscultation
did not reveal any rales or rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Echocardiogram
[**2187-8-9**]: LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (area 0.8-1.0cm2). Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
PREBYPASS: Preserved LV systolic function. LV EF > 55%, no
segmental wall motion abnormalities. Severe Aortic stenosis with
aortic valve area of 0.9 cm2 by continuity eqn. The left atrium
and right atrium are normal in cavity size. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Right ventricular chamber size and free
wall motion are normal. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is a trivial/physiologic pericardial
effusion. Diastolic dysfunction is present with e' =7-8 cm/sec.
Intact interatrial septum. No clot seen in LAA but the images
were not outstanding. Normal size coronary sinus. All findings
discussed with surgeon.
POSTBYPASS:
Normally functioning AV prosthesis, no significant AI or AS
(mean gradient = 16 mmHg) otherwise unchanged.
Carotid Duplex [**2187-8-9**]:Duplex evaluation was performed of
bilateral carotid arteries. On the right there is no plaque in
the ICA. On the left there is no plaque in the ICA.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 60/27, 103/47, 98/38
cm/sec. CCA peak systolic velocity is 95 cm/sec. ECA peak
systolic velocity is 57 cm/sec. The ICA/CCA ratio is 1.1. These
findings are consistent with 0 stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 63/16, 77/39, 60/25 cm/sec. CCA peak
systolic velocity is 100 cm/sec. ECA peak systolic velocity is
55 cm/sec. The ICA/CCA ratio is 0.8. These findings are
consistent with 0 stenosis.
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Brief Hospital Course:
CCU Course:
ASSESSMENT AND PLAN
63 F admitted for symptomatic aortic stenosis with plans for
[**Hospital 64315**] hospital course complicated with ventricular tachycardia,
now sp VT ablation complicated with RV perforation and
pericardial effusion with tamponade physiology. Pt transferred
to CCU for close monitoring in setting of RV perforation and
pericardial effusion.
# Pericardial effusion: pt is sp RV perforation as complication
of VT ablation, now with expanding effusion, that is moderate in
size, with tamponade physiology. 280 cc were initially drained
from the pericardium during the procedure. She was transferred
to the CCU for monitoring. Patient had a lot of post-procedural
pain which was adequately controlled on Dilaudid, ketorolac, and
Tylenol. The drain was also moved back 5 cm as it was thought
to be excessively irritating the pericardium. There was only 70
cc of fluid drainage overnight and repeat echo did not show re
accumulation of fluid. However, severe AS was found and she was
taken for cardiac surgery.
Cardiac Surgery Course
The patient was brought to the operating room on [**2187-8-9**] where
the patient underwent Aortic Valve Replacement([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] 25 mm
Porcine). Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Vancomycin was
used for surgical antibiotic prophylaxis. She required
epinephrine drip for a low cardiac output and Lidocaine drip for
history of VT which were titrated off POD1 with no further
ectopy. On POD 1 found the patient extubated, alert and oriented
and breathing comfortably. The patient was neurologically
intact and hemodynamically stable on no inotropic or vasopressor
support. Beta blocker was initiated. Electrophysiology
continued to follow her. She had no further ectopy and her
beta-blockers were titrated as needed. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
She was gently diuresed to her preoperative weight.
Electrolytes were replete to maintain potassium greater than 4.0
and Magnesium greater than 2. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD #4 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to home in
good condition with appropriate follow up instructions.
Medications on Admission:
Simvastatin
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/fever
2. Aspirin EC 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*1
5. Metoprolol Tartrate 25 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
6. Potassium Chloride 40 mEq PO DAILY
Hold for K+ > 4.5
RX *potassium chloride 20 mEq 2 mEq by mouth once a day Disp
#*28 Tablet Refills:*0
7. Oxycodone-Acetaminophen (5mg-325mg) [**1-22**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**1-22**] tablet(s) by mouth
every four (4) hours Disp #*65 Tablet Refills:*0
8. Atorvastatin 20 mg PO DAILY
RX *Lipitor 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Aortic stenosis
Mitral Valve Prolapse
Syncope
Obesity
Hypertension
Diverticulitis
PSH:
Benign breast mass
C-section x 3
Partial Colectomy for fistula
Tonsillectomy
Left Cataract
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema; generalized edema of upper and lower extremities
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema; generalized edema of upper and lower extremities
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema; generalized edema of upper and lower extremities
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming, and look at your incisions
NO lotions, cream, powder, or ointments to incisions
Daily weights: keep a log
No driving for approximately one month and while taking
narcotics
No lifting more than 10 pounds for 10 week
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Follow-up appointments:
Cardiac surgery [**Hospital 409**] Clinic:[**2187-8-21**] at 10:15am in the [**Hospital 2577**]
Medical Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2187-9-26**] at 1:15pm in the [**Hospital 2577**]
Medical Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist Dr. [**Last Name (STitle) 4610**] on [**2187-9-4**] at 3:00p
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Telephone/Fax (1) 12295**] for a follow-up
appointment in [**4-26**] weeks
Please call Dr. [**Last Name (STitle) **] in [**Location (un) 620**] to schedule a follow up
appointment in 3 weeks.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2187-8-13**]
ICD9 Codes: 4271, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4178
} | Medical Text: Unit No: [**Numeric Identifier 74002**]
Admission Date: [**2107-8-3**]
Discharge Date: [**2107-8-5**]
Date of Birth: [**2107-8-3**]
Sex: M
Service: NB
HISTORY: [**First Name8 (NamePattern2) **] [**Known lastname **] is a full-term baby born on [**2107-8-3**] to a 31-year-old G2, para 0-1 mother.
Prenatal screens: blood type O+, antibody negative, hepatitis B
surface antigen negative, rubella immune, RPR nonreactive, group
B strep positive. The pregnancy was complicated by maternal
uterine fibroids and anemia. The mother presented in spontaneous
labor with rupture of membranes less than 24 hours prior to
delivery. Maternal temperature to 99.7 treated with
antibiotics greater than 4 hours prior to delivery. The
delivery was vaginal and baby emerged vigorous and was dried
and suctioned. Apgar's were 9 and 9. He was transferred to
the newborn nursery with his mother. On exam on day of life
1, the baby was found to have a murmur and was transferred to
the NICU for further evaluation.
PHYSICAL EXAMINATION AT DISCHARGE: Weight is 3.14 kilograms,
20-1/2 inches. HEENT: Anterior fontanelle open and flat.
Mucous membranes dry, no cleft. Chest: Clear to auscultation
bilaterally, no retractions. Heart: Regular rate and rhythm,
+[**3-1**] pansystolic harsh murmur heard loudest in the mid to
upper left sternal border. Heart rate 120. Abdomen:
Nondistended, active bowel sounds, soft, nontender, no masses
or organomegaly. Extremities: Strong peripheral pulses, warm
and pink, negative Ortolani-Barlow. Neuro: Positive Moro
grasp, strong cry and suck, good tone. GU: Normal
uncircumcised male, left testis descended and right testicle
low in the inguinal canal.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory. The baby
has been in room air, breathing comfortably. Respiratory rate
in the 40s.
Cardiovascular. The baby presented with a grade 3/6 systolic
murmur. A cardiac evaluation was performed. A hyperoxia test
revealed a preductal saturation of 310. Four extremities
blood pressures were performed, the right leg 82/56, right
arm 65/38 mean 52, left leg 85/44 mean 57, left arm 66/36
mean 44. An EKG was also performed which was normal axis,
regular sinus rhythm.
An echo was performed on [**2107-8-5**] by [**Hospital3 1810**]
Cardiology Service which revealed a mild to moderate pulmonary
stenosis currently with a gradient of 35 mmHg. The valve is
thickened and doming. The annulus measured 7 mm. Also present is
a small patent ductus arteriosus with a continuous left-to-right
flow, restrictive by 36 mmHg. The left aortic arch with bovine
trunk, no obstruction, trivial pericardial effusion, good
biventricular function, no other structural heart disease
identified.
The baby remained hemodynamically stable with blood pressures in
normal range for age. He is pink and well perfused with good
peripheral pulses. Cardiology follow-up will be with
[**Hospital3 1810**] Cardiology at a month of age with Dr.
[**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 65613**].
Fluids, electrolytes and nutrition. The baby was breast fed
and was feeding fairly well at time of discharge - parents were
supplementing with finger feedings. The mother met
with lactation consultant and was given a number of the
lactation department at [**Hospital1 **] [**Telephone/Fax (1) 42703**] for follow-up
questions. The baby received brief IV fluids of [**Name (NI) 44084**]
supplement but his parents declined PC feedings. D-stick was
92. The baby is voiding and having transitional stools.
Weight at discharge is 3140 kg.
GI. The baby was not jaundiced. Serum bilirubin was obtained
on day of discharge, day of life 2, and that value was 8.7/0.3.
Hematology. There were no investigations.
Infectious disease. The baby remained clinically well. There
were no risk factors for sepsis, only GBS colonization
treated appropriately with maternal intrapartum antimicrobial
prophylaxis.
Neurology. The baby was term with normal neurologic exam.
Sensory, audiology. Hearing screening was performed with
automated auditory brainstem response and the baby passed
bilaterally.
Psychosocial. The family has been with the baby throughout the
admission to the NICU. Extended family was present
during cardiology's visit with the family to explain anatomy
and physiology and need for follow-up care.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) **] of
[**Hospital 47**] Pediatrics, [**Apartment Address(1) 74003**] in
[**Location (un) 47**], [**Numeric Identifier 59599**], phone number [**Telephone/Fax (1) 43144**].
CARE RECOMMENDATIONS AT DISCHARGE: Feedings are breast
feeding with lactation support as needed. The baby will be
seen by primary pediatrician on Sunday after discharge on
[**2107-8-7**] for a weight check.
MEDICATIONS: None at this time.
CAR SEAT POSITION SCREENING: Not indicated.
STATE NEWBORN SCREENING STATUS: Sent on [**2107-8-5**],
results of which are pending at this time.
FOLLOW-UP APPOINTMENTS SCHEDULED: With [**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) **] of
[**Hospital 47**] Pediatrics on [**2107-8-7**] at 10 a.m. and with
cardiology at [**Hospital3 1810**] in [**Hospital1 **] with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 65613**] on [**2107-9-5**] at 9 a.m.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2107-8-5**].
Synagis RSV prophylaxis (starting in [**Month (only) **]) is recommended for
infants with congenital heart disease - this should be reviewed
with Cardiology. It is also recommended that the parents both
recieve the influenza vaccine.
DISCHARGE DIAGNOSES:
1. Term infant.
2. Congenital heart disease consisting of valvar pulmonary
stenosis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern1) 54678**]
MEDQUIST36
D: [**2107-8-5**] 19:57:55
T: [**2107-8-5**] 20:43:26
Job#: [**Job Number 74004**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4179
} | Medical Text: Admission Date: [**2120-9-17**] Discharge Date: [**2120-12-5**]
Date of Birth: [**2078-5-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2120-9-18**]
1. Open treatment and fracture/dislocation of C2-3.
2. Open treatment and fracture/dislocation of C6-7.
3. Open treatment and fracture/dislocation of C7-T1.
4. Posterior cervical arthrodesis, C2-3.
5. C2 laminectomy.
6. C5-6, C6-7, C7-T1 posterior cervical arthrodesis.
7. Posterior cervical instrumentation, C5-6, C6-7, C7-T1.
8. Left iliac crest bone graft.
9. Application of local allograft.
[**9-19**]
1. Open reduction and internal fixation of left maxillary sinus
fracture.
2. Closed reduction of nasal bone fracture.
[**2120-9-19**]
1. Open treatment of fracture dislocation C2-C3.
2. Anterior cervical diskectomy C2-3.
3. Anterior cervical arthrodesis/fusion C2-C3.
4. Application of anterior cervical plate C2-C3.
5. Right iliac crest bone graft.
[**2120-9-19**]
1. Tracheostomy.
2. [**Last Name (un) **] gastrostomy.
[**2120-9-20**]
1. Tracheostomy exchange day 1 post prior tracheostomyplacement.
2. Right femoral inferior vena cava filter (Bard G2 type)
3. Fluoroscopic control of IVC filter placement
History of Present Illness:
42 yo male, unrestrained driver who was +EtOH; s/p high speed
motor vehicle crash hit jersey barrier and was then hit from
behind by a truck and ejected from the car. He had a period of
asystole and was resuscitated with epinephrine and atropine. He
was taken to an area hospital where found to have multiple
traumatic injuries and was then immediately transferred to
[**Hospital1 18**] for further care.
Past Medical History:
Unknown
Social History:
Has a mother who is very involved in his care; 2 sisters and a
10 yo daughter [**Name (NI) **] in [**Name (NI) 3844**]
Family History:
Noncontributory
Physical Exam:
Exam on admission:
P: 70 BP 116/45 RR: 17 O2: 90% intubated
GCS 9T
HEENT: bilat pupils 6 mm, minimally reactive with divergent
gaze; proptosis of left eye with eccymosis. Lacs on left and
midline occiput, as well as the L pinna. Blood in the nares
Resp: breathsounds bilat
CV: heart sounds heard
ab: soft
ext: open fx of L forarm; LLE deformity and laceration
Neuro: nl rectal tone; moves bilat LE spont, will move deltoids
of BUE with noxious stimuli
Pertinent Results:
head CT [**9-17**]:
1. Extensive intracranial injury including right frontal and
parietal subarachnoid hemorrhage, frontal contusions, small
subdural collections and scattered foci of increased attenuation
at the [**Doctor Last Name 352**]-white matter junction concerning for diffuse axonal
injury.
Further characterization with MR [**First Name (Titles) **] [**Last Name (Titles) **] echo sequences may
be helpful for further characterization.
2. Incompletely imaged facial bone fractures as above for which
a
maxillofacial CT is recommended for further evaluation.
3. Metallic foreign body of unclear etiology in the region of
the
nasopharynx. Clinical correlation is recommended.
CT sinus [**9-17**]:
1. Multiple fractures of the left frontal and parietal bones.
Comminuted
fracture of the left orbital walls and comminuted fractures of
the left
maxillary sinus walls.
2. Comminuted fracture of the left parasymphyseal region of the
mandible as well as fractures of the alveolar ridge of the
central-to-right body of the mandible as well as the left
maxillary alveolar ridge.
3. Additional fractures of the anterior wall of the right
maxillary sinus and the pterygoid plates bilaterally. Fracture
of the left hard palate and right nasal bone.
4. Comminuted fracture of the right lamina of C2 and the left
pedicle and
body of C2. Please refer to concurrent CT of the cervical spine
for
additional findings.
5. Tiny left subdural hematoma and right subarachnoid
hemorrhage. Please
refer to the concurrent CT of the head as well as head MR for
additional
significant findings.
MR head [**9-17**]:
1. Multiple small areas of slow diffusion in teh cortex
suspicious for
contusions, although embolic infarction could present a similar
appearance.
2. Enlarged extra- axial CSF space over the frontal and temporal
lobes
bilaterally, which may represent with intensity slightly greater
than CSF.
These likely represent subdural hygromas. No significant change
in size of a thin T2 hyperintense extra- axial hemorrhage over
the left frontal, temporal and parietal lobes.
3. Bilateral subarachnoid hemorrhages.
C-spine CT [**9-17**]
The skull base through the superior endplate of T2 is well
visualized on the lateral view. An endotracheal tube is noted in
place.
Multiple fractures are identified. There is a comminuted
fracture of the C2 left body lamina junction which extends to
the vertebral foramen. A
comminuted fracture of the right C2 lamina is seen extending
into the pars
inferior facet. There is clockwise rotation of C2 in relation
with the C1
vertebral body. The right inferior articulating facet of C2
appears subluxed lying anterior to the inferior facet of C3.
Additional fractures include a comminuted C5 spinous process
fracture, a
comminuted fracture of the C6 spinous process extending slightly
into the
bilateral laminae, a distracted fracture of the C7 pedicle and a
nondisplaced fracture of the right C7 lamina. Nondisplaced
fractures are also noted involving the anteroinferior C7 and
anterosuperior T1 vertebral bodies. There is a unilateral
"jumped" left facet, C6 on C7. CT does not provide intrathecal
detail comparable to MR. [**First Name (Titles) **] [**Last Name (Titles) **] material within the spinal
canal at C6-C7 likely compresses the cord and may represent
hematoma or disk material. Bullous changes are present at the
lung apices. A metallic foreign body is noted in the nasopharynx
of unclear origin. Please refer to the accompanying CT facial
bone regarding numerous skull fractures.
MR [**Name13 (STitle) 2853**] [**9-17**]
1. Edema and/or contusion of the cervical cord at the C2/3
level.
2. T2 and STIR hyperintensity of the disc at the C2/3 level with
disruption
of the disc margin posteriorly. Similar findings at the C7/T1
level.
3. Disruption of the ligamentum flavum at the C6/7 level.
4. Edema and/or hemorrhage of the interspinous ligaments
extending from C3
through T1.
5. Left C6/7 unilateral interfacet dislocation and right C2/3
and left C7/T1 facet joint disruption.
6. For full description of the cervical spinal fractures, please
refer to the concurrent CT of the cervical spine.
7. No large epidural hematomas. No cord compression.
8. Prevertebral hematoma suspicious for anterior longitudinal
ligament injury.
CT C/A/P [**9-17**]
1. Focal irregularity of the intima in the descending aorta
concerning for
minimal aortic injury. As the location is not classic
differential diagnosis includes atherosclerotic plaques,
although this is considered less likely. Follow-up CT in 24
hours is recommended to ensure stability.
2. No mediastinal hematoma.
3. Patchy airspace opacity likely representing pulmonary
contusion with
aspiration in the right mid lower lobes. Dense consolidation at
the lung
bases, greater than left, may represent atelectasis versus
effusion.
4. Fractures of the fourth and fifth ribs with tiny amount of
subpleural air.
5. Fractures of the lumbar spine as described above.
6. Thickening of the bladder wall extending into the distal left
ureter with proximal dilatation of the ureter. The constellation
of findings is
comcerning for transitional cell carcinoma and atypical for
traumatic
injury. Follow- up CT with delayed images of the ureter and a
filled bladder are recommended for better delineation of the
process.
ADDENDUM: Upon further review, it was noted that the patient had
a
nondisplaced fracture of the medial right scapula. Findings were
discussed
with Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **] [**2120-9-18**].
L femur XR/L tib fib XR [**9-17**]: Minimally displaced fracture
through the distal fibula. Soft tissue defect anterior to the
tibia containing foci of linear hyperdensity consistent with
retained foreign bodies.
LUE XR [**9-17**]: no fx
LENI [**9-18**]: neg
CT head/sinus [**9-22**]
1. Overall unchanged appearance of the brain with diffuse
subarachnoid
hemorrhage, subdural hematoma, and contusion. Slightly decreased
[**Doctor Last Name 352**]-white differentiation, which can be technical. Please
correlate clinically.
2. Numerous comminuted fractures of the skull and facial bones
as described above post-surgery. Fractures of the cervical
spine, only partially visualized.
SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT PORT [**2120-11-15**]
4:40 PM
SHOULDER (AP, NEUTRAL & AXILLA
Reason: r/o fracture or other processes
[**Hospital 93**] MEDICAL CONDITION:
42 year old man s/p fall out of bed now with increased right
shoulder pain and point tenderness.
REASON FOR THIS EXAMINATION:
r/o fracture or other processes
EXAMINATION: Right shoulder.
INDICATION: Pain. Fall out of bed.
Views of the right shoulder show no evidence of acute displaced
fracture. There is, however, inferior subluxation of the humeral
head by approximately 1-1.5 cm.
IMPRESSION:
Inferior subluxation of right humeral head from glenoid.
CT HEAD W/O CONTRAST [**2120-11-14**] 7:52 PM
CT HEAD W/O CONTRAST
Reason: eval for fx, interval change in ICH
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with chronic subdural, s/p fall out of bed, no
LOC, unknown head trauma
REASON FOR THIS EXAMINATION:
eval for fx, interval change in ICH
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Chronic subdural hematoma, status post fall off bed,
no loss of consciousness. Evaluate for change.
COMPARISON: [**2120-11-7**].
TECHNIQUE: Non-contrast head CT scan.
FINDINGS: There is no evidence of acute hemorrhage. Again seen
are bilateral frontal extra-axial collections, not significantly
changed compared to prior studies, again consistent with
subdural hematomas. Maximum thickness again measures upwards of
9 mm, not significantly changed from prior study. There is no
shift of normally midline structures. Ventricles appear stable.
[**Doctor Last Name **]- white matter differentiation appears preserved. Likely
mucous retention cyst within the right maxillary sinus, not
significantly changed from prior. Post- surgical sinus changes
also again seen.
IMPRESSION: No evidence of acute hemorrhage. Bifrontal subdural
hematomas versus hygromas are again seen, not significantly
changed in appearance from prior.
CHEST (PA & LAT) [**2120-11-11**] 10:52 AM
CHEST (PA & LAT)
Reason: eval for PNA
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with multiple traumatic injuries, central cord
syndrome, trach + PEG w/ increasing sputum production
REASON FOR THIS EXAMINATION:
eval for PNA
INDICATION: 42-year-old man with multiple traumatic injury,
central cord syndrome, tracheostomy tube and PEG tube placement
with increasing sputum production.
COMPARISON: AP upright portable chest x-ray dated [**2120-10-22**].
AP UPRIGHT PORTABLE CHEST X-RAY: A tracheostomy tube is in
place. The PEG tube catheter is not clearly seen. The cardiac
silhouette and mediastinal contours are normal and stable.
Atelectasis at both lung bases has increased. There is a small
left pleural effusion, which appears stable in size. An
underlying pneumonia is not excluded. The surrounding soft
tissue and osseous structures are unchanged, with cervical
plates in the lower neck.
IMPRESSION: Increased bibasilar atelectasis. Pneumonia,
particularly at the left lung base, may be obscured.
C-SPINE (AP, FLEX & EXT) 3 VIEWS
Reason: assess for any cervical spine postoperative
changes/processe
[**Hospital 93**] MEDICAL CONDITION:
42 year old man s/p MVC with cervical spine fractures; s/p spine
stabilization on [**9-18**]
REASON FOR THIS EXAMINATION:
assess for any cervical spine postoperative changes/processes
CERVICAL SPINE
HISTORY: 42-year-old man status post motor vehicle collision
with cervical spine fractures status post stabilization. Assess
for any postop change.
TECHNIQUE: Four views of the cervical spine were obtained
including lateral flexion and extension views.
FINDINGS: Comparison is made to prior films of the cervical
spine from [**2120-10-17**].
Again seen is anterior fixation plate and screws spanning C2 and
C3 with apparent bony fusion across the disc space. There is
also posterior spinal fusion extending from C5-T1. No evidence
of hardware breaks. The lower pedicle screws are not well
evaluated on the lateral films. There is no evidence of
loosening of the superior pedicle screws. There is no abnormal
alignment of the visualized cervical spine down to the C6 level
upon flexion or extension.
The atlantoaxial interval is maintained.
Also again seen is a tracheostomy as well as multiple fixation
plates, screws, and cerclage wires of the mandible and maxilla.
Periapical lucencies are seen around the roots of a few
mandibular teeth, which may represent periodontal disease.
IMPRESSION: No abnormal alignment of the cervical spine upon
flexion or extension down to the C6 level.
The lower portion of the posterior cervical fusion is not well
visualized due to the overlying shoulders.
Brief Hospital Course:
He was admitted to the Trauma Service. Orthopedic Spine surgery
was consulted given his spine fractures; he was taken to the
operating room on [**9-18**] for posterior instrumentation and on [**9-19**]
was taken back for anterior instrumentation; during this time he
underwent placement of tracheostomy and gastrostomy tube by
Trauma Surgery. His multiple facial fractures were also repaired
on the 9th in the operating room by Oral Maxillo Facial Surgery.
Behavioral Neurology was consulted for anoxic brain injury.
Several recommendations were made pertaining to his medications.
He was loaded with Dilantin, and remained on this for 10 days
for seizure prophylaxis. There was no evidence of any seizure
activity.
He remained in the Trauma ICU for several weeks; he was
difficult to wean from the ventilator despite early tracheostomy
placement. He would eventually be weaned; is currently
tolerating a trach mask. Transfer to the regular nursing unit
took place on HD #30.
Throughout his hospital stay he had episodes of diarrhea; he did
have a positive C-Diff culture on [**10-5**]; this was treated with
Flagyl course and resolved. Subsequent stool cultures were
obtained and were negative (most recent on [**11-1**]); he did
continue to have intermittent loose stools. His tube feeding
formula was adjusted; Imodium and DTO were added which has
significantly decreased his amount of stools to 1-2x/day.
As a result of his loose stools he did have some altered skin
integrity in his peri-anal region. The Wound Nurse Specialist
was consulted; several recommendations were made and his skin
has improved. He was placed on a First Step Mattress as well;
tube feeding nutrients were optimized.
A Speech consult was placed for evaluation of Passy Muir valve;
he was unable to tolerate this on the initial try. Subsequent
trials were not as successful given copious upper airway
secretions. He was started on a Scopolamine patch to help with
drying some of the secretions; this did seem to help some. His
trach was eventually removed on [**12-1**]. His voice is strong, he
is able to communicate his needs.
He was seen in follow up by Oral Maxillo Facial Surgery for
removal of his jaw wires; his oral screws were removed 2 weeks
later at bedside by OMFS without difficulty.
He was also seen in follow up by Spine Surgery; follow up
flexion & extension cervical spine films were done; his cervical
collar was removed. He may wear a soft collar for comfort if
needed. Orthopedics was re-consulted for a right shoulder
dislocation; this injury was non operative; he was placed in a
sling for comfort. He will follow up in about 1 month in
[**Hospital 5498**] clinic.
Nutrition was closely involved in his care throughout his stay;
tube feedings were initiated early on and are now being cycled
given that he is now on an oral diet. The rate of the tube
feeding should be decreased as his appetite improves.
He is also being treated for a UTI with Ciprofloxacin 7 day
course; he has 3 more days left in this course. His foley
catheter was changed as well.
Physical and Occupational therapy were consulted; he will
require a rehab stay post acute hospital discharge.
Medications on Admission:
Unknown
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): hold for SBP <110; HR <60.
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
ML Inhalation Q8H WITH MUCOMYST ().
5. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q8H (every 8 hours).
6. Opium Tincture 10 mg/mL Tincture Sig: Five (5) Drop PO BID (2
times a day).
7. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO twice a day.
8. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO 8X/DAY () as
needed for diarrhea.
10. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 3 days.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
s/p Motor vehicle crash
1) C2,5,6,7,T1,L4,5 fractures
2) Ant/Post Maxillary Sinus fracture
3) Fractures 4,5 Ribs
4) Pulmonary Contusion
5) Nasopharynx-Foreign Body
6) Non-displaced Left frontal/parietal fx
7) Left Lateral wall of orbit fracture
8) Mandibular fracture
9) Nasal Bone fracture
10) Left Fibula fracture
11) Right SAH
12) Right medial scapula fracture
13) Game Keeper's thumb
14) Inferior subluxation of right humeral head from glenoid
(nonperative)
15) UTI
Discharge Condition:
Good
Followup Instructions:
Follow up in Trauma Clinic with Dr. [**Last Name (STitle) **] in 4 weeks, call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow up in [**Hospital 5498**] Clinic in 4 weeks, cal [**Telephone/Fax (1) 1228**] for
an appointment.
ICD9 Codes: 5180, 5185, 5990, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4180
} | Medical Text: Admission Date: [**2136-12-1**] Discharge Date: [**2136-12-5**]
Date of Birth: [**2069-5-26**] Sex: F
Service: MEDICINE
Allergies:
Rofecoxib
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Flexible Sigmoidoscopy
History of Present Illness:
67yo female with uterine CA s/p XRT complicated by procatitis
and rectal ulcer. Pt received multilpe XRT tx for uterine CA in
[**2134**] and had subsequently underwent resection (incomplete) for
vaginal recurrence. Pt had initially noticed some rectal
spotting as early as [**2134**] subsequent to receiving XRT treatments
for her uterine CA, however due to her pressing cardiac issues
had not paid it much mind. The patient underwent a flexible
sigmoidoscopy in [**2136-7-5**] which showed severe radiation
change in rectum and sigmoid and areas of active bleeding within
the rectum which were treated with bipolar coagulation of the
bleeding. The patient subsequently underwent another
sigmoidoscopy in [**2136-8-5**] which found an area of nodular
thickened mucosa on the anterior wall of the rectum about 5-7cm
from the anal verge. The bleeding was thought to be secondary
to radiation change and or infiltrating recurrent uterine cancer
submucosally and was treated with bipolar coagulopathy. The
patient was in her usual state of health until Thurs, after
[**Holiday **], pt had noticed some brisk bleeding from the rectum
which were described as bright red clots coming by the handful.
She went to [**Hospital **] [**Hospital 41987**] Medical Center where she was found
to have stable vital signs, and Hct of 32.8. She was given
1unit PRBC and admitted for observation and bed rest. On [**12-1**], the patient reported increased bleeding, now described as
gushing out when sitting down on the toilet to go urinate. The
bleeding was no longer clots but now flowing bright red blood.
The patient was given another unit of PRBCs and transferred to
[**Hospital1 18**] for surgical evaluation.
Past Medical History:
PAST MEDICAL HISTORY:
1. Hypercholesterolemia
2. Hypertension
3. Insulin-dependent diabetes mellitus
4. Methicillin resistant staphylococcus aureus
5. Gastroesophageal reflux disease
6. Congestive heart failure
7. Ovarian cancer
8. Postoperative atrial fibrillation following coronary
artery bypass graft
9. Asbestosis
.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft x 3, off-pump complicated by
recurrent wound infection of sternal site
2. Status post cholecystectomy
3. Status post appendectomy
4. Status post right leg plate, open reduction and internal
fixation
5. Status post bilateral cataract extraction
Social History:
The patient is a retired teacher. She lives alone.
She has no tobacco or ETOH history.
Family History:
The patient denies any history of CA in her family
Physical Exam:
-VS: HR: 50 BP: 161/39 RR: 12 SaO2: 100%
-GEN: well nutritioned female lying in bed in NAD, pale, alert,
oriented, appropriate, speaking in full sentences in soft voice.
-CV: RRR, S1, S2, no murmurs, rubs, gallops
-CHEST: CTA bilaterally
-ABD: obese, vertical 10cm well healed surgical scar (presumably
from prior hysterectomy), soft, tympanic, non-tender, BS+
-EXT: warm, well perfused, no clubbing, cyanosis, edema.
-NEURO: alert, oriented x3.
Pertinent Results:
[**2136-12-1**] 05:46PM WBC-5.5 RBC-3.85* HGB-11.2* HCT-33.5* MCV-87
MCH-29.1 MCHC-33.5 RDW-15.7*
[**2136-12-1**] 05:46PM PLT COUNT-337#
[**2136-12-1**] 05:46PM PT-13.0 PTT-20.1* INR(PT)-1.1
[**2136-12-1**] 05:46PM TSH-1.2
[**2136-12-1**] 05:46PM ALBUMIN-3.5 CALCIUM-9.4 PHOSPHATE-3.6
MAGNESIUM-2.2
[**2136-12-1**] 05:46PM ALT(SGPT)-10 AST(SGOT)-13 LD(LDH)-157 ALK
PHOS-70 TOT BILI-0.3
[**2136-12-1**] 05:46PM GLUCOSE-130* UREA N-45* CREAT-1.6* SODIUM-144
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-33* ANION GAP-11
AP UPRIGHT PORTABLE CHEST [**2136-12-2**] AT 8:15 AM: The most recent
prior study that I have for comparison is a study dated [**2134-10-12**].
There has been interval placement of a bipolar pacer. The
patient is in failure with gross pulmonary edema.
[**2136-12-3**]: A-V paced rhythm 50 bpm
Pacemaker rhythm - no further analysis
Since pervious tracing, no significant change
[**2136-12-4**]: Colonoscopy
Findings:
Excavated Lesions A large >3 cm ulcer with active oozing of
blood was found in the distal rectum. Hemostasis and tissue
destruction were successfully achieved with argon plasma
coagulation.
Other Extensive telangiectasis with active oozing of blood was
visualized up to 30 cm into sigmoid colon. Hemostasis and tissue
destruction at sites of most active oozing were successfully
achieved with argon plasma coagulation.
Impression: 1. Ulcer in the distal rectum and extensive
telangiectasis with active oozing of blood was visualized up to
30 cm into sigmoid colon. These findings are consistent with
radiation proctocolitis.
2. Hemostasis and tissue destruction at sites of most active
oozing was successfully achieved with argon plasma coagulation
Brief Hospital Course:
A/P: 67yo female with uterine CA s/p XRT complicated by
procatitis and rectal ulcer who now presents with BRBPR.
.
1. GI Bleed: She was initially sent to the ICU for monitoring.
She did not have any active bleeding and her vital signs and
hematocrit were stable. She was transferred to the floor on
[**2136-12-2**] for further management. She underwent a flexible
sigmoidoscopy on [**2136-12-4**] which showed an ulcer in the distal
rectum and extensive telangiectasis with active oozing of blood
up to 30 cm into the sigmoid colon. The most active lesions
were coagulated with an argon plasma laser. A repeat
sigmoidoscopy as an outpatient was scheduled for [**2136-12-12**] for
further plasma coagulation. Post procedure, she passed several
clots and hematocrit dropped four points, and this was expected
per GI. She had no brisk rectal bleeding and was otherwise
hemodynamically stable. She was discharged to home with strict
instructions to return immediately if she developed further
bleeding prior to her scheduled GI appointment. She was advised
to stop all Aspirin/NSAIDS.
.
2. CV:
A) Coronaries: The patient has a significant CAD history
including multiple catheterizations, stent placements and CABG
in past. Her Aspirin was held. Her long acting beta= amd
calcium channel blockers were switched to shorter acting.
B) Pump: The patient also has a known history of CHF with EF of
50% (however with 3+MR). Her lasix was initially held on
transfer to the floor. She then developed shortness of breath
with wheezing and was in mild acute heart failure. This
improved quickly with diuresis, upright positioning, and oxygen.
She was therafter maintained on lasix and remained euvolemic
for the rest of her hospitalization.
C) Rhythm: Pt has a history of afib but is currently in NS
with a pacemaker. She was continued on amiodarone.
.
3. DM: The patient has DM I. Her NPH dose was halved while
NPO and covered with HISS.
.
4. CRI: The patient's creatinine remained within her baseline
throughout the admission.
Medications on Admission:
MEDICATIONS:
1. Protonix 40 mg by mouth once daily
2. Cardizem Ext Release 120mg once daily
3. Lasix 80 mg by mouth twice a day
4. Lescol 40 mg QHS
5. Toprol XL 150 mg by mouth once daily
6. Insulin NPH 34 units in the morning, 10 units in the
evening, humalog sliding scale
7. Amiodarone 200mg once daily
8. Nitroglycerin patch 0.2mg/hour on 8AM and off at 8PM
9. Fe sulfate 325mg once daily
.
ALLERGIES:
1. Percocet
2. Vioxx
3. Fried shrimp
Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Insulin NPH Human Recomb 150 unit/1.5 mL Syringe Sig: 34
units in am and 10 units in pm units Subcutaneous twice a day:
Take your NPH insulin and Humalog sliding scale as you were
prior to admission.
Check your blood sugar at least 3 times daily.
7. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: 1.5
Tablet Sustained Release 24HRs PO once a day.
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
staff builders TLC out of [**Hospital1 **]
Discharge Diagnosis:
Radiation induced proctocolitis
Radiation induced rectal ulcers
Lower gastrointestinal bleeding
Congestive Heart failure
Coronary artery disease
Hypertension
Diabetes Mellitus
GERD
Ovarian Cancer
Discharge Condition:
Stable and improved. She was passing decreasing amounts of
clots, and occasional specks of bright blood per rectum. She
was hemodynamically stable with stable hematocrit and no brisk
rectal bleeding. She was able to ambulate independently without
difficulty.
Discharge Instructions:
1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
2. Adhere to 2 gm sodium diet
3. Fluid Restriction: 1.5 Liters.
4. Call your doctor or return to the emergency room immediately
if you experience shortness of breath or if you experience brisk
bleeding from your rectum. You should expect to have a small
amount of blood from your rectum after your recent procedure.
5. Follow up with GI for another flexible sigmoidoscopy on
[**2136-12-12**].
Followup Instructions:
1.Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2136-12-12**] 11:30
2. Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Where: GI ROOMS Date/Time:[**2136-12-12**]
11:30
3. Follow up with your primary care provider within one week.
ICD9 Codes: 4280, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4181
} | Medical Text: Admission Date: [**2160-11-3**] Discharge Date: [**2160-11-6**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
head and neck pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85F, transferred from [**Hospital6 3105**] s/p MVC.
Per EMS report, she was restrained passenger in back seat of
vehicle and collision occurred on pt's side of vehicle. Pt
experienced LOC briefly. CT head showed small intracranial
hemorrhage and she is tx for further evaluation.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. NIDDM
PSH
1. S/P right hand surgery
Social History:
Widower, lives with children
Tobacco none
ETOH none
Family History:
non contributory
Physical Exam:
97.4 112 164/73 16 99
Awake and alert, cooperative with exam, normal affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or
paraphasic errors.
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
XII: Tongue midline without fasciculations.
Motor: strength is full, [**4-8**], in all four extremities
symetrically. Pronator drift not tested due to Rt clavicle fx.
Sensation: Intact to light touch throughout.
Rt frontal skin laceration.
Neck C collar in place non tender to palpation
Chestclear, no crepitus
COR RRR
Abd soft, non tender, normal rectal tone
Ext Ecchymotic right clavicle, tender
Head right occipital laceration
Pertinent Results:
[**2160-11-3**] 08:20PM WBC-15.9* RBC-3.83* HGB-11.4* HCT-33.9*
MCV-89 MCH-29.6 MCHC-33.5 RDW-13.9
[**2160-11-3**] 08:20PM NEUTS-93.7* LYMPHS-3.8* MONOS-2.0 EOS-0.3
BASOS-0.1
[**2160-11-3**] 08:20PM PLT COUNT-233
[**2160-11-3**] 08:20PM PT-12.1 PTT-24.9 INR(PT)-1.0
[**2160-11-3**] 08:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2160-11-3**] 08:20PM GLUCOSE-179* UREA N-45* CREAT-1.6* SODIUM-137
POTASSIUM-6.6* CHLORIDE-106 TOTAL CO2-17* ANION GAP-21*
[**2160-11-3**] CT Torso : 1. Hypodensity within the periphery of the
spleen, which on sagittal and coronal images has a wedge-shaped
configuration. Punctate and coarse calcifications in the spleen
are noted. Differential diagnosis includes splenic infarct vs.
small perisplenic hematoma. Close followup is recommended.
2. Left tenth rib fracture and comminuted right mid clavicle
fracture, as
described above.
3. Multiple hypodense lesions within the pancreas, differential
includes IPMN or other neoplasm. Non-urgent MRI/MRCP recommended
for further evaluation.
4. Prominent endometrium measuring up to 1.0 cm. Pelvic
ultrasound is
recommended for further evaluation in this postmenopausal
patient.
5. Multiple thyroid hypodensities which can be further evaluated
on
ultrasound.
111/30/09 Head CT :
Small left superior parietal subarachnoid hemorrhage, stable to
slightly increased when compared to prior exam. A smaller
intraparenchymal
component of the hemorrhage cannot be excluded. No evidence of
new hemorrhage identified. Short term interval follow up is
recommended
[**2160-11-3**] CT C spine : 1. No acute cervical spine fracture seen.
2. Multilevel degenerative changes which cause focal canal
narrowing, as
above, which increases the risk for spinal cord injury. If high
clinical
concern, MRI is more sensitive for spinal cord or ligamentous
injury.
3. Comminuted right clavicle fracture, partially imaged.
[**2160-11-4**] Head CT : 1. Stable focal area of subarachnoid
hemorrhage in the sulci of the upper left posterior frontal
lobe. Intraparenchymal hemorrhage is unlikely given the
appearance and lack of surrounding parenchymal edema. No new
hemorrhage.
2. Scalp swelling at the vertex seen on the lateral scout view
is more
pronounced on today's study.
Brief Hospital Course:
Mrs.[**Doctor Last Name 4145**] was evaluated by the Trauma team in the
Emergency Room then admitted to the Trauma ICU for frequent
neurologic checks and serial hematocrits. She remained
hemodynamically stable, had no neurologic deficits and a stable
hematocrit. The Neurosurgery service was consulted in light of
her SAH and a repeat head CT was done on [**2160-11-4**] which showed no
interval change in the small left parietal SAH.
She was transferred to the Trauma floor for further management
and Physical Therapy. Her right clavicle will be treated non
operatively in a sling and she is encouraged to do both active
and passive range of motion of the right arm/shoulder.
Her hematocrit was stable at 27 and she was able ambulate and
carry out her ADL's without tachycardia. shortness of breath or
dizziness. She was able to tolerate a diabetic diet and her
blood sugars were controlled on her pre admission oral
hypoglycemics.
Of note, on her initial Abdominal CT there were cystic lesions
in the pancreas which were suspicious for intraductal papillary
mucinous neoplasm or some type of neoplasm. MRI/MRCP was
recommended as an outpatient and this can be done at Dr.[**Name (NI) 2989**]
discretion. Dr.[**Name (NI) 2989**] office was notified of her admission and
significant findings.
Mrs.[**Doctor Last Name 4145**] was discharged home on [**2160-11-6**] with VNA services
for cardiovascular assessment, Physical Therapy and scalp staple
removal on [**2160-11-10**].
Medications on Admission:
1. Aspirin 81 mg PO Daily
2. Lisinopril 10 mg PO Daily
3. Glucotrol 5 mg PO Daily
4. Actonel 35 mg PO QWeek
5. Vesicare 5 mg PO Daily
6. Zestoretic 10mg/12.5mg PO Daily
7. Alprazolam 0.25 mg PO TID prn
8. Simvastatin 0 mg PO daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
4. Zestoretic 10-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Glucotrol 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Vesicare 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
11. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q4H (every
4 hours) as needed for pain.
Disp:*250 mg* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary diagnosis
S/P MVC
1. Comminuted right mid clavicle fracture
2. Small left parietal subarachnoid hematoma
3. Left 10th rib fracture
4. right posterior scalp laceration
5. small splenic hematoma
Secondary diagnoses
1. Hypertension
2. Hypercholesterolemia
3. NIDDM
4. S/P right hand surgery
Discharge Condition:
Stable, tolerating a diabetic diet, working with Physical
Therapy to improve her balance and doing active and passive
range of motion of right arm/shoulder.
Discharge Instructions:
* Wear your sling on your right arm for comfort when you are up
and walking
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Call [**Telephone/Fax (1) 1228**] for a follow up appointment in 4 weeks with
Dr. [**Last Name (STitle) 1005**].
Call [**Telephone/Fax (1) 84059**] for a follow up appointment with Dr. [**Last Name (STitle) **] in
4 weeks.
Call Dr. [**First Name (STitle) 1022**] at [**Telephone/Fax (1) 81482**] for a ollow up appointment in [**12-7**]
weeks.
Completed by:[**2160-11-6**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4182
} | Medical Text: Admission Date: [**2105-5-28**] Discharge Date: [**2105-6-2**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization with balloon angioplasty
History of Present Illness:
87 y.o woman with past medical history significant for
hypertension, hyperlipidemia and ischemic colitis who presents
with a [**First Name3 (LF) **]. The patient woke up this morning and felt unwell,
with a sensation of fullness in her chest. She then felt
nauseous and then started developing frank pain that was in the
centre of her chest and radiating to her back.
.
She was brought to the [**Hospital1 **] [**Location (un) 620**] ED where her EKG was
significant for ST elevations in II, II, V2-V6 and reciprocal
depression in aVR. The patient was transferred then from [**Hospital1 **]
[**Location (un) 620**] to [**Hospital1 18**] for emergent cardiac catherization. The
catherization was complicated initially with dissection of the
right femoral artery. Angiography demonstrated a thrombus in
the LAD. However with wiring, the procedure was then
complicated by dissection of the LAD as well. Balloon
angioplasty was performed up and down the LAD with no stent
placed.
.
On review of systems, she denies any past history of chest pain
or MI. Her functional status is excellent and is able to walk
up several flights of stairs without difficulty. No history of
asthma, COPD or stroke.
Past Medical History:
Hypertension
Hypothyroid
GERD
Ischemic colitis
Diverticulosis
Anemia
Social History:
Lives with her husband in a condominium. She is independent in
all of her ADLs and IADLs. Has 4 children.
-Tobacco history: Denies
-ETOH: Denies
-Illicit drugs: Denies
Family History:
Positive for all 4 of her brothers having [**Name2 (NI) **]. Her father
passed away from an MI at the age of 61.
Physical Exam:
Admission Exam:
General: Well appearing woman in NAD, AAOx3
Heent: Sclerae anicteric. EOMI. JVP not elevated. No carotid
bruits.
CV: Regular rate and rhythm, [**2-1**] blowing systolic murmur
radiating to apex. Obscured S1, normal S2. No rubs or gallops.
Pulmonary: Clear to auscultation bilaterally.
Abdomen: Soft, non-tender, non distended. Bowel sounds present.
Groin: Introducer sheath in right inguinal region with 1cm of
sheath extending out. Small hematoma.
Extremities: No edema. 2+ radial and dorsalis pedis pulses
throughout.
Discharge Exam :
Pertinent Results:
ECHO ([**5-29**]): The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. LV ejection fraction (50 percent) is
borderline/mildly depressed secondary to akinesis of the apex
and hypokinesis of the apical half of the anterior free wall and
anterior septum. The basal half of the inferior, posterior, and
lateral walls are hyperdynamic. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2; not
quantitated due to difficulty obtaining a clear left ventricular
outflow tract flow velocity spectrum). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is no
pericardial effusion.
Brief Hospital Course:
ACTIVE ISSUES:
#[**Name (NI) **] -
Pt was transfered from [**Hospital1 **] [**Location (un) 620**] with EKG showing evidence of
ST elevations in I, II, V2-V5 with reciprocal change in AVR.
Cardiac enzymes were CK: 227, CKMB: 12.5, Trop-T: 0.172. At
[**Hospital1 18**], pt had cardiac catheterization which was complicated by
dissected LAD. Balloon angioplasty was performed, no stent
placed. Procedure also complicationed by R. femoral artery
dissection and R. groin hematoma. Cardiac enzymes trended down.
Patient was medically managed and started on aspirin, plavix,
metoprolol, nitro drip, and heparin. Echo showed LVEF of 50%
with hypokinesesis of apical half of anterior free wall and
anterior septum. At time of discharge she had been chest pain
free for 3 days and was stable on a medication regimen including
ASA, plavix, metoprolol, Imdur, and lisinopril. She will follow
up with DR. [**Last Name (STitle) **] in cardiology.
.
#rhythm - stable in sinus rhythm
.
#femoral artery dissection - Patient developed R. groin
hematoma. When sheath was pulled had difficulty achieving
hemostasis. C-clamp was required for 15-30 minutes. HCTs
remained stable. No transfusions were required. Distal pulses
intact. At time of discharge ecchymosis of R. groin resolving
and hematoma decreasing in size.
.
CHRONIC ISSUES:
#hypothyroid: stable. continued on home dose of levothyroxine
.
#GERD: stable. continued on home dose of omeprazole.
.
TRANSITIONAL ISSUES:
#R. groin hematoma - Follow up with PCP to examine hematoma for
resolution
Medications on Admission:
levothyroxine 50mg daily
omeprazole 20mg daily
Iron (unknown dose)
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
primary diagnosis
- ST elevation myocardial infarction
- hematoma (right groin)
secondary diagnosis
- hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Completed by:[**2105-6-4**]
ICD9 Codes: 9971, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4183
} | Medical Text: Admission Date: [**2196-1-29**] Discharge Date: [**2196-2-3**]
Date of Birth: [**2161-4-2**] Sex: M
Service: [**Company 191**]
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 34 year old man
with history of obstructive sleep apnea and hypertension who
presented with sudden onset coughing fit and syncope and was
found to have bilateral massive pulmonary embolism by CT
angiogram. The patient had noted some shortness of breath
and pallor with exercise starting in [**2195-4-2**]. During the
summer, the patient noticed that he was short of breath after
climbing stairs.
In [**Month (only) **], the patient was diagnosed with question of lung
disease and given Albuterol. The patient's dyspnea
progressed and he was started on Pulmicort with some response
on pulmonary function tests. A few days before presentation,
the patient called his doctor [**First Name (Titles) 1023**] [**Last Name (Titles) 2875**] the patient with
a Prednisone burst treatment without success. The patient was
at home and dyspneic with minimal activity. The patient had
a chest CT on [**2196-1-29**]. It was noncontrast which was read as
normal.
The day before presentation the patient had a coughing fit
with witnessed syncope. The patient denies any hemoptysis.
He admitted to fifteen pound weight loss over the last few
months. The patient had been on a 24 hour nonstop trip to
[**State 108**] since [**Month (only) **]. The patient denied any family
history of clots or personal history of clots. No recent
trauma and no recent surgery.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Obstructive sleep apnea on CPAP.
3. Tonsillectomy.
4. Question of asthma.
5. History of echocardiogram that revealed mild decreased
left ventricular function.
6. History of dyspnea on exertion since [**2195-4-2**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Univasc.
2. Prilosec.
3. Prednisone.
4. Multivitamin.
SOCIAL HISTORY: The patient works as a computer networker.
He is married with three children. The patient denies any
tobacco or alcohol use.
FAMILY HISTORY: Significant for rheumatoid arthritis and
leukemia.
PHYSICAL EXAMINATION: The patient had a blood pressure of
115/70 with a pulse of 118. Respiratory rate was 20 with
oxygen saturation of 100% on two liters. Generally the
patient was a fairly ill appearing man in no apparent
distress. Head, eyes, ears, nose and throat examination
revealed extraocular movements intact. The pupils are equal,
round, and reactive to light and accommodation. On neck
examination, jugular venous distention was approximately six
centimeters of water. On cardiac examination, the patient
was tachycardic with normal S1 and S2 and a III/VI blowing
systolic murmur at the left upper sternal border and left
lower sternal border. There were no lifts or heaves
appreciated. Pulmonary examination revealed lungs that were
clear to auscultation bilaterally. Abdominal examination
revealed the belly to be soft, nontender, nondistended with
no hepatosplenomegaly. Rectal examination was negative.
Extremity examination revealed no edema although there were
decreased pulses bilaterally.
LABORATORY DATA: The patient had a white blood cell count of
16.0 with a hematocrit of 44.5. The patient had a blood urea
nitrogen of 18 and creatinine of 1.0. The patient's INR was
1.2. The patient had initial CK of 134, CK MB of 7.0 and
troponin of less than 0.3.
Chest x-ray was read as normal. Chest CT angiogram revealed
bilateral pulmonary emboli that were extensive but without
saddle emboli. Lower extremity ultrasound revealed left
distal superficial femoral to popliteal vein clot.
HOSPITAL COURSE: The patient is a 34 year old with a history
of obstructive sleep apnea, reversible airway disease on
pulmonary function tests, and dyspnea on exertion for six
months who presented with extensive bilateral pulmonary
emboli.
1. Cardiovascular - The patient with extensive pulmonary
emboli with evidence of right ventricular dilatation and
strain on an echocardiogram. Because of the patient's stable
hemodynamics, he did not receive thrombolytics but was rather
started on Heparin infusion after a bolus. Workup of
hypercoagulable states were started in the Intensive Care
Unit where the patient was admitted.
The patient had protein C and S, antithrombin III, factor [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 5244**], prothrombin gene mutation 202-10 analysis,
homocysteine level, antiphospholipid antibody,
anticardiolipin antibody studies sent.
The patient was provided with supplemental oxygen. He was
maintained on therapeutic level Heparin. The patient was
stabilized and eventually transferred to the floor. He was
started on Coumadin 5 mg p.o. for the first day and then this
was increased to Coumadin 7.5 mg p.o. for the next two days.
The patient was monitored on telemetry. The patient had
occasional episodes of ventricular bigeminy and premature
ventricular contractions but otherwise remained in sinus
rhythm. His homocysteine level returned within normal
limits.
On the day of discharge, the patient had a therapeutic INR of
2.6. He was discharged on Coumadin 5 mg p.o. q.d. with INR
followed by his primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 4127**].
2. Hematologic - The patient with decreased hematocrit from
42.0 to 37.0 while in the Intensive Care Unit. He was guaiac
negative and this was thought to be secondary to dilution.
His hematocrit remained stable throughout the rest of the
hospital stay.
3. Pulmonary - The patient with obstructive sleep apnea on
CPAP. He was maintained on CPAP throughout the
hospitalization and was gradually weaned off supplemental
oxygen to the point where he was saturating 98% in room air.
4. Gastrointestinal - The patient presented with history of
elevated liver function tests. The patient remained with
elevated liver function tests throughout the hospitalization.
His ALT was 112 on the day of discharge and AST was 62. He
will likely need to have these followed up by his primary
care physician.
CONDITION ON DISCHARGE: Excellent.
DISCHARGE STATUS: The patient was discharged home.
MEDICATIONS ON DISCHARGE:
1. Coumadin 5 mg p.o. q.d.
2. Protonix 40 mg p.o. q.d.
The patient was advised to follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 4127**] in one week. The patient
will have INR checked a location close to him with results
faxed to his primary care physician. [**Name10 (NameIs) **] patient will be
referred to the hypercoagulation clinic at [**Hospital1 346**]. He was advised to call to make an
appointment at [**Telephone/Fax (1) 5245**].
DISCHARGE DIAGNOSES:
1. Extensive bilateral pulmonary emboli.
2. Possible hypercoagulable state.
3. Mild hypertension.
4. Obstructive sleep apnea.
5. Question of asthma.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 910**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2196-2-3**] 12:59
T: [**2196-2-9**] 12:55
JOB#: [**Job Number 5247**]
cc:[**Name8 (MD) 5248**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4184
} | Medical Text: Admission Date: [**2112-9-17**] Discharge Date: [**2112-9-28**]
Date of Birth: [**2037-10-1**] Sex: M
Service: Cardiothoracic Surgery .
HISTORY OF PRESENT ILLNESS: Briefly, this is a 75 year old
male with type 2 diabetes mellitus and hypertension, positive
smoking history, who presented with dyspnea during the night
and some minimal chest discomfort. The patient denied any
nausea, vomiting, diaphoresis, and was brought to an outside
hospital and found to be in congestive heart failure. He
desaturated to 88% on three liters. The EKG showed sinus
tachycardia and chest x-ray showed left atrial enlargement.
The patient was given Lasix and the EKG showed flipped T
waves. He has been on heparin, Nitroglycerin and Lopressor
and was transferred here.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2.
2. Hypertension.
3. High cholesterol.
4. Mild COPD
ALLERGIES: He had no known drug allergies.
MEDICATIONS:
1. Nifedipine 300 mg q. day.
2. Avandia 4 mg q. day.
3. Metformin 800 mg three times a day.
4. Lisinopril 10 mg q. day.
5. Glyburide 5 mg twice a day.
6. Lipitor 10 mg q. day.
PHYSICAL EXAMINATION: On physical examination he was
afebrile. His vital signs were stable. He was rhonchorous
breath sounds throughout. His heart was regular rate and
rhythm with a positive murmur at the apex. His abdomen was
soft, nontender and nondistended. He had no calf tenderness
or swelling.
LABORATORY: His labs at the outside hospital were white
blood cell count 13.0, hematocrit of 39, platelets 254,
troponin was 0.4.
EKG showed normal sinus rhythm with flipped T's in V3 through
V6. The patient was admitted for Telemetry and followed.
HOSPITAL COURSE: The patient ruled in for a heart attack and
Cardiothoracic was consulted. He was found to have
multi-vessel disease. The patient was taken to the Operating
Room on [**2112-9-22**], where a coronary artery bypass graft
times three and a aortic valve replacement was performed.
The patient did well postoperatively and was transferred to
the CSRU for recovery.
The patient was slowly extubated and chest tubes were
discontinued. The patient was transferred to the Floor.
Wires were removed and Foley catheter was also removed. The
patient continued to do well, however, prior to chest tube
removal, the patient had a slow air leak which required
prolonged suction. The patient was transferred to the floor
with the chest tube in place and continued to do well.
Physical Therapy was consulted for mobility and for strength
and he continued to improve on the floor. He handled a
regular diet and chest tube was put on water-seal. After
repeated chest x-rays, he still showed continued expansion of
the lung. The chest tube was discontinued on [**2112-9-26**]
after chest x-ray examination post pull chest x-ray which
showed no pneumothorax and the patient continued to do well.
The patient was discharged to a rehabilitation facility in
stable condition.
DISCHARGE INSTRUCTIONS:
1. He was instructed to follow-up with Dr. [**Last Name (STitle) 27267**] in one
to week weeks.
2. He is also instructed to follow-up with Dr. [**Last Name (STitle) 1911**]
from Cardiology in two to four weeks.
DISCHARGE MEDICATIONS:
1. Lopressor 12.5 mg p.o. twice a day.
2. Metformin 500 mg p.o. three times a day.
3. Protonix 40 mg p.o. q. day.
4. Lipitor 10 mg p.o. q. day.
5. Glyburide 2.5 mg p.o. twice a day.
6. Vicodin one to two tablets p.o. q. four hours p.r.n.
7. Enteric coated aspirin 325 mg p.o. q. day.
8. Lasix 20 mg twice a day.
9. Potassium 40 mEq p.o. twice a day.
DISCHARGE STATUS: The patient is discharged to
rehabilitation in stable condition and instructed to
follow-up with Dr. [**Last Name (STitle) **] in one to two weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2112-9-27**] 15:21
T: [**2112-9-27**] 16:46
JOB#: [**Job Number 27268**]
ICD9 Codes: 4280, 4241, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4185
} | Medical Text: Admission Date: [**2125-10-12**] Discharge Date: [**2125-10-31**]
Date of Birth: [**2049-7-28**] Sex: F
Service: SURGERY
Allergies:
Desipramine / Nortriptyline / Penicillins / Nsaids /
Erythromycin Base / Sulfonamides / Ceclor / Aspirin /
Doxycycline / Ticlid / Elavil / Neurontin / Vioxx / Bupropion /
Latex / Singulair / Iodine; Iodine Containing / Heparin Agents
Attending:[**First Name3 (LF) 7760**]
Chief Complaint:
76 year old female admitted to [**Hospital1 18**] with abdominal distention
and pain consistent with large and small bowel obstruction,
treated with NG tube and IV TPN x 10 days without relief,
confirmed today by CT scan - preliminary [**Location (un) 1131**] looks
same or worse than 2 mo ago; pt had improved in interim and is
now worse. Previous colonoscopies showed increasing obstruction
in sigmoid area, ? due to diverticulitis but patient now has
confirmed lung cancer by biopsy.
Major Surgical or Invasive Procedure:
S/P Loop transverse colostomy on [**2125-10-17**]
History of Present Illness:
Patient has history of small bowel obstructions and recently a
10 day history of abdominal pain and bloating,treated at
[**Hospital1 **] with decompression with nasogastric tube and total
parenteral nutrition. Symptoms have continued. Admitted to [**Hospital1 18**]
on [**2125-10-12**] for further work up of lung cancer and definitive
treatment of her bowel obstruction. CT of abdomen shows
dilatation of large and small bowel with an area of change of
caliber at the junction of the descending colon and sigmoid. Dr.
[**Last Name (STitle) 6633**] has spoken extensively with patient and family and they
have decided to proceed to surgery.
On [**2125-10-17**] transverse loop colostomy performed.
Past Medical History:
- h/o saddle PE's diagnosed by [**2125-8-23**] chest MRI (pt has
contrast allergy): c/b HIT, resp failure requiring intubation,
was on argatroban, now on coumadin. Discharged from [**Hospital1 18**] to
[**Hospital1 **] on [**2125-9-7**].
- h/o coag neg staph bacteremia s/p several week vanc course (to
have ended [**9-13**])
- recurrent ileus
- Aortic atherosclerosis, ?CAD
- Allergic rhinitis
- Hypertension
- Spinal stenosis: h/o herniated cervical, lumbar disks with
lumbar radiculopathy
- PUD
- Basal cell carcinoma
- Cerebrovasvular disease (small vessel infarcts)
- Hypercholesterolemia
- Rheumatoid arthritis diagnosed age 20s, currently in remission
and untreated.
- Migraines
- Left eye blindness
- Depression
- Asthma
- RUL lung mass with R lung nodules, currently being worked up
as outpatient
- s/p cholecystectomy (open procedure) [**2101**]
- s/p hysterectomy
Social History:
Quit tob, past use 1ppd x 50 years. Denies current or past
alcohol or drug use.
Family History:
2 sons with juvenile rheumatoid arthritis. One daughter with
multiple sclerosis. Father died of a PE after surgery.
Physical Exam:
Per Dr. [**First Name (STitle) **] on [**2125-10-12**]
VS: 103.6 HR 133 BP 81/56 RR 22 98% on 2 liters
NAD, Nasogastric tube with nonbilious, nonbloody gastric content
Mildly uncomfortable
RIJ, CVL in place
RRR, systolic click
Poor respiratory effort
no w/r/r, equal bilaterally
Distended , occasionally bowel sounds, but hypoactive mildly
Tender diffusely without rebound or guarding. guiac negative
brown stool,
no masses.
1+ peripheral edema, cool periperally
Foley with cloudy urine.
Pertinent Results:
[**2125-10-12**] 11:04PM GLUCOSE-90 UREA N-28* CREAT-0.6 SODIUM-133
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-26 ANION GAP-10
[**2125-10-12**] 11:04PM WBC-7.2 RBC-2.67* HGB-7.9* HCT-23.5* MCV-88
MCH-29.6 MCHC-33.6 RDW-16.6*
[**2125-10-12**] 11:04PM NEUTS-81.5* BANDS-0 LYMPHS-13.7* MONOS-4.0
EOS-0.4 BASOS-0.3
[**2125-10-12**] 09:00PM URINE RBC-[**6-17**]* WBC-[**11-27**]* BACTERIA-MOD
YEAST-MANY EPI-0-2
Chest x-ray - Single AP view of the chest is obtained on [**2125-10-13**]
at 09:00 and compared with the prior evening's radiograph
performed at 17:40. Right upper lobe opacity is little less
apparent than on the prior examination. Remainder of the
appearances of the lung fields are essentially unchanged with no
acute process identified. Tubes and lines are unchanged. Mild
distension of visualized colon. No evidence of free
intraperitoneal air.
Cat Scan - CT OF THE ABDOMEN WITHOUT IV CONTRAST: The lung bases
demonstrate two noncalcified lung nodules in the right middle
lobe measuring 9 mm and right lower lobe measuring 4 mm (S2,
I1). Atelectatic changes in the dependent portions are noted.
The previously described mass in the right upper lobe is
excluded in this study. There is no pleural effusion. Coronary
artery calcifications. Heart is normal in size. The liver is
diffusely hypodense consistent with fatty infiltration. The
patient is status post cholecystectomy. There is no intra- or
extra-hepatic biliary ductal dilatation. The spleen, adrenal
glands, and pancreas are unremarkable. The kidneys appear
grossly unremarkable. There is no hydronephrosis. Small
mesenteric and retroperitoneal lymph nodes are noted, not
pathologically enlarged by CT criteria. Persistent diffuse
dilatation of large and small bowel with an area of change of
caliber at the junction of the descending colon and sigmoid.
When compared to the prior study, the degree of dilatation
appears slightly worse. There is no free air or free fluid
within the abdomen. An NGT is noted.
Brief Hospital Course:
This is a 76 year old female admitted with persistent abdominal
pain and bloating from [**Hospital **] Rehab. By CT - shows stricture
in the sigmoid region as well as an upper R lung mass. On
[**2125-10-17**] patient underwent a tranverse loop colostomy for small
bowel obstruction. Postoperative course complicated by
tachycardia, respiratory failure, nonoperative lung mass,
urinary tract infection, several admissions to ICU for
tachycardia and respiratory difficulty.
Cardiology Consult - Postoperatively patient had several periods
where she became tachycardic 130's she remained tachycardic
after fluid resuscitation and no longer febrile. They continue
to feel that her tachycardia is related to fluid shifts and
normal physiologic response.
Geriatric Consult - Patient is somewhat angry regarding
diagnosis and need for colostomy. Geriatric service was helpful
prior to patient's surgery in helping her through her anger.
Social Work - Patient has been followed throughout hospital
course. Working with patient and family.
Thoracics Consult - nonoperative lung mass, small cell lung
cancer to be followed up with radiation/oncologist - Dr. [**Last Name (STitle) **]
for radiation treatments.
Problems
1. Respiratory - Saddle PE/sm. cell lung cancer/CHF/Asthma -
postoperative course as above. Current respiratory status -
Bilateral breath sounds clear with few exp. wheeze and fine
crax. in R base. For last 4 days patient has been running
95-100% oxygen saturations.
2. Cardiac - tachycardia/hypertension - postoperative course as
above. Echo [**2125-10-24**] normal RV size amd free wall motion. LVEF
45-50%, septal hypokinesis, No asd/vsd seen. Mild pulmonary
artery hypertension. No effusion. Currently patient remains
tachycardic 100-120. Blood pressures ranging 100-140 systolic.
Remains on lopressor 25mg [**Hospital1 **].
3. Anticoagulation - Currently patient on coumadin 5mg po daily
and fondaparinux sc. INR today [**10-31**] = 1.7. Fondaparinux should
be discontinued when INR [**2-10**]. Then titrate coumadin to maintain.
4. Infectious Disease - MRSA - via nasal swab, VRE - via rectal
swab
5. Malnutrition - Currently patient on soft diet with cycled
TPN. Needs much encouragement with PO intake.
6. Fluid Shifts - Patient continues to have a large amount of
ostomy output. Will need strict monitoring of intake and output
to ensure balance.
7. Follow up - Dr. [**Last Name (STitle) 6633**] (surgeon) in one week.
Dr. [**Last Name (STitle) **] (radiation oncologist) for radiation
therapy for lung ca.
Will fax this discharge summary to PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1683**] in [**Location (un) **] for
continuation of care.
Medications on Admission:
Atenolol 100mg daily
HCTZ 25 mg daily
Lipitor 10mg daily
MVI
NTG 400mcg sl
Tylenol 500mg 1 at HS
verapamil 240mg daily
Zyrtec 10mg daily
Discharge Medications:
1. Fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) .6
Subcutaneous DAILY (Daily).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
titrate to keep INR [**2-10**]. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
S/P Transverse Loop Colostomy
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
Followup Instructions:
Follow up wtih Dr. [**Last Name (STitle) 6633**] in one week tel. # [**Telephone/Fax (1) 2998**]
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office (Hematology/Oncology)
tomorrow to schedule an appointment for follow-up regarding your
cancer treatments and your anticoagulation.
Follow-up with Dr. [**Last Name (STitle) **] regarding radiation therapy for lung
cancer.
# [**Telephone/Fax (1) 9710**]
Completed by:[**2125-10-31**]
ICD9 Codes: 0389, 5990, 5185, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4186
} | Medical Text: Admission Date: [**2171-5-7**] Discharge Date: [**2171-5-11**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
85 year-old woman with a history of a left frontal meningioma
and seizures, s/p recent cyberkife treatments completed [**2171-5-2**], who presents as a transfer from and outside hospital with
seizures.
The patient initially presented to [**Hospital3 **] on [**2171-1-4**] with finding herself down at home on the floor. She was
apparently found by family and neighbors and taken to [**Name (NI) 5109**] for evaluation. A left frontal lobe lesion was noted
on imaging and she was transferred to [**Hospital1 18**] for further
evaluation. She was noted to have non-fluent speech and
preserved
comprehension here. After stabilization and initiation of
Keppra, she was discharged in early [**Month (only) 956**]. She was followed
serially with scans and maintained on seizure medications.
[**Month (only) 958**] and [**Month (only) 116**] imaging showed stable size of the lesion, though
there was significant peritumoral edema. However, she remained
seizure free on Keppra. After a neurosurgical consult deemed
her a a
non-surgical candidate due to her age and the location of the
tumor (proximity
to the sagittal sinus), she underwent Cyberknife therapy from
[**4-30**]-29th and reportedly tolerated the procedure without
difficulties.
Today the patient was reportedly found "confused" by neighbors,
with speech "difficulties", and seemed to be staring off at the
environment around her. She was brought to [**Hospital3 **]
at ~2:30 pm. A preliminary laboratory evaluation was performed,
and revealed a leukocytosis of 11.5 with left shift (77% PMN),
BUN 24, glucose 97. Electrolytes and coagulation studies were
within normal limits. Outside hospital scans reveal that the
lesion had not changed in size from [**2170-12-6**]. No hemorrhage
or mass effect was noted. Chest x-ray was read as consistent
with [**Hospital1 **]-basilar atelectasis or scar, greater on the left than
right. She was transferred to [**Hospital3 **] for further
evaluation.
Here, the patient was found to be febrile to 101.4 F. She was
noted to have several episodes of fencer-like posturing to the
right. She has thus far-received 2 mg lorazepam twice.
Broad-spectrum antibiotics (including vancomycin, ceftriaxone,
and ampicillin) and anti-virals (acyclovir) are being initiated.
The patient has been given 10 mg dexamethasone. However, the
CXR
is concerning for a patchy LLL opacity.
Past Medical History:
osteoporosis
basal cell carcinoma
glaucoma
s/p vertebral kyphoplasty
Social History:
Lives alone in an [**Hospital3 **] with functional capacity as
per HPI. Quit smocking in the [**2121**]. Ambulates independently.
Family History:
No siblings. Father died at 52 from unknown cancer and a "[**Last Name **]
problem"
Physical Exam:
Vitals: T 101.4 F BP 104/93 P 65 RR 28 SaO2 91 on 3LNC,
improves to 100 on 5LNC
General: elderly woman, initially somewhat awake, but later
sleepy after lorazepam administered
HEENT: NC/AT, sclerae anicteric, MMM, no exudates seen in
oropharynx
Neck: no nuchal rigidity, no bruits
Lungs: poor effort, and decreased breath sounds bilaterally
CV: regular rate and rhythm, no MMRG
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated
Neurologic Examination:
Mental Status:
Initially awake between episodes, but gets more sleepy as time
passes. She does not speak or follow commands.
Cranial Nerves:
Optic disc difficult to see given miosis; appears to blink to
threat bilaterally. Pupils equally round and minimally reactive
to light, at 1.5 mm bilaterally. Looks left and right while
awake, but does not follow commands for vertical gaze. Corneal
and nasal tickle intact bilaterally. Appears to have a subtle
right facial droop, upper motor neuron pattern. Gag intact.
Sensorimotor:
Fencer-like posturing to the right, associated with head and eye
deviation in that direction are noted as well. She withdraws
minimally to noxious in any extremity, but does grimace
throughout.
Reflexes:
2's at the biceps, difficult to elicit elsewhere. Toes were
upgoing on the right and downgoing on the left.
Coordination and gait: Unable to perform.
Pertinent Results:
CT chest/[**Last Name (un) 103**]/pelvis
1. No evidence for pulmonary nodule or mass.
2. Small bilateral pleural effusions with associated
atelectasis.
3. Mild biliary prominence likely secondary to prior
cholecystectomy.
4. No evidence for intra-abdominal malignancy. Mild splenomegaly
is of
uncertain significance.
5. Extensive degenerative changes in the thoracolumbar spine,
with
compression deformities of T6 and T7 vertebral bodies, status
post T6
vertebroplasty.
6. Hypoattenuating thyroid nodules. Correlation with ultrasound
is
recommended on a non-emergent basis.
[**2171-5-10**] 05:55AM BLOOD WBC-7.4 RBC-5.05 Hgb-14.9 Hct-46.5 MCV-92
MCH-29.5 MCHC-32.0 RDW-15.4 Plt Ct-360
[**2171-5-10**] 05:55AM BLOOD Neuts-77.4* Lymphs-16.4* Monos-3.8
Eos-1.7 Baso-0.7
[**2171-5-10**] 05:55AM BLOOD Plt Ct-360
[**2171-5-10**] 05:55AM BLOOD Glucose-100 UreaN-10 Creat-0.7 Na-144
K-3.7 Cl-107 HCO3-27 AnGap-14
[**2171-5-9**] 05:25AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-145
K-3.8 Cl-108 HCO3-27 AnGap-14
[**2171-5-10**] 05:55AM BLOOD ALT-19 AST-23 AlkPhos-52
[**2171-5-7**] 10:00PM BLOOD ALT-20 AST-21 LD(LDH)-188 AlkPhos-47
TotBili-1.8*
[**2171-5-10**] 05:55AM BLOOD Albumin-3.6 Calcium-8.3* Phos-2.6* Mg-2.0
[**2171-5-9**] 05:25AM BLOOD Calcium-8.2* Phos-2.0* Mg-2.1
[**2171-5-10**] 05:55AM BLOOD Vanco-19.5
[**2171-5-8**] 01:28AM BLOOD Phenyto-13.6
[**2171-5-7**] 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6.0
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2171-5-7**] 08:00PM BLOOD LtGrnHD-HOLD
[**2171-5-7**] 08:09PM BLOOD Lactate-2.0 K-4.4
Brief Hospital Course:
Ms [**Known lastname **] is an 85 year-old woman with a history of left
frontal meningioma, s/p recent Cyberknife treatments, who
presented as a transfer from [**Hospital3 **] with seizures.
She was noted to have fencer-posturing toward the right. On
examination, she had an expressive aphasia. Comprehension and
repetition were preserved. There was concern for a possible
pneumonia based on the left lower lobe opacity, in addition to a
meningitis. Ms [**Known lastname **] was admitted overnight into the neuro
ICU service. She had a lumbar puncture in the unit, she was
covered with Ceftriaxone, Acyclovir and Vancomycin until her CSF
Gram stain results were negative. Since her CXR was suggestive
of a pneumonia, she was started on Vancomycin and Zosyn. Her
Vancomycin level prior to discharge was 19.5. However, on Zosyn
she developed a right focal motor seizure in her arm, so this
was discontinued, and she was started on Ceftazidine. Her
primary care physician was [**Name (NI) 653**], who mentioned that her
compliance was an issue, which is probably why she developed
seizures. She was initially loaded on Dilantin and then
maintained on Dilantin and Keppra. Once the therapeutic dose of
Keppra was obtained, a Dilantin taper was planned in the
outpatient setting. The Keppra dose was increased from 750 mg
[**Hospital1 **] to 1000 mg [**Hospital1 **], to try and stop the focal motor seizures. It
is however, not necessary to eliminate the focal motor seizures
completely with benzodiazepines because these agents may
compromise her airways.
On [**5-11**] the day she was planned to be discharged to rehab she had
sudden syncopal episode followed by respiratory decompensation
and subsequent cardiovascular collapse of unclear etiology.
Code Blue was called and she was not able to be resusitated
despite aggressive CPR measures. She passed away at 9:47am on
[**2171-5-11**].
Medications on Admission:
DEXAMETHASONE - (Dose adjustment - no new Rx) - 4 mg Tablet -
One Tablet(s) by mouth twice a day Take as directed, taper as
follows: Take 4 mg [**Hospital1 **] on [**5-2**] thru [**5-5**]. Take 4 mg QAM & take
2
mg QPM on [**5-6**] thru [**5-9**]. Take 2 mg [**Hospital1 **] on [**5-10**] thru [**5-13**]. Take 2
mg daily on [**5-14**] thru [**5-17**]. Take 2 mg every other day on [**7-28**], [**5-22**] & [**5-24**]. Stop taking Decadron after the morning dose
on [**2171-5-24**].
DONEPEZIL [ARICEPT] - (Prescribed by Other Provider) - Dosage
uncertain
LEVETIRACETAM - (Prescribed by Other Provider) - 750 mg Tablet
-
1 Tablet(s) by mouth twice a day
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth once a day;
Take
one tablet 30 minutes prior to your CyberKnife treatment
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 0.5 Tablet(s) by mouth twice a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth DAILY (Daily)
TIMOLOL MALEATE - (Prescribed by Other Provider) - 0.25 % Drops
- 1 Drops(s) in the right eye at bedtime
Medications - OTC
CALCIUM CARBONATE - (Prescribed by Other Provider) - 500 mg
(1,250 mg) Tablet - 1 Tablet(s) by mouth DAILY (Daily)
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth DAILY (Daily)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. CeftazIDIME 2 g IV Q12H Duration: 7 Days
The zosyn had to be stopped, as this triggered focal motor
seizures, changed to Ceftazidime.
7. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q
12H (Every 12 Hours) for 7 days.
8. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Expired
Discharge Diagnosis:
Seizures
left frontal meningioma, s/p recent Cyberknife treatments
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired unexpectedly on [**5-11**] despite aggressive CPR
measures. Her HCP [**Name (NI) **] [**Name (NI) **] was notified.
Followup Instructions:
Expired
Completed by:[**2171-5-11**]
ICD9 Codes: 486, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4187
} | Medical Text: Admission Date: [**2154-11-5**] Discharge Date: [**2154-11-15**]
Date of Birth: [**2110-2-8**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Percocet / Vicodin / Codeine
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Direct laryngoscopy with gelfoam injection for vocal cord
medialization.
History of Present Illness:
The patient is a 44 year old woman with hx of IVDU, and COPD
with a recent hospitalization (for tricuspid and mitral valve
MRSA endocarditis complicated by hypoxic respiratory failure,
VAP, c dif colitis, failed swallowing eval who presents fevers
and shortness of breath. She was first evaluated at [**Hospital1 **] in the rehab center where last night she had a fever
101.2, WBC 27k, and had 1 episode of hemoptysis. She has had
greenish sputum x 2 weeks. An ABG at [**Hospital1 392**] was 7.51/41/61 on
4LNC. She had a UA that was positive for [**9-16**] WBC and 40-50 RBC
and culture was pending. She states that today she has been
feeling well. Her breathing is at her baseline. She has chronic
abdominal pain in LLQ but this is unchanged for several weeks.
She has a foley catheter and has no dysuria. She states that her
foley catheter was placed before she left [**Hospital1 18**]. Her PICC line
was placed on [**2154-10-14**].
.
In the ED she was found to have the following vitals 97.7 126/83
16 93%4L. She was given 1 dose of ceftriaxone and zosyn then
transitioned to the ICU.
.
ROS on presentation: denies CP/HA/runny nos/congestion/sore
throat/diarrhea/ hematuria/new rashes/joint pain
.
Past Medical History:
Tricuspid and Mitral valve endocarditis (MRSA) complicated by
both brain and pulmonary emboli
clostridium dificile colitis
funguria
VAP
Chronic kidney disease: Cr baseline 1.4
IVDU
COPD
s/p appy
interstial lung disease.
s/p G-tube placement
Anemia of Chronic disease (hct 23-27)
PICC line placed ([**2154-10-14**])
Social History:
She lives with her mother outside [**Name (NI) 86**] and does have long
history of IVDU. She has a daughter 21 years old in school in
[**Hospital1 789**]. +tobacco use. estranged husband. mother recently
appointed emergency guardian which is active until [**Month (only) 956**]
[**2154**].
Family History:
NC
Physical Exam:
Vitals: 96.6 90 105/63 20 98%4L
Gen: cachetic. chronically ill appearing. hoarse voice
HEENT: thin. MMM. PERRL (5->3mm bilat) EOMI. poor dentition
Neck: IJ to mid-thyroid cart
Chest: early inspiratory crackles
CV: RRR III/VI holosystolic murmur at LLSB
Abd: G-tube in place. flat. minimal tenderness to LLQ w/o
rebound or guarding
Ext: ankle contractures. thin, waisted hand muscles. 2+DP, no
edema
Skin: no rash, no splinters
Neuro:
-MS: alert and oriented x 3. coherent responses to interview
-CN: II-XII intact
-Motor: moving all 4 extremities
-[**Last Name (un) **]: light touch intact to face/hands/ankles
Pertinent Results:
Admission Labs:
[**2154-11-5**] 06:49PM GLUCOSE-77 UREA N-14 CREAT-1.2* SODIUM-134
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-24 ANION GAP-17
[**2154-11-5**] 06:49PM ALT(SGPT)-11 AST(SGOT)-14 LD(LDH)-217 ALK
PHOS-125* TOT BILI-0.4
[**2154-11-5**] 06:49PM ALBUMIN-3.3* CALCIUM-9.0 PHOSPHATE-4.6*
MAGNESIUM-1.8
[**2154-11-5**] 06:49PM VANCO-9.0*
[**2154-11-5**] 06:49PM WBC-12.7* RBC-2.77* HGB-8.6* HCT-25.3* MCV-91
MCH-31.1 MCHC-34.1 RDW-16.8*
[**2154-11-5**] 06:49PM NEUTS-74.4* LYMPHS-19.5 MONOS-2.3 EOS-3.7
BASOS-0.1
[**2154-11-5**] 06:49PM PT-14.1* PTT-26.1 INR(PT)-1.2*
[**2154-11-5**] 06:49PM PLT COUNT-358
[**2154-11-5**] 06:45PM LACTATE-0.9
[**2154-11-5**] 06:23PM URINE COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.007
[**2154-11-5**] 06:23PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
[**2154-11-5**] 06:23PM URINE RBC-162* WBC-8* BACTERIA-MOD YEAST-NONE
EPI-0
[**2154-11-5**] 03:00PM GLUCOSE-90 UREA N-16 CREAT-1.2* SODIUM-133
POTASSIUM-3.1* CHLORIDE-92* TOTAL CO2-27 ANION GAP-17
[**2154-11-5**] 03:00PM estGFR-Using this
[**2154-11-5**] 03:00PM ALT(SGPT)-11 AST(SGOT)-13 LD(LDH)-205 ALK
PHOS-143* AMYLASE-47 TOT BILI-0.5
[**2154-11-5**] 03:00PM LIPASE-16
[**2154-11-5**] 03:00PM CK-MB-3 cTropnT-0.02*
[**2154-11-5**] 03:00PM ALBUMIN-3.5
[**2154-11-5**] 03:00PM WBC-15.1* RBC-2.79* HGB-8.7* HCT-25.7* MCV-92
MCH-31.4 MCHC-34.0 RDW-16.7*
[**2154-11-5**] 03:00PM NEUTS-81.1* LYMPHS-13.8* MONOS-3.0 EOS-1.6
BASOS-0.5
[**2154-11-5**] 03:00PM PLT COUNT-400
Pertinent Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2154-11-15**] 09:36AM 9.8 2.81* 8.9* 26.7* 95 31.6 33.3 16.8*
514*
VANCO TROUGH (6-8AM)
[**2154-11-14**] 05:46AM 6.8 2.45* 7.9* 22.7* 93 32.1* 34.7 16.9*
385
Source: Line-picc
[**2154-11-13**] 05:45AM 7.3 2.51* 8.1* 23.6* 94 32.3* 34.2 16.8*
471*
Source: Line-picc line
[**2154-11-12**] 05:36AM 10.5 2.64* 8.2* 25.0* 95 31.1 32.8 16.7*
363
Source: Line-picc
[**2154-11-11**] 05:14AM 9.9 2.62* 8.1* 24.2* 92 30.9 33.4 16.6*
400
Source: Line-picc
[**2154-11-10**] 06:08AM 9.4 2.79* 8.8* 25.8* 92 31.6 34.3 16.6*
396
Source: Line-PICC
[**2154-11-9**] 05:40AM 7.4 2.70* 8.4* 25.2* 93 31.0 33.3 16.7*
343
Source: Line-PICC
[**2154-11-8**] 07:18AM 8.7 2.65* 8.3* 24.9* 94 31.5 33.4 16.9*
417
Source: Line-picc
[**2154-11-7**] 05:08AM 8.2 2.55* 8.1* 23.2* 91 31.6 34.8 16.7*
344
Source: Line-picc
[**2154-11-5**] 06:49PM 12.7* 2.77* 8.6* 25.3* 91 31.1 34.1 16.8*
358
SPECIMEN COLLECTED AT 2:00 A.M. [**2154-11-6**]
[**2154-11-5**] 03:00PM 15.1* 2.79* 8.7* 25.7* 92 31.4 34.0 16.7*
400
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2154-11-15**] 09:36AM 137* 15 1.2* 136 3.7 95* 29 16
VANCO TROUGH (6-8AM)
[**2154-11-14**] 05:46AM 110* 17 1.3* 136 3.5 94* 31 15
Source: Line-picc
[**2154-11-13**] 05:45AM 100 16 1.3* 136 3.6 95* 32 13
Source: Line-picc line
[**2154-11-12**] 05:36AM 93 17 1.3* 137 3.6 95* 31 15
Source: Line-picc; TROUGH
[**2154-11-11**] 05:14AM 101 17 1.2* 134 3.6 93* 31 14
Source: Line-picc
[**2154-11-10**] 06:08AM 89 14 1.1 137 4.1 94* 32 15
Source: Line-PICC
[**2154-11-9**] 05:40AM 119* 13 1.1 136 3.2* 94* 34* 11
TROUGH
[**2154-11-8**] 07:18AM 112* 12 1.0 140 3.3 95* 34* 14
Source: Line-picc
[**2154-11-7**] 05:08AM 92 11 1.1 136 3.3 93* 33* 13
Source: Line-picc
[**2154-11-5**] 06:49PM 77 14 1.2* 134 4.0 97 24 17
SPECIMEN COLLECTED AT 2:00 A.M. [**2154-11-6**]
[**2154-11-5**] 03:00PM 90 16 1.2* 133 3.1* 92* 27 17
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili
[**2154-11-5**] 06:49PM 11 14 217 125* 0.4
SPECIMEN COLLECTED AT 2:00 A.M. [**2154-11-6**]
[**2154-11-5**] 03:00PM 11 13 205 143* 47 0.5
CHEMISTRY Alb Calcium Phos Mg
[**2154-11-10**] 06:08AM 10.0 4.8* 1.9
Source: Line-PICC
[**2154-11-9**] 05:40AM 9.4 5.5* 1.9
TROUGH
[**2154-11-7**] 05:08AM 8.9 5.2* 2.1
Source: Line-picc
[**2154-11-5**] 06:49PM 3.3 9.0 4.6* 1.8
HIV SEROLOGY HIV Ab
[**2154-11-8**] 11:15AM NEGATIVE
ANTIBIOTICS Vanco
[**2154-11-15**] 09:36AM 15.51
VANCO TROUGH (6-8AM)
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-14**] 05:46AM 25.7*1
TROUGH
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-13**] 05:45AM 24.7*1
Source: Line-picc line
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-12**] 05:36AM 23.5*1
Source: Line-picc; TROUGH
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-11**] 05:14AM 24.0*1
Source: Line-picc
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-9**] 05:40AM 19.21
TROUGH
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-8**] 07:18AM 17.11
Source: Line-picc
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-5**] 06:49PM 9.0*1
Pertinent Imaging:
.
[**2154-11-5**]: CXR - Interval replacement of Dobbhoff tube with
gastrostomy. Diffuse interstitial air space opacities with areas
of nodularity again noted. Interval resolution of left greater
than right small pleural effusions.
.
EKG ([**2154-11-5**]) - sinus @95. nl axis and intervals. TWI V2-5 (no
change from [**2154-10-24**])
.
Micro: blood culture x3 NGTD
CT of Thorax, Abdoman, Pelvis ([**2154-11-6**]):
CT OF THE CHEST WITH IV CONTRAST: The heart and great vessels
are unremarkable. There is no pericardial effusion. A large
prevascular lymph node measures 3.1 x 1.1 cm (2:19). This lymph
node is probably stable in size compared to the non-contrast CT
examination of [**2154-10-16**]. A right hilar lymph node is enlarged
measuring 1.4 cm in diameter (2:23). No other pathologically
enlarged mediastinal, hilar or axillary lymph nodes are noted.
There are diffuse cystic changes, most notably at the lung
apices, which are overall slightly worse in appearance compared
to the examination of three weeks prior. Cavitary lesions noted
at the left and right lung apex are largely unchanged. Numerous
scattered opacities throughout both lungs are overall smaller in
size compared to the previous examination. For example, a
nodular opacity located in the left lower lobe, superior
segment, now measures 1.3 cm in diameter compared to the
previous measurements of 1.7 cm (2:26). However, there are
several low-attenuation lesions located in the right lower and
right middle lobes with hyperdense rims consistent [**Last Name (un) **]
appearance with small abscesses. A more inferiorly located
lesion measures 1.5 x 1.0 cm (2:39). A lesion located in the
right middle lobe measures 1.3 x 0.7 cm (2:42). The liver,
gallbladder, spleen, adrenal glands, pancreas, and kidneys are
unremarkable. The patient is status post gastrostomy tube
placement. The abdominal portions of large and small bowel
appear grossly unremarkable. A small amount of perihepatic free
fluid is noted. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes are noted.
CT OF THE PELVIS WITH IV CONTRAST: A small amount of free fluid
is present within the pelvis. The rectum, sigmoid colon,
intrapelvic loops of small bowel, uterus and adnexa appear
unremarkable. A Foley balloon is present within the decompressed
bladder.
OSSEOUS STRUCTURES: Compared to the examination of [**2154-10-16**],
there has been new interval destruction of the endplates between
the T7 and T8 vertebral bodies (series 301B:Image 33). A mixed
lytic/sclerotic lesion of the right femur is stable.
IMPRESSION:
1. Endplate destruction at the T7-8 level highly worriesome for
discitis and osteomyelitis in this clinical setting. Correlation
with MR examination of the thoracic spine is recommended.
2. At least 3, approximately 1 cm foci at the right lung base
consistent in CT appearance with abscesses versus early septic
emboli. Whether these lesions are new compared to the previous
examination cannot be definitively commented upon given the
previous lack of intravenous contrast administration. Interval
decrease in size of several nodular opacities in the left lung.
Persistent cavitary lesions involving the lung apices.
3. Prominent, parenchymal pulmonary cystic disease, most notable
in the lung apices in the setting of bibasilar ground glass
opacities. This appearance of the lungs once again raises the
possibility of several etiologies including
lymphangioleiomyomatosis, although the cysts would be more even
and round than in this case; langerhans cell granulomatosis; PCP
is again [**Name Initial (PRE) **] diagnostic possibility given the ground glass
appearance of the lung bases; and if there is a history of HIV
infection, both lymphocytic interstitial pneumonia and an
accelerated, advanced form of emphysema could also appear like
this radiographically.
TTE ([**2154-11-6**])
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with mild hypokinesis of
the anterior septum. Right ventricular chamber size and free
wall motion are normal. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is a
moderate-sized vegetation on the mitral valve. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is a large vegetation on the tricuspid
valve. Moderate to severe [3+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Moderate (1 x 1.1 cm) vegetation on the posterior
leaflet of the mitral valve. Large (1 x 1.5cm) vegetation that
appears attached to the annulus near the septal leaflet of the
tricuspid valve.
Compared with the prior study (images reviewed) of [**2154-10-16**],
the size and position of the vegetations appear similar. The
degree of tricuspid regurgitation may be slightly worse.
Moderate pulmonary artery systolic hypertension is seen (not
determined on the prior study).
Panorex ([**2154-11-8**])
INDICATION: Endocarditis with osteomyelitis.
FINDINGS: Multiple dental fillings. Teeth #7 in the left upper
jaw shows a subtle periradicular increase of transparency that
could correspond to a periradicular inflammatory granuloma. The
other teeth are unremarkable.
IMPRESSION: Potentially inflammatory granuloma in periradicular
location in the seventh tooth of the left upper jaw.
KUB ([**2154-11-9**])
Application of contrast material over pre-positioned stomatic
stump. Even distribution of contrast material through the colon,
contrast marking of the rectum.
MRI-T-Spine ([**2154-11-10**])
There is abnormal T1 hypointensity and T2 hyperintensity of the
inferior endplate of the T7 vertebral body and superior endplate
of the T8 vertebral body demonstrated. There is abnormal T1 and
T2 hyperintensity of the intervening disc space of the T7-T8
intervertebral disc visualized. These regions enhance with
gadolinium administration. There is questionable anterior
epidural enhancement at the level of T7 and T8 levels
appreciated on the sagittal post-contrast sequence only. There
is thickening and enhancement of the anterior paravertebral soft
tissues.
The remaining of the thoracic spine appears normal. The thoracic
cord demonstrates normal signal intensity. The posterior
elements at all levels appear normal. The neural foramina and
lateral recesses at all levels appear normal.
IMPRESSION:
Discitis and osteomyelitis with anterior paraspinal soft tissue
infection at the level of T7-T8. There is questionable anterior
epidural extension at this level. The thoracic cord appears
normal.MRI-Brain ([**2154-11-10**])
MRI OF THE BRAIN ([**11-11**]):
The [**Doctor Last Name 352**]-white matter differentiation of the brain is well
preserved. There are two new tiny foci of acute infarcts
visualized in the left periventricular deep white matter, which
enhances on contrast administration, suspicious for septic
emboli. There is no evidence of intracranial hemorrhage, edema,
mass effect, shift of normally midline structures, or
hydrocephalus. The ventricles and extra-axial CSF spaces appear
normal. There is no abnormal pachy or leptomeningeal
enhancement. The visualized orbits and paranasal sinuses appear
normal.
MRA OF THE BRAIN: The anterior circulation including the
intracranial internal carotid artery, anterior and middle
cerebral arteries bilaterally appear normal. The posterior
circulation including the vertebrobasilar system and bilateral
posterior cerebral arteries appear normal. There is no evidence
of filling defect, stenosis or aneurysm (greater than 3 mm)
IMPRESSION:
1. Acute infarcts with enhancement in the left periventricular
deep white matter suspicious for septic emboli.
2. Normal MRA study of the brain.
LENI ([**2154-11-13**])
This study was originally booked as a right lower extremity
non-invasive study, but clinical information indicated left calf
pain and this was confirmed by the patient and therefore a left
lower extremity non-invasive study was performed. All of the
deep veins in the left lower extremity show normal
compressibility, normal pulse Doppler waveforms and wall-to-wall
flow on color flow imaging. Numerous patent vessels were
identified in the calf, again with no signs of thrombosis.
CONCLUSION: No evidence of DVT in the left lower extremity
Video Swallow ([**2154-11-15**])
Summary: Ms. [**Name13 (STitle) **] has improved vocal cord closure and improved
oral and pharyngeal strength but conitnues to aspirate during
the swallow with thin and nectar thick liquids. Hoever, she can
begin small trials of nectar thick liquids and pureed solids
with the strategies below when with an SLP or trained staff
member to help cue her. She can identify wet vocal quality and
her cough is effective at clearing her secretions and the
intermitten trace aspiration what wil occur on the above diet.
She will also benefit from voice therary as able and f/u with
ENT to evaluate cord closure with question of additioanl
intervention.
Recommendations:
1) Continue with tube feedings for primary means of nutrition.
2) Trials of nectar thick liquids and pureed solids 1-2x's daily
with SLP and/or trainedstaff with the floowing aspiration
precautions.
a) Nectar thick liquids by tsp only no larger sips
b) when drinking, swallow, cough /clear throat and then swallow
again.
c_ tsp size bites of puree, tuckiung your chin to your chest and
swallow hard.
d) Follow each bite of puree with a sip of nectar think liquid.
e) clear your throat of you hear your vocal quality change.
f) Sit upright for approximately 30 minutes after each meal.
3)All mediations via the PEG tube
4) Consider follow-up with ENT
5) Patient will need repeat video swallow before she can be
safely advanced.
Brief Hospital Course:
In summary, this is a 44 yo F with MRSA endocarditis complicated
by septic emboli to brain, lung, kidneys, history of c. diff
colitis, that re-presents from rehab with fever, increased WBC,
subacute cough and sub-therapeutic vancomycin levels.
.
MICU:
The patient was admitted to the MICU for observation, though the
patient was hemodynamically stable. Her vancomycin trough was
sub-therapeutic and her vancomycin dose was increased to 1gm
Q24h per ID recommendation. The source of her fever at rehab
was thus likely [**1-4**] persistent endocarditis infection on
sub-therapeutic antibiotics. Other potential sources included
the lung given her history of septic emboli and a CT scan was
ordered to evaluate for change. CXR showed no clear changes.
Her PICC line was also a possible source of infections, thus
cultures were sent but PICC was not removed given endocarditis
as more probable source. Pt denied diarrhea and recurrent C Diff
was unlikely. Her u/a showed signs of possible UTI but no new
antibiotics were started pending cultures.
.
HOSPITAL COURSE BY PROBLEM:
.
# Fever and Increased WBC:
Outside hospital records indicate that the patient originally
presented with a WBC of 27K. Upon admission to the [**Hospital1 **] her WBC
was 15.1 and subsequently decreased to normal levels. The
patients Vancomycin trough levels were found to be
sub-therapeutic (9) and thus were increased from 750 mg PO daily
to 1 gram daily. Blood Cultures showed no growth to date. Repeat
echo showed no change in terms of her endocarditis and her
vegetations appeared the same. She also had a CT of the abdomen
showing ?osteomyelitis. MRI confirmed osteomyelitis at the T7-8
level. This was thought to be new radiographic evidence of her
previous bacteremia. CT surgery was reconsulted and did not
think she needed surgery. ID and Neurology followed the patient
throughout her course. Throughout her hospital course the
patient remained afebrile and her WBC stabilized. The patient's
U/A was unrevealing and urine cultures were negative to date.
Patient also had some cough that was initially productive.
Sputum was contaminated. Her cough resolved. CT chest did not
show any infiltrates but did show stable bullous disease. She
remained initially on 4L of O2 by NC but this has improved to
1-2L. The patient agreed to HIV testing was serology was
subsequently negative.
# Endocarditis:
Upon presentation the patient was hemodynamically stable with
stable PR interval on EKG. [**Hospital1 **] Disease was consulted and
her Vancomycin dose was increased from 750 mg per day to 1,000
mg per day due to sub-therapeutic trough levels. TTE was
performed on [**11-7**] revealing a stable moderate (1 x 1.1 cm)
vegetation on the posterior leaflet of the mitral valve. Large
(1 x 1.5cm) vegetation that appears attached to the annulus near
the septal leaflet of the tricuspid valve. CT surgery evaluated
the patient at that time and believed that she was not a
surgical candidate due to her new diagnosis of osteomyelitis and
due to her stable echo findings and stable valvular
abnormalities. Throughout her hospital course the patients blood
cultures showed no growth to date. Patient is to continue on a
current regimen of Vancomycin 850 mg q 24 hrs with ID follow up
scheduled. She will need repeat MRI in the future (not yet
ordered and to be arranged by ID). She needs a vanco trough
level 3 days prior to her ID appointment.
.
# Osteomyelitis/Septic Emboli
The patient also underwent a CT with contrast of the thorax to
assess her previously identified septic emboli to the lungs.
Review of the Ct revealed newly identified destruction of the
end plates between the T7 and T8 vertebral bodies. A mixed
lytic/sclerotic lesion of the right femur is stable. This test
was subsequently followed up with a thoracic MRI that revealed a
discitis and osteomyelitis with anterior paraspinal soft tissue
infection at the level of T7-T8. The patient reports no
increases in back pain nor was any back pain or paraesthesia
elicited on during exam. rectal exam revealed normal tone with
normal sacral sensations. On [**11-11**] the patient had a repeat MRI
of her brain that had questionable new acute finding showing
infarcts within very close proximity of previous septic emboli
to the brain. These results were reviewed with Neuroradiology on
two occasions and these lesions were determined to be very small
and of questionable significance. It is also not entirely clear
if these represent new lesions within the same territory. Final
consensus from radiology was that they may be small adjacent new
lesions. Neurology did not feel that she required any change in
treatment. ID also agreed. CT surgery was reconsulted and again
did not feel this would change her management and did not think
surgery was warranted given that infection of a replaced valve
would be devastating in the setting or active osteomyelitis.
.
# Cranial Nerve Deficits: The patient had new complaints of
right heading loss. In addition the patient complained of a
hoarse voice. The patient had a PEG placed on previous admission
as she had a history of failed swallowing evaluations. Upon
transfer to the floor the patient failed both bedside swallowing
evaluation as well as a video oropharyngeal swallow that found
right vocal cord paralysis. ENT was subsequently consulted and
found additional CN XII findings with right tongue deviation.
Thus, given her cranial nerve findings (deficits of 8, 9, 10,
12) they possibility of a central process was entertained. A
brain MRI was performed to investigate potential centrally
located medulla or pons lesions, however were found to be
negative for septic emboli or infarction. The patient underwent
vocal cord Gelfoam injection for improved speech on ([**11-12**]) with
questionable benefit. She requires ongoing speech therapy and
remained NPO after again failing her swallow evaluation prior to
discharge. Neurology was consulted and suggested further
audiometry testing for her right hearing loss which is scheduled
as an outpatient. Neurology also agreed with the cranial nerve
findings, however they believed that these finding may be
independent and peripheral in nature. They recommend follow-up
as outpatient and she has scheduled follow up. A repeat video
swallowing evaluation was performed on her final day and he diet
was advanced (see last video swallow report).
# Hypoxia: Upon re-admission the patient was requiring
supplemental O2 requirement most likely due to her history of
septic pulmonary emboli from endocarditis, emphysema secondary
to tobacco abuse as well as a recent history of ventilator
associated pneumonia. The patient denied shortness of breath on
re-admission. CT scan showed severe emphysema (unchanged from
prior). From the time of admission the patients pulmonary
symptoms slowly improved clinically with decreased sputum
production and the patient was weaned from 4L NC down to 2L NC.
She was continued on nebulizer treatments. The patient had one
report of left calf tenderness during her admission, however
LENI were negative for DVT and she remained on heparin SC
injections for prophylaxis.
.
# History of C Diff colitis: The patient had recently completed
course of PO vancomycin prior to admission. The patient had no
complaints of diarrhea, however reported persistent lower
quadrants abdominal pain. KUB revealed moderate stool and thus
the patient was given lactulose for constipation. The patients
stool frequency increased dramatically with slight improvement
in her abdominal pain symptoms. C. Diff assays were resent and
were negative. She remains on a bowel regimen given she is on
narcotics for chronic pain.
# Anemia: The patient presented with a HCT in the low to mid
20s, this was stable and at her baseline. Over her hospital
course her Hct remained above a goal of 21. Iron studies from
late [**Month (only) 359**] were consistent with anemia of chronic disease. The
patient had no signs of active bleeding. Prior to discharge the
patient was started on iron supplementation.
# Renal failure: The patient had a baseline Cr of 0.8 upon
admission in [**2154-9-2**]. Upon discharge in late [**Month (only) **]
her Cr increased to 1.2 although it had been as high as 1.6.
Since re-admission the patients Cr has ranged between 1.0 and
1.3.
Patient was discharged in good condition, improved O2
requirements, afebrile, improved functional capacity. Her voice
remains hoarse and she still cannot swallow normally. She is to
remain NPO and requires ongoing treatment of her
endocarditis/osteomyelitis. She has scheduled follow up with a
new primary care physician, [**Name10 (NameIs) 1083**] disease, neurology and
audiology which are all very important for her ongoing care and
management.
Medications on Admission:
Bisacodyl 10 mg HS:prn
Senna 8.6 mg [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Olanzapine 5 mg TID:prn
Vancomycin 250 mg Q6H (completed [**2154-11-3**])
Pepcid 20 mg [**Hospital1 **]
Folic Acid 1 mg DAILY
Thiamine HCl 100 mg DAILY
Acetaminophen 325-650 mg PO Q6H:prn
DuoNeb q4:prn
Nicotine patch 7 mg/24 hr DAILY
Methadone 30 mg TID
Fentanyl 50 mcg/hr Patch Q72H
Heparin 5,000 unit TID
Heparin Flush PICC
Ondansetron 4 mg IV Q8H:PRN
Vancomycin 750 mg q24H (until [**2154-11-28**])
Metoclopramide 10 mg PO TID
Robitussin [**4-11**] mL q6
Cephulac 30 mL TID
Dilaudid 2 mg po q4:prn
Klonopin 0.5 mg [**Hospital1 **]
Lidoderm patch
Protonix 40 mg daily
Ventolin q6:prn
Discharge Medications:
1. Outpatient Lab Work
[**2154-11-19**] Chem 7 with Bun/Cr, CBC, Vanco trough [**5-10**] am and sent
to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] at [**Hospital1 **] at fax [**Telephone/Fax (1) 1419**]
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed.
3. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. Vancomycin 850 mg IV Q 24H Start: In am
hold dose 12/13
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [**12-4**]
Inhalation Q4H (every 4 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
14. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
15. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day).
16. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed.
17. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
18. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
20. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
21. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-4**] Sprays Nasal
QID (4 times a day) as needed.
22. Ondansetron 4 mg IV Q8H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
1. MRSA Endocarditis - Mitral and Tricuspid
2. Osteomyelitis T7-8
3. Right sided Hearing loss
Secondary:
- Clostridium dificile colitis s/p rx
- h/o VAP
- Chronic kidney disease: Cr baseline 1.4
- h/o IVDU
- COPD --severe bullous disease on CT on 4L NC O2
- s/p G-tube placement for vocal cord dysfunction, cannot eat
(failed S&S and video swallow, s/p ENT gelfoam injection)
- Anemia of Chronic disease (baseline hct 23-27)
- PICC line placed ([**2154-10-14**])
Discharge Condition:
Good - afebrile, therapeutic vancomycin levels, improved
functional capacity, improved oxygentation
Discharge Instructions:
You were admitted with Endocarditis (infection of the heart
valves)and Osteomylitis (infection of the spine). You were
treated with and increased dose of IV antibiotics.
Please take all of your medications as directed.
Please ensure that you follow up with the appointments listed
below.
Please return to the emergency room with any fevers, chills,
back pain, shortness of breath, chest pain, abdominal pain,
diarrhea, incontinence or any other problems.
Followup Instructions:
You have the following appointments scheduled:
[**Month/Day/Year **] Disease:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2154-12-13**]
10:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2154-11-22**]
9:30
.
Neurology:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2154-12-12**] 4:00
.
Audiology:
Provider: [**Name10 (NameIs) 6410**] [**Name Initial (NameIs) **] [**Last Name (NamePattern4) **], AU.D. Phone:[**Telephone/Fax (1) 6411**]
Date/Time:[**2154-11-20**] 1:00
.
New Primary Care Doctor:
[**2155-1-15**] 03:30p [**Last Name (LF) **],[**First Name3 (LF) **]
[**Hospital6 29**], [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5845, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4188
} | Medical Text: Admission Date: [**2171-4-16**] Discharge Date: [**2171-4-21**]
Date of Birth: [**2089-12-7**] Sex: M
Service: SURGERY
Allergies:
Seldane / antihistamines
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Acute onset of chest and back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81M Jehovah's Witness w/ h/o AAA, ? TIAs, prostate CA and
chronic back pain presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital ED earlier
today when he had acute onset of chest, abd and back pain
occurring simultaneously. He denied ever having
this type of pain before and denied additional symptoms (no
F/C/diaphoresis/N/V/pain elsewhere). He has been passing flatus
and having BMs. Esmolol drip started for SBP in 150's (now in
130's) and w/ morphine, pain improved.
Past Medical History:
PAST MEDICAL HISTORY: prostate CA [**2150**]'s, AAA 4.3cm [**2170-10-21**],
HTN, ? TIAs [**2170-9-17**] & [**2171-4-8**], L2 fx/stenosis, L knee fx [**2169**]
PAST SURGICAL HISTORY: L hip replacement [**2161**], tonsillectomy,
appendectomy as child
Social History:
smoked for 20yrs, quit long time ago, denies ETOH, no IVDU
Family History:
N/A
Physical Exam:
Vital Signs: Pulse: 67 BP: 138/95 RR: 18 O2: 97% 4LNC
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No right carotid bruit, No left carotid bruit.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, No AAA.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, abnormal: Bilat LE edema,
resolving venous stasis ulcers.
Pertinent Results:
[**2171-4-21**]
131 97 24 AGap=14
------------< 103
4.9 25 0.6
Ca: 8.6 Mg: 2.4 P: 2.6
[**2171-4-22**]
128 96 30 122 AGap=13
------------< 122
4.3 23 0.7
Ca: 8.6 Mg: 2.1 P: 2.0
11.2
12.5 >< 841
31.4
[**2171-4-18**] CTA Torso:
CT ANGIOGRAM: A type B aortic dissection originates just distal
to the left subclavian takeoff and extends to the right
superficial and right deep femoral arteries and definitely to
the left external iliac artery and possibly into the left common
femoral artery, although complete evaluation is limited due to
artifact from left hip arthroplasty. The dissection does not
extend into the mesenteric, renal, or internal iliac arteries.
The dissection course is stable from [**2171-4-16**]. The largest aortic
diameter is 4.5 cm, just above the diaphragm. The entire false
lumen is perfused, unchanged from the prior study.
The celiac trunk, SMA, and renal arteries originate from the
true lumen. The [**Female First Name (un) 899**] originates from the false lumen with no
perfusion over a 5 mm segment just distal to the origin of the
[**Female First Name (un) 899**], but the [**Female First Name (un) 899**] is very well perfused distally. Calcifications
and possible stenosis at the celiac artery origin are noted with
a widely patent celiac artery just beyond the origin. There is
decreased perfusion of the right kidney relative to the left
kidney, although the right renal artery originates from the true
lumen. The intramural hematoma at the level of the aortic arch
is stable.
1.Type B aortic dissection as described above. Dissection is
stable since
[**2171-4-16**] with no evidence of extension.
2. Mesenteric and renal arteries originate from the true lumen.
The [**Female First Name (un) 899**]
originates from the false lumen.
3. Decreased perfusion of the right kidney relative to the left
kidney,
although the right renal artery originates from the true lumen
and is patent.
4. Perfusion of the entire false lumen is unchanged from
[**2171-4-16**].
5. Small bilateral pleural effusions and associated compressive
atelectasis
are new from [**2171-4-16**].
6. Stable compression fractures of L1 and L2.
Brief Hospital Course:
The patient was admitted to the vascular surgery service on
[**2171-4-16**] to manage his aortic dissection. Upon admission, the
patient was started on nitro and esmolol drips to keep his MAP <
70. He was closely monitored in the ICU. As the patient started
to tolerate po intake, he was transitioned to oral
anti-hypertensive medications. He was kept on a regimen of
atenolol, hydralazine, and lisinopril which was very effective
in keeping his blood pressure low. Once on po blood pressure
regimen, the patient was transferred to the floor. On HD 3,
patient had worsening abdominal pain and nausea in the morning.
A CTA was performed that showed stable aortic dissection and no
signs of impending rupture. As such, patient continued to be
managed medically with strict blood pressure control. His diet
was advanced to regular and was well tolerated. Physical therapy
worked with the patient and determined that he was safe for
home, but recommended physical therapy at home. Patient is a
Jehovah's witness and as such is not a good surgical candidate.
This fact was discussed with the patient and he understood all
the issues. At the time of discharge, patient was feeling well.
He was afebrile with stable vital signs, pain was well
controlled, and he was tolerating regular diet. He will be sent
home with new BP medications for strict blood pressure control
and will follow up with Dr. [**Last Name (STitle) 1391**] in clinic.
Medications on Admission:
atenolol - 25 mg Tablet 1 Tablet(s) by mouth daily
fentanyl - 75 mcg/hour Patch 72 hr 1 patch q72 hours
furosemide - 20 mg Tablet 1 Tablet(s) by mouth every other day
leuprolide (3 month) [Lupron Depot (3 Month)]
lidocaine - 5 % (700 mg/patch) Adhesive Patch, Medicated 1 patch
q12 hours
metaxalone - 800 mg Tablet 1 Tablet(s) by mouth twice a day
oxycodone-acetaminophen - 10 mg-325 mg Tablet 1 Tablet(s) by
mouth q4 hours
aspirin - 81 mg 1 Tablet(s) by mouth daily
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): PMD
will provide and manage lidocaine patch.
2. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): PMD will prescribe and manage
your fentanyl patch.
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. 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*
9. hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours): Hold if SBP<100.
Disp:*150 Tablet(s)* Refills:*2*
10. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold if SBP<100, HR<60.
Disp:*50 Tablet(s)* Refills:*2*
11. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold if SBP<100.
Disp:*30 Tablet(s)* Refills:*2*
12. metaxalone 800 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
Type B aortic dissection
PMH:
prostate CA
AAA 4.3cm [**2170-10-21**],
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were found to have an aortic dissection. As such it is very
important that you maintain strict control of your blood
pressure. You will be sent home on new medications to manage
your blood pressure. Please take these medications exactly as
directed.
Please call your doctor or come to the emergency room if you
develop worsening pain, shortness of breath, chest pain, nausea,
vomiting, fevers, chills, or any other concerns that you may
have.
Please refrain from any heavy lifting greater than 10 lbs or any
strenous activity. Get plenty of rest, and slowly restart your
normal activities.
You may resume your normal diet as tolerated. You may restart
your home medications unless instructed not to by your doctor.
Please take all new medications exactly as prescribed.
Please follow up with your surgeon and primary care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 19379**]d.
Followup Instructions:
Call Dr.[**Name (NI) 1392**] office to schedule a follow up [**Telephone/Fax (1) 4852**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4189
} | Medical Text: Admission Date: [**2139-7-14**] Discharge Date: [**2139-7-19**]
Date of Birth: [**2076-5-4**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
headache and unresponsive
Major Surgical or Invasive Procedure:
intubation by OSH prior to arrival.
extubation with trach placement.
History of Present Illness:
Mr. [**Known lastname 89692**] is a 63 yo Haitian man with history of DM and
HTN
who presented with severe headache and vomiting to [**Hospital3 9683**].
The patient was at home with his wife, when he suddenly
developed
the worst headache of his life at 11pm. He had previously been
in
his normal state of health, and his daughter spoke to him at
8pm.
The patient apparently did have headache 1 day prior to
presentation, but had no other symptoms.
When his headache became severe on the night of admission, he
was taken to [**Hospital3 9683**]. Upon arrival he was vomiting and becoming increasingly
somnolent, so
was intubated for airway protection. This was a traumatic
intubation causing some oral bleeding, most likely because the
intubation had punctured the soft palate. NCHCT showed 19mm R
SDH. Patient was transferred to [**Hospital1 18**] for surgical eval.
On arrival to [**Hospital1 18**] ED, patient was intubated and on propofol.
Head CT showed significant enlargement of R SDH to 21mm, with
19mm L midline shift and compression of the brainstem pushing
the brainstem to the left
c/w uncal herniation. Initial exam showed pupils fixed and
dilated, no corneals, not responding to noxious stimuli.
Neurosurgical consult did
not feel that patient would benefit from surgery since pupils
were fixed and there was no change in his neurological
examination in particular in his pupillary reactions and
cornealreflex after he had received a 100g Mannitol challenge.
Pt continued to receive a high dose of mannitol, nicardipine gtt
for HTN and Dilantin for seizure prophylaxis.
Per patient's family, he had not been ill, no recent trauma or
falls, no changes to medications. He takes ASA 81 mg daily but
no
other blood thinning medications. He has never had profuse
bleeding with surgery/dental work/injuries/etc, and there is no
family history of bleeding disorders.
Past Medical History:
HTN
HL
DM for decades c/b peripheral neuropathy
Social History:
lives with wife, no tobacco, EtOH or illicits.
Family History:
NC
Physical Exam:
At admission:
VS: T afebrile HR 80s BP 130s/60s
General: intubated, no responding to verbal commands or noxious
stimuli even without sedating agents turned off.
HEENT: NC/AT, no scleral icterus noted
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
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
NEURO:
Off propfol approx 1 hour:
Eyes closed. Eyes do not open to sternal rub, no response to
noxious stimuli. No spontaneous limb movements.
Pupils 8mm and nonreactive. No VORs, very sluggish right corneal
reflex noted, no corneal reflex on the left; vestibulo-ocular
reflex absent; +strong cough
and gag.
Tone decreased. Intermittently a decerebrate posturing in his UE
with very severe noxious stimuli.
DTR 2+ in bilateral [**Hospital1 **], tri, brachiorad, absent in LEs, toes
mute.
At discharge: deceased
Pertinent Results:
At admission:
[**2139-7-14**] 01:50AM PT-13.2 PTT-22.4 INR(PT)-1.1
[**2139-7-14**] 01:50AM WBC-14.7* RBC-5.29 HGB-15.8 HCT-44.2 MCV-84
MCH-29.8 MCHC-35.7* RDW-13.5
[**2139-7-14**] 01:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-7-14**] 01:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2139-7-14**] 01:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2139-7-14**] 01:50AM URINE RBC->182* WBC-8* BACTERIA-FEW YEAST-NONE
EPI-0
[**7-14**] CTA with and without Recon
IMPRESSION:
1. Right-sided subdural fluid collection with acute hemorrhage
along with
hypodense areas which may related to ongoing
hemorrhage/coagulopathy. Maximum transverse dimension of 23 mm
with mass effect on the right erebral hemisphere, lateral
ventricles and shift of the midline structures to the left side
by approximately 21.3 mm. Hypodense appearance of the cerebral
hemispheres may relate to a component of cerebral edema.
Right sided uncal herniation; brain stem compression and
distortion with
leftward shift. Assessment for osseous structures/fractures is
limited on the present study. Please see the outside study for
additional details. To
correlate clinically, for trauma/coagulopathy and close followup
as clinically necessary.
2. Patent major intra- and extra-cranial arteries as described
above with
decreased caliber of the Basilar artery, A1 and A2 segments of
the anterior cerebral arteries on both sides, part of which may
relate to mass effect/spasm from cerebral edema.
3. Small focus of enhancement in the right-sided subdural
hemorrhagic
collection may relate to contrast extravasation. No abnormally
dilated
vessels to suggest an obvious vascular malformation in this
location.
Recommended review of the images by neurosurgery to decide on
further workup.
4. Multilevel degenerative changes in the cervical spine along
with a focus of prominent posterior disc osteophyte complex at
C5-6 resulting in moderate canal stenosis and varying degrees of
foraminal narrowing. MR can be considered if not CI and if
clinically necessary.
[**2139-7-19**] Nuclear Brain Scan:
INTERPRETATION:
Following injection of tracer, SPECT images of the brain were
obtained in
multiple projections and show no evidence of perfusion to the
cerebral cortex.
IMPRESSION:
The perfusion abnormalities are consistent with brain death.
Findings discussed with Dr [**Last Name (STitle) **] via phone at [**Pager number **] on [**2139-7-19**].
Brief Hospital Course:
The patient was admitted to the NeuroICU for subdural hematoma.
Patient was intubated at OSH prior to transfer. Neurological
exam showed patient to be nonresponsive, with pupils fixed and
dilated 6mm bilaterally. Right corneal reflex could be
elicited, but was very sluggish; no left cornealreflex; cough
intact, and extensor posturing on applying severe noxious
stimuli in the UE. CTA showed 23 mm mass effect on the right
cerebral hemisphere, lateral ventricles and shift of the midline
structures to the left side by approximately 21.3 mm, as well as
right sided uncal herniation, brain stem compression and
distortion with leftward shift. Neurosurgery saw the patient but
did not feel there was any surgical intervention that they could
offer that would be of benefit given the patient's presenting
neuro exam, in particular his fixed pupils and the lack of any
change in his neurological exam after he got a Mannitol
challenge of 100g.
Neuro:
The patient was continued to be treated with mannitol after the
initial Mannitol challenge to decrease cerebral edema and
herniation. Administration was limited by checking for
hypernatremia and serum hyperosmolality. He was continued on
fosphenytoin for seizure prophylaxis. Neuro exam initially
slight worsened, since he lost a cough and gag reflex and he did
not breath over the vent anymore. He continue to have a very
sluggish right corneal reflex and some extensor posturing to
severe noxious stimuli in his UE. All other brainstem reflexes
were absent. His neurological exam worsened on [**2139-7-19**]. He no
longer had any brain stem reflexes on exam and no posturing to
noxious stimuli. Given his hemodynamic instability, apnea test
was forgoed for fear of worsening hemodymanics. Instead a
nuclear brain scan was done to evaluate for brain death. The
scan showed no activity and subsequently the patient was
pronounced brain dead.
Pulmonary:
The patient arrived intubated from the OSH. It was discovered
that the endotracheal tube was traversing the right tonsillar
pillar and ENT was consulted. They evaluated the patient and
then took the patient for trach in order to remove the
endotracheal tube. The trach was placed without complication.
The patient was started on Unasyn for empiric coverage given the
tonsil perforation.
Infectious disease:
The patient was febrile throughout the majority of his stay.
Initial culture data failed to show any infection. Sputum
culture on [**7-16**] grew staph aureus coag positive and H.
influnzae.
Cardiovascular:
The patient became hypotensive on HD 5 and required pressor
support.
Renal:
The patient was maintained on IVF as well as free water through
his NG tube to maintain hydration with care not to worsen ICP.
GI:
NG tube was placed and tube feeds were started [**7-16**].
Code:
Multiple family meetings were had with the patient's wife and
daughters who shared that based on previous, specific
discussions they had held with him in the past, they felt that
he would want all heroic measures done. The patient remained
full code through out his hospital course.
Medications on Admission:
ASA 81 mg daily
Metformin
Sitagliptin
Lisinopril
Lantus
Lispro
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
subdural hematoma with midline shift, uncal herniation and
brainstem compression leading to brain death
Discharge Condition:
deceased
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 2760, 3572, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4190
} | Medical Text: Admission Date: [**2155-4-16**] Discharge Date: [**2155-5-7**]
Date of Birth: [**2089-12-13**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / Indomethacin / Actonel / Reglan
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Hypoxia, altered mental status
Major Surgical or Invasive Procedure:
[**2155-4-26**]: EGD/Colonoscopy
[**2155-4-30**]: EGD
[**5-6**]: PICC removed
History of Present Illness:
Ms. [**Known lastname **] is a 65 year old female with extensive medical
history including DM II, ESRD, and nonalcoholic steatohepatitis
s/p liver and kidney transplant in [**7-/2153**], who recently
underwent exploratory laparotomy, evacuation of intra-abdominal
blood, exploration of retroperitoneal hematoma, and left
salpingo-oophorectomy for retroperitoneal bleed. Her post-op
course was complicated by [**Last Name (un) **], volume overload requiring
diuresis and CVVHD for ultrafiltration, gout flare. She also had
an abdominal wall hematoma required evacuation on [**4-11**] and stay
overnight for overvation. She was also treated for ESBL UTI with
Meropenem on [**4-14**]. Per report, patient was noted to be hypoxic
when working with PT and confused at the rehab on [**2155-4-16**]. She
was then transferred to [**Hospital1 18**] for evaluation. In the ED, the
patient reported that she hasn't been feeling well. She reported
having shortness of breath. She reported tolerating her diet and
TF, having regular BMs. She denied any fever, abdominal pain,
fever, chills.
Past Medical History:
- Diabetes Mellitus Type 2, on Insulin, c/b retinopathy,
nephropathy, and neuropathy
- Dyslipidemia
- Hypertension
- Atrial fibrillation, on coumadin
- High-degree AV block, s/p PPM [**2154-2-5**] ([**Company 1543**] Sensia DDD
pacemaker), now pacer dependent
- Diastolic heart failure, NYHA II-[**Last Name (LF) 1105**], [**First Name3 (LF) **] >65% on TTE [**1-/2154**]
- Calcific aortic stenosis, moderate (area 1.0-1.2cm2) on TTE
[**1-/2154**]
- Moderate mitral annular calcification and mitral regurgitation
- Mild tricuspid regurgitation
- Moderate pulmonary hypertension
- End-stage renal disease, [**3-12**] diabetes & contrast-induced
nephropathy, s/p cadaveric transplant [**2153-7-21**]
- Non-alcoholic steato-hepatitis cirrhosis (Stage IV, Grade 2),
c/b portal HTN, ascites, encephalopathy, grade I-II esophageal
varices s/p banding s/p TIPS [**8-/2152**], s/p OLTx [**2153-7-21**]
- saphenous vein interposition graft repair of the hepatic
artery and harvesting of the left saphenous vein graft [**2154-3-14**],
Hepatic artery s/p stent [**2154-4-25**]
- s/p VATS decortication [**11/2153**]
- Splenic vein thrombosis, on coumadin
- Anemia
- Thrombocytopenia
- h/o C.diff
- h/o Seizures
-headaches ? [**3-12**] occipital neuralgia
- Meningioma, small left frontal lobe
- GERD
- OSA has CPAP at home but does not use
- Cervical DJD
- Dermoid cyst
- Right adrenal mass
-osteoporosis
- Recurrent MDR UTI (ESBL Klebsiella)
- Status post cholecystectomy followed by tubal ligation
- Status post left oopherectomy
- Status post appendectomy
- ? Restless legs syndrome
- Abdominal wall hematoma s/p evacuation
Social History:
Widowed, lives in [**Hospital3 **] facility in [**Hospital1 6930**] MA. Has 4
children, 3 in MA, one in [**State 3908**]. Smoking: None; EtOH: Never;
Illicits: None.
Family History:
Mother and Father with CAD. Father with stroke at 90. No other
family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Physical exam in the ED:
Vitals: T 102.4 HR 79 (ventricular paced) BP 125/56 RR 24 Sat
95%4L
Gen: moderately distress, orientedx2
HEENT: NC/AT, dry mucosa, no lymphadenopathy, no JVD appreciated
Chest: no tachypnea, b/l crackles
CV: regularly paced, +murmur
Abd: obese; soft; nt/nd; lower abdominal wound clean, no
exudate, no erythema
Extrem: trace edema
Rectal: normal tone, no gross blood, no mass
Physical exam at time of discharge:
Afebrile, vitals wnl
Gen - A&O x 3 NAD
CV - rrr no m/g/r
Pulm - CTAB
Abd - soft NTND, LLQ incision w/ WTD dressing along inferior 3
cm, good granulation tissue, no surrounding erethema or
induration, incision otherwise CDI
Extrem - no c/c/e
Pertinent Results:
Labs on Admission: [**2155-4-16**]
WBC-35.4* RBC-2.76* Hgb-9.0* Hct-27.2* MCV-99* MCH-32.6*
MCHC-33.1 RDW-20.0* Plt Ct-569*
PT-14.4* PTT-28.4 INR(PT)-1.2*
Glucose-125* UreaN-73* Creat-1.7* Na-135 K-5.2* Cl-95* HCO3-30
AnGap-15
ALT-22 AST-20 CK(CPK)-19* AlkPhos-208* TotBili-1.5 Lipase-12
CK-MB-1 proBNP-9697*
Albumin-3.1* Calcium-8.6 Phos-3.9 Mg-2.0
[**2155-4-17**] tacroFK-25.8*
At Discharge [**2155-5-7**]
WBC-17.6* RBC-3.45* Hgb-10.7* Hct-33.2* MCV-96 MCH-31.1
MCHC-32.3 RDW-17.1* Plt Ct-603*
PT-12.2 PTT-23.4 INR(PT)-1.0
Glucose-134* UreaN-43* Creat-1.0 Na-138 K-3.7 Cl-97 HCO3-31
AnGap-14
ALT-12 AST-15 LD(LDH)-274* AlkPhos-98 TotBili-0.8
Albumin-3.1* Calcium-8.3* Phos-2.8 Mg-2.0
tacroFK-5.7
.........
CXR [**2155-4-16**]:
FINDINGS: Portable AP chest radiograph compared with [**2155-4-11**]
demonstrates
interval increase in bilateral basal and perihilar airspace
opacities with
increase in bilateral pleural effusions right greater than left
and fluid
tracking along the minor fissure. A left chest two-lead
pacemaker remains
stable in appearance. There is a feeding tube with its tip
positioned in the third portion of the duodenum.
TTE [**2155-4-17**]: The left atrium is dilated. 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 number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. There is
moderate thickening of the mitral valve chordae. There is mild
functional mitral stenosis (mean gradient 7 mmHg) due to mitral
annular calcification. Moderate to severe (3+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.
Renal US [**2155-4-17**]:
IMPRESSION:
1. Progression of the abnormal appearance of renal transplant
vascularity,
now with diffuse reversal of flow in diastole. Renal vein
remains patent.
2. No significant change in appearance of the large midline/left
abdominopelvic and retroperitoneal hematoma.
CT Chest w/o constrast [**2155-4-17**]:
IMPRESSION:
1. Bilateral lower lobe consolidations concerning for pneumonia
in the
setting of fever.
2. Asymmetrically distributed ground-glass opacities and smooth
septal
thickening, most likely due to hydrostatic pulmonary edema.
Infectious
etiology (such as viral) for these opacities is less likely.
3. Small, dependent left and small-to-moderate, partially
loculated right
pleural effusion.
Colonoscopy [**2155-4-26**]:
Friability and ulceration in the distal transverse colon,
splenic flexure and proximal descending colon compatible with
ischemic colitis
Normal mucosa in the hepatic flexure and distal ascending colon
Otherwise normal colonoscopy to cecum
EGD [**2155-4-26**]:
Normal esophagus. Normal stomach. Normal duodenum.
Brief Hospital Course:
Ms. [**Known lastname **] was evaluated in the ED and thought to have
pulmonary edema. Due to her high oxygen requirement and clinical
picture, she was given IV [**Known lastname 11573**] with minimal response. She was
admitted to the SICU where [**Known lastname 11573**] [**Known lastname **] was initiated. Below is
her hospital course by system:
1. Neurologic: mental status improved by hospital day 2.
Confusion was felt to be secondary to hypoxia and UTI. Psych
meds were continued. She was noted to have tremor and weakness
on her right side. Neurology was consulted and made
recommendations for EEG to r/o seizures, head CT to eval
evolution of stroke. Keppra was continued at current dose. Head
CT without contrast on [**4-22**] demonstrated unchanged left frontal
parafalcine dural calcification. No mass effect, bleed or
midline shift. Mild atrophy was noted. CPAP was recommended to
decrease change of hypoxia that could increase seizure
potential. This was set up, but she refused to wear due to
claustraphobia sensation.
2. Pulmonary: pulmonary edema responded to diuresis. Chest CT
was done on [**4-17**] demonstrating pulmonary edema with possible
bilateral pneumonia. Cardiology consult was obtained and it was
deemed that she had CHF secondary to worsening MR. [**First Name (Titles) 11573**] [**Last Name (Titles) **]
and Metolazone were given. She was also treated with a
7-day-course of Vancomycin for pna.
3. Cardiac: due to her history of diastolic CHF and a BNP of
~10,000 at admission, patient was thought to be in CHF which
exacerbated her [**Last Name (un) **]. TTE on [**2155-4-17**] showed normal LVEF with
worsening MR compared to previous TTE on 2/[**2155**]. Cardiology
agreed with the plan. Recommendations were to continue to
diurese then re-echo to evaluate MR and AS once euvolemic.
4. GI: Dobbhoff tube was clogged on admission and was exchanged
on HD#1. TF was restarted to 40 ml/hr of NorvaSource with
Beniprotein 21g/day. She developed diarrhea likely r/t tube
feeds. Stool was negative for C.diff on [**4-24**] and [**4-26**].
Colchicine which was started [**4-21**] was likely causing diarrhea.
On HD 10 the patient passed multiple clots per rectum and had a
Hct drop. She was transferred to the ICU and was transfused 6
Units of FFP and 6 Units of PRBC's. Her Hct stabalized at 30 and
she did not require any further transfusions after HD 12. A
colonoscopy done on [**4-26**] was significant for friability and
ulceration in the distal transverse colon, splenic flexure and
proximal descending colon compatible with ischemic colitis. Tube
feedings were stopped allowing for bowel rest. On [**4-29**],
hepatology was consulted to place post pyloric feeding tube. on
[**5-1**] a feeding tube was placed and tube feeds were advanced
slowly during the remainder of her stay. At the time of
discharge her tube feeds were to goal. Peptamen 1.5 3/4 strength
@ 60cc/hr. She should continue daily calorie counts.
5. GU: diuresed with furosemide, Metolazone and Chlorothiazide.
Creatinine was 1.7 on admit. This trended down to 1.1 but
trended up again to 1.9 after the LGI bleed. At the time of
discharge her CR was at baseline.
6. HEM/ID: on admit WBC was 35K with fever of 102.4. She was
treated on Meropenem for ESBL Klebsiella UTI from her UCx on
[**4-12**]. Meropenum was given from [**4-17**] thru [**4-22**]. Vancomycin was
added empirically and given for 6 days ([**4-17**] thru [**4-22**]) for
presumed pneumonia. Serum WBC trended down to 16. Blood cultures
from [**4-16**] were negative. As discussed above her Hct dropped [**3-12**] a
lower GI bleed and stabalized after multiple transfussions.
Cipro and Flagyl were started and should complete a 14 day
course.
7. Musculoskeletal: She complained of increased discomfort in
wrists. Rheumatology was consulted and felt that she likely had
a gout flare. Recommendations were to increase her prednisone to
10mg per day and start colchicine daily. Joint pain decreased.
Prednisone was tapered to 5mg daily. Colchicine was stopped due
to an increase in her Cr, therefore prednisone was increased to
10 mg daily with good effect
8. Immunosuppression: Prograf levels were monitored closely
during this admission. Dosing based on levels. MMF was kept at
500 [**Hospital1 **] and prednisone dosing as discussed under MS is 10 mg at
discharge.
Medications on Admission:
Albuterol neb q6 prn, amlodipine 10mg', aripiprazole 5mg'',
carvedilol 25mg'', Plavix 75mg', desvenlafaxine ER 50mg', [**Hospital1 11573**]
120mg qAM/80mg qPM, insulin glargine 30units qAM & qHS,
ipratropium neb q6 prn, Prevacid 30mg', Keppra 500mg'', Ativan
0.5mg [**Hospital1 **] prn anxiety, meropenem 1gm q8 (started [**4-14**]), MMF
500'', prilosec 20mg', zofran
8mg q8 prn, oxycodone 5-10mg q4prn, pred 2.5mg', bactrim
ss',FK [**2-8**], trazodone 25 qhs, ursodiol 300mg'', ASA 325mg'',
calicum 500+D 2tab', ferrous sulfate 325mg', miconazole TP",
insulin regular ss
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (4) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
2. carvedilol 25 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO twice a day.
3. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (4) **]:
Two (2) Puff Inhalation QID (4 times a day) as needed for
wheezing.
4. levetiracetam 500 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2
times a day).
5. lorazepam 0.5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
6. mycophenolate mofetil 500 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO
BID (2 times a day).
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Month/Day (4) **]: One (1)
Tablet PO DAILY (Daily).
8. miconazole nitrate 2 % Powder [**Month/Day (4) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day): To groin area.
9. trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime).
10. ursodiol 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times
a day).
11. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
13. prednisone 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
14. furosemide 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
15. clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
16. aripiprazole 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
17. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
18. ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: End date [**5-9**].
19. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
20. insulin glargine 100 unit/mL Solution [**Month/Day (4) **]: Thirty Two (32)
units Subcutaneous once a day: AM dose
34 Units PM dose
Please see printout.
21. insulin lispro 100 unit/mL Solution [**Month/Day (4) **]: per sliding scale
Subcutaneous four times a day: Follow sliding scale per FSBS.
22. tacrolimus 0.5 mg Capsule [**Month/Day (4) **]: One (1) Capsule PO Q12H
(every 12 hours): Check levels Monday/Thursday. Dose changed by
transplant clinic only.
23. metronidazole 500 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q8H
(every 8 hours) for 4 days: End date [**2155-5-11**].
24. venlafaxine 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]- [**Hospital1 8**]
Discharge Diagnosis:
chf (Diastolic dysfunction)
uti
gout flare
h/o liver/kidney transplant
GI bleed/colitis
occlusive and nonocclusive thrombus in left basilic vein. (PICC
removed)
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 will be transferring to [**Hospital3 **] in [**Hospital1 8**]
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any
of the following: fever, chills, nausea, vomiting, jaundice,
increased fluid retention, decreased urine output, increased
pain over the graft kidney or abdominal pain
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, Phone [**Telephone/Fax (1) 673**], [**Hospital **] Medical
Building [**First Name8 (NamePattern2) **] [**Location (un) 86**], Date/Time: [**2155-5-14**] 11:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2155-5-15**] 8:30am
[**2155-5-15**] 10:00a ECHO EAST-GRYZ-4 [**Hospital Ward Name **] BUILDING [**Location (un) **]
CARDIOLOGY ECHO LAB
[**2155-5-28**] 09:00a Dr [**First Name (STitle) **] (Cardiology) [**Hospital Ward Name **] CLIN CTR, [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2155-5-7**]
ICD9 Codes: 486, 5990, 5849, 4280, 3572, 4019, 2724, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4191
} | Medical Text: Admission Date: [**2158-10-5**] Discharge Date: [**2158-10-10**]
Date of Birth: [**2101-4-8**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Penicillins / Chocolate Flavor / Erythromycin Base /
Tape [**12-18**] / Monosodium Glutamate / Mold Extracts / Oxycodone / IV
Dye, Iodine Containing Contrast Media / Iodine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Left sided thoracentesis
History of Present Illness:
Pt is a 57yo woman with RCC metastatic to lungs with recent
progression of disease in the area of the right mainstem
bronchus, s/p mechanical debridement of endobronchial exophytic
lesion, now being transferred from [**Hospital6 15083**] with
SOB. She has a h/o recurrent pleural effusions and has baseline
DOE. She was recently admitted [**Date range (1) 17949**] with dyspnea at rest,
cough, and chest pressure, and was found to have a pericardial
effusion with tamponade physiology. She required
pericardiocentesis and [**Date range (1) 19843**] placement with improvement, and
chemotherapy was restarted prior to discharge.
Yesterday, she was experiencing worsening of her respiratory
distress, so she was taken to [**Hospital6 15083**] ED and was
admitted. Labs were unremarkable including a negative troponin,
although BNP was elevatd at 361. Her dyspnea was thought to be
multifactorial, related to pleural effusion, atelectasis,
pericardial effusion, and pulmonary masses. TTE showed a
moderate pericardial effusion without hemodynamic significance.
V/Q scan was low to intermediate probability for pulmonary
embolus, and CXR and CT revealed progression of large soft
tissue mass with atelectasis and increased loculated right
pleural effusion. She is transferred here for further care.
Currently, her breathing is somewhat improved. She endorses
chest congestion and cough that is sometimes productive of a
yellow sputum. She also endorses occasional wheezing. Denies
chest pain, abdominal pain, or vomiting, but endorses nausea.
She feels very tired, but generally feels improved since
restarting her Sutent a few days ago.
ROS: Appetite is poor, and she has a headache that is less
severe than a migraine. Reports weight loss over the last six
months. No fevers, chills, palpitations, dysuria, rashes,
arthralgias, myalgias. Otherwise negative in complete detail.
Past Medical History:
ONCOLOGIC HISTORY:
- [**9-/2151**] CT scan showed Large left renal mass. MRI/MRV
demonstrated a large 7.5 cm left lower pole mass, with no
filling
defect of the left renal vein. Bone scan negative for osseous
metastases.
- [**2151-10-13**]: Left nephrectomy/adrenalectomy. Pathology: 5.5 cm
mass, extending locally beyond the capsule, [**Last Name (un) 19076**] grade II to
III, not extending beyond Gerota's fascia. Venous invasion was
present; the renal vein margin was negative. There were negative
margins and negative adrenal glands. (pT3a Nx Mx)
- [**2154-2-8**]: A CT scan demonstrated multiple bilateral pulmonary
nodules, the largest 7 mm in diameter.
- [**2154-3-4**] PET scan: Multiple pulmonary nodules and posterior
cervical lymphadenopathy.
- [**2154-4-5**]: Video-assisted thoracoscopic right lower lobe and
right middle lobe wedge resections and mediastinal lymph node
dissection. Pathology confirmed the presence of metastatic
carcinoma of renal origin in the two wedge resections and in the
level 8R paraesophageal lymph node.
- [**2154-8-26**]: Cycle 1, Weeks [**12-18**] of high-dose IL-2 ([**11-29**] and
[**4-29**] doses received).
- [**2154-10-14**] CT scan: Increase in the size of a right
infra-hilar
lymph node. Decrease in size of numerous small pulmonary
nodules.
- [**2154-11-11**] CT scan: Right hilar lymph node slightly increased
in
size. Stable tiny pulmonary nodules as well as nodular scarring
in the right lower lobe.
- [**2154-12-18**] CT torso showed slight increase in dominant right
infrahilar mass when measured in the axial plane compared to the
prior two exams.
- [**2155-1-2**]: Flexible bronchoscopy revealed extrinsic
compression, with near complete occlusion of the
anterior segment of the right lower lobe bronchus and mucoid
secretions emanating from the superior segment of the right
lower
lobe. Transbronchial needle aspiration was performed x3 with
pathology revealing atypical clusters of epithelioid cells
suspicious for metastatic renal cell carcinoma. In addition,
bronchial washings and brushings were obtained, revealing
atypical cells in scattered clusters.
- [**2155-1-29**]: Flexible bronchoscopy and video-assisted thoracic
surgery with right lower lobe wedge resection and intralobar
pulmonary artery lymph node excision. Pathology revealed lymph
node fragments with metastatic carcinoma consistent with renal
cell carcinoma. The excised fragment of the right lower lobe
demonstrated no evidence of malignancy.
- [**3-/2155**]: Cycle 2, Weeks [**12-18**] high-dose IL-2 ([**8-30**] and [**4-29**] doses
received)
- [**2155-9-8**] - [**2156-5-24**]: Multiple CT Torso showing gradual
growth of right hilar lymphadenopathy.
- [**2156-7-19**]: Began therapy with MDX 1411 on Phase I protocol 08-209
- [**2156-10-18**]: Began palliative sunitinib after scans showed disease
progression with MDX 1411; needed to terminate first cycle one
week early due to severe thrombocytopenia (platelets 27k). Began
cycle 2 on [**2156-11-29**] at reduced dose of 37.5 mg daily. Began
cycle
3 on [**2157-1-10**] at 25 mg daily.
- [**2157-3-19**]: Switched to pazopanib because of progressive
difficulties tolerating sunitinib (and progressing disease on
lower doses of sunitinib); dose reduced to 600 mg daily due to
side effect. On [**6-8**] pazopanib dose was increased to 800 mg
daily
considering worsening clinical symptoms.
- [**2157-7-25**] CT TORSO shows overall improvement of pulmonary
nodules and hilar lymphadenopathy
- [**2157-9-8**] CT TORSO shows disease progression
- [**2157-9-12**] bronchoscopy showed tumor infiltration of the
endobronchial mucosa throughout the right main stem and bronchus
intermedius. Endobronchial exophytic lesion partially
obstructing the opening of the right main stem, which was
mechanically debrided.
- [**0-0-**] external beam radiation to the lesion in
the R hilum. [**0-0-**] additional palliative XRT
- [**2158-9-16**] everolimus
- [**2157-12-7**] - [**2158-3-27**] Avastin, d/c due to worsening symptoms
- [**2158-3-30**] CT torso shows disease progression
- [**4-18**] start Gemcitabine 750 mg/m2 D1 and D8 q21d, [**4-20**] start
Sutent 25 mg 2 weeks ON 1 week OFF
- [**7-3**] - Progression of pulmonary disease on gemcitabine/sutent,
but patient experiencing symptomatic improvement.
- [**7-10**] - C4D1 gemzar/sutent
- [**2158-7-24**] - C4D15 gemzar/sutent
- [**2158-8-9**] - Rigid bronchoscopy and tumor debridement
- [**2158-8-14**] - C5D15 gemzar/sutent
- [**2158-8-28**] - C6D1
Past Medical History:
- osteoarthritis of her lower spine
- asthma
- cluster migraines
Social History:
Ms. [**Known lastname 38472**] is married and lives with her husband. She worked as
a phlebotomist part time. She used to smoke one to one and a
half packs per day for 25 years, but quit at the age of 38.
Family History:
Ms. [**Known lastname 57098**] family history is largely unknown as she was
adopted. Her son was [**Name2 (NI) **] with spina bifida and her daughter had
mitral valve prolapse.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 97.0F, BP 122/88, HR 103, R 20, SaO2 99% 2L
General: chronically-ill appearing woman in NAD, comfortable,
appropriate
HEENT: NC/AT, PERRL/EOMI, sclerae anicteric, dry MM, OP clear
Neck: supple, no LAD or thyromegaly
Lungs: decreased BS at right base, mild bibasilar crackles
Heart: RRR, nl S1-S2, no MRG
Abdomen: +BS, soft/NT/ND, no palpable masses or HSM
Extrem: WWP, no c/c/e
Skin: no concerning rashes or lesions
Neuro: non-focal
.
DISCHARGE EXAM:
Tcurrent: 36.7 ??????C (98 ??????F)
HR: 100 (91 - 110) bpm
BP: 120/76(87) {111/64(77) - 136/87(94)} mmHg
RR: 18 (14 - 28) insp/min
SpO2: 97%
General: Very well appearing, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: No accessory muscle use. Clear to auscultation
bilaterally, no wheezing
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops; pulsus 10
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:
[**2158-10-5**] LABS OSH:
WBC 4.2, Hgb 10.1 / Hct 30.9 (MCV 102.5, RDW 20.2), Plt 187
Na 137, K 4.2, Cl 101, CO2 27, BUN 6, Cr 0.79, Glucose 81, Ca
8.3
ALT 14, AST 28, Alk Phos 103, TBili 0.7, LDH 325
BNP 361, trop 0.04
Labs on admission:
[**2158-10-6**] 07:40AM BLOOD WBC-4.1 RBC-3.29*# Hgb-11.2*# Hct-34.7*#
MCV-106* MCH-34.1* MCHC-32.3 RDW-18.1* Plt Ct-231
[**2158-10-6**] 07:40AM BLOOD Neuts-85.8* Lymphs-7.2* Monos-5.7 Eos-0.9
Baso-0.4
[**2158-10-6**] 07:40AM BLOOD PT-14.3* PTT-38.0* INR(PT)-1.2*
[**2158-10-6**] 07:40AM BLOOD Glucose-85 UreaN-6 Creat-0.6 Na-138 K-4.2
Cl-101 HCO3-28 AnGap-13
[**2158-10-6**] 07:40AM BLOOD ALT-14 AST-31 AlkPhos-108* TotBili-0.4
[**2158-10-6**] 07:40AM BLOOD Albumin-2.9* Calcium-8.7 Phos-2.4* Mg-2.0
[**2158-10-7**] 04:49PM BLOOD Type-ART pO2-143* pCO2-38 pH-7.39
calTCO2-24 Base XS--1
[**2158-10-7**] 04:49PM BLOOD Lactate-1.9
[**2158-10-6**] 06:16PM PLEURAL WBC-1075* RBC-2300* Polys-61* Lymphs-1*
Monos-0 Meso-4* Macro-34*
[**2158-10-6**] 06:16PM PLEURAL TotProt-2.5 Glucose-85 LD(LDH)-199
Cholest-63 Triglyc-35
[**2158-10-6**] 6:16 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2158-10-6**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2158-10-9**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2158-10-7**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Labs on discharge:
[**2158-10-10**] 03:09AM BLOOD WBC-6.6 RBC-2.84* Hgb-9.8* Hct-29.2*
MCV-103* MCH-34.6* MCHC-33.7 RDW-19.0* Plt Ct-152
[**2158-10-10**] 03:09AM BLOOD Glucose-122* UreaN-10 Creat-0.7 Na-137
K-3.4 Cl-100 HCO3-26 AnGap-14
[**2158-10-10**] 03:09AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.9
CXR [**2158-10-4**] OSH: There has been progression of the large soft
tissue mass obscuring the right hilum with resultant volume loss
and atelectasis in the right hemithorax. Right pleural effusion
has slightly increased. Left pleural effusion is not
significantly changed. Aerated left lung is clear.
CT Chest w/o Contrast [**2158-10-4**] OSH:
1. Trachea is patent.
2. Dense consolidation and partial collapse of the right lung
along with bilateral pulmonary masses. These findings are
consistent with presumed clinical history of lung cancer. The
extent of disease has significantly increased since the prior
exam.
3. Loculated pleural fluid on the right.
4. Small pericardial effusion.
5. Small left pleural effusion.
V/Q SCAN [**2158-10-5**] OSH:
1. Low to intermediate probability for PE in the left lung
(approx 20-30%). Duplex ultrasound of lower cavities may be
helpful adjunctive study.
2. Large matched defect in the right lung which corresponds to
prior imaging.
TTE [**2158-10-5**] OSH:
Fair image quality study. A moderate pericardial effusion was
identified circumferential to the heart. The greatest collection
appears along the RV wall. There is no clear hemodynamic effect
seen in by respirophasic change in mitral inflow velocities. In
addition, the IVC appears to be normal in size with
respirophasic change. These both argue against a hemodynamically
significant effusion. However, the RV appears small, markedly so
in the subcostal view, which would be consistent with increased
intrapericardial pressures.
TTE [**2158-10-6**]:
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. There is abnormal septal
motion/position. The aortic valve is not well seen. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. The mitral valve leaflets are not well seen. Trivial
mitral regurgitation is seen. There is a small pericardial
effusion, predominantly around the apex. Stranding is visualized
within the pericardial space c/w organization. No right
ventricular diastolic collapse is seen. There is minimal
respiratory variation in intracardiac flow velocities that does
not meet criteria for tamponade. Mild elevation of pulmonary
arterial systolic pressure. Echocardiographic signs of tamponade
may be absent in the presence of elevated right sided pressures.
IMPRESSION: Normal LV size and overall low-normal LV systolic
function. The study is of suboptimal technical quality and
regional dysfunction, particularly in the anterior septum,
cannot be fully excluded. Small pericardial effusion
predominantly around the apex with evidence of stranding. There
is no definitive evidence of pericardial tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2158-9-22**], there appears to be a slight increase in the size
of the pericardial effusion, also evidence of stranding and echo
density suggestive of blood, cellular elements.
CXR [**2158-10-6**]:
Moderate left pleural effusion is larger. Combination of large
central masses and right pleural or extrapleural abnormality and
severe atelectasis in the right lung is unchanged. Progressive
rightward mediastinal shift suggests combination of worsening
right-sided atelectasis and the influence of the enlarging left
pleural effusion. Heart size is indeterminate, obscured by
adjacent pleural and parenchymal abnormality.
TTE [**2158-10-7**]:
Suboptimal image quality. The estimated right atrial pressure is
5-10 mmHg. There is a small to moderate sized pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. No overt right
ventricular diastolic collapse is seen (RV not well visualized
in some views).
Compared with the prior study (images reviewed) of [**2158-10-6**],
no clear change.
CXR [**2158-10-8**]:
The degree that the left main stem bronchus is visualized, it
does appear to be somewhat narrowed, but possibly slightly
improved compared with [**2158-10-7**] at 09:42 a.m. There has been
progressive accumulation of pleural fluid at the left lung base,
with underlying collapse and/or consolidation, through the
effusion remains relatively small. Left hilum again appears
slightly prominent. Diffuse opacity in the right lung is
essentially unchanged.
IMPRESSION:
1. Possible minimal improvement in the degree of narrowing of
the left main stem bronchus.
2. Progressive slight increase in a small left effusion at the
left lung base, with underlying collapse and/or consolidation.
TTE [**2158-10-9**]:
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). The mitral
valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a small to moderate sized pericardial
effusion. The effusion appears circumferential though primarily
around the distal half of the ventricles and partially
echo-filled/organized. No right atrial or right ventricular
diastolic collapse is seen.
Compared with the prior study (images reviewed) of [**2158-10-7**],
the findings are similar.
Brief Hospital Course:
57 yo woman with RCC metastatic to lungs, with progression of
disease in the area of the right mainstem bronchus, s/p
mechanical debridement of endobronchial exophytic lesion, also
with recurrent pleural effusions and recent admission for
pericardial effusion with tamponade physiology requiring
pericardiocentesis and [**Year (4 digits) 19843**] placement, now admitted with
dyspnea.
.
ACTIVE ISSUES:
#. Dyspnea: Likely multifactorial. OSH evaluation revealed
progression of underlying pulmonary disease with increased
volume loss and atelectasis as well as bilateral pleural
effusions. Pt was transferred to [**Hospital1 18**] for further management
and underwent had left sided thoracentesis with approximately
800cc drained. She also had a V/Q scan with no evidence of PE.
Additionally, TTE revealed a moderate-sized pericardial
effusion, without evidence of tamponade physiology. On hospital
day 2, pt developed sudden worsening of shortness of breath and
difficulty breathing for which she was transferred to the
intensive care unit. She was treated for COPD exacerbation with
IV Solu-Medrol initially that was transitioned to oral
prednisone taper. Repeat TTEs did not show enlarging
pericardial effusion or tamponade. Interventional pulmonary was
consulted who felt that acute episode of dyspnea was likely from
mucus plug. Pulsus was checked daily and remained [**9-28**]. She
improved dramatically overnight and was no longer feeling
dyspneic by the next morning. She was able to be discharged from
the ICU directly to rehab.
.
CHRONIC ISSUES:
#. Headache: She was continued on home Relpax PRN
.
#. RCC: Metastatic to lungs. Feeling improved on Sutent after
restarting a few days ago. She was continued on Sutent with
close monitoring of blood counts
.
#. Hypothyroidism: continue home levothyroxine
.
TRANSITIONAL ISSUES:
Pt would like to be full code for reversible conditions.
.
Per cardiology, pt needs repeat TTE next week (Monday [**10-16**]) at
her appointment with Dr. [**Last Name (STitle) **].
Medications on Admission:
MEDICATIONS ON TRANSFER FROM [**Hospital1 **]:
- Combivent inhaler PRN
- Benzonatate 100mg TID PRN
- Colace 200mg QHS
- Synthroid 75mcg daily
- Bactroban 2% PRN
- Omeprazole 20mg daily
- Zofran 4mg Q6hrs PRN nausea
- Relpax
- Simethicone 80mg PO Q4hrs PRN
- Tessalon Pearls 1 tab Q4hours PRN cough
- Trazodone 25mg PO QHS
Discharge Medications:
1. Relpax 40 mg Tablet Sig: One (1) Tablet PO PRN (as needed) as
needed for headache.
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ipratropium bromide 0.02 % Solution Sig: One (1) spray
Inhalation PRN as needed for allergy symptoms.
4. benzonatate 100 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
5. sunitinib 25 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
8. prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: Until [**10-11**].
9. lidocaine HCl 20 mg/mL (2 %) Solution Sig: Twenty (20) mL
Injection twice a day as needed for mouth pain: Swish and spit.
10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
MASONIC [**Hospital1 **] HEALTH
Discharge Diagnosis:
PRIMARY:
respiratory distress due to pleural effusions, mucus plugging
and COPD exacerbation
SECONDARY:
pericardial effusion
metastatic renal cell carcinoma
hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 38472**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because of increasing
shortness of breath. You had some fluid drained from your lungs,
though you continued to having trouble with your breathing. For
this reason, you were transfered to the intensive care unit. We
managed your breathing with nebulizer treatments and steroids.
Please make the following changes to your medications:
1. START prednisone 20 mg on [**10-11**] and [**10-12**]. You can then stop
the prednisone.
Please continue all other medications as prescribed.
You should have a repeat ECHO at your appointment with Dr.
[**Last Name (STitle) **] next week. In the interim, please call your doctor
immediately if you notice increasing shortness of breath or
difficulty breathing.
Followup Instructions:
Department: RADIOLOGY
When: TUESDAY [**2158-10-24**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2158-10-24**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2158-10-16**] at 3:00 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2158-10-10**]
ICD9 Codes: 5180, 2762, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4192
} | Medical Text: Admission Date: [**2161-10-5**] Discharge Date: [**2161-10-9**]
Date of Birth: [**2099-7-19**] Sex: M
Service: CSU
Mr. [**Known lastname **] is a 62-year-old man who was a direct admission to
the Operating Room, where he underwent coronary artery bypass
grafting.
HISTORY OF PRESENT ILLNESS: This is a 62-year-old man who
has no prior history of coronary artery disease who had an
abnormal EKG during a routine physical exam prompting a
further workup echo that revealed an ejection fraction of 40
percent. An ETT done on [**2161-9-25**] was stopped secondary to
EKG changes with ST depressions in the inferior leads and
inferoseptal hypokinesis as well as chest heaviness. MIBI at
that time showed an ejection fraction of 36 percent. He
reports increasing fatigue over the past year with increased
diaphoresis and chest heaviness with exertion over the past
several months. Denies any shortness of breath at rest.
Catheterization done on [**2161-10-2**] showed an ejection
fraction of 43 percent with inferior hypokinesis and mid
right coronary artery 100 percent lesion, proximal left
anterior descending 85 percent lesion, diagonal with an 85
percent lesion, and obtuse marginal with an 80 percent
lesion.
PAST MEDICAL HISTORY: Significant for hypertension,
hypercholesterolemia, and osteoarthritis of the back and hip
as well as right shoulder surgery.
ALLERGIES: No known drug allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Aspirin 325 q.d.
2. Lisinopril 5 q.d.
3. Celebrex 200 q.d.
4. Crestor 10 q.d.
SOCIAL HISTORY: Lives with his wife. [**Name (NI) **] is very active.
Works as a landscaper and a carpenter. Wife was a nurse.
Alcohol: 8 to 10 beers a day. Tobacco: Quit 8 years ago;
prior to that, 60 plus pack-year history.
FAMILY HISTORY: None known.
REVIEW OF SYSTEMS: Noncontributory.
PHYSICAL EXAMINATION: Height: 5 feet, 7 inches. Weight:
165 pounds. Vital signs: Heart rate 76, blood pressure
140/82, respiratory rate 20. General: Lying flat in bed, in
no acute distress. Neurologically: Alert and oriented times
three, grossly intact. HEENT: Anicteric, non-injected.
Neck is supple; no lymphadenopathy; no bruits. Respiratory:
Clear to auscultation. Cardiovascular: Regular rate and
rhythm; S1, S2 with no murmurs, rubs, or gallops. Abdomen is
soft and nontender, nondistended, with positive bowel sounds.
Extremities are warm and well perfused with no edema.
Pulses: 2 plus radials bilaterally, 2 plus dorsalis pedis, 1
plus posterior tibial bilaterally, right femoral 1 plus, left
femoral 2 plus.
LABORATORY DATA: White count 6, hematocrit 37, platelets
185, PT is 13.8, PTT 33.7, INR 1.2, sodium 130, potassium
4.0, chloride 100, CO2 22, BUN 21, creatinine 0.9, glucose
135, ALT 21, AST 17, alkaline phosphatase 57, amylase 100,
total bilirubin 0.6, albumin 4.0.
Chest x-ray shows no acute cardiopulmonary process.
Urinalysis at that time was negative.
EKG: Sinus rhythm at a rate of 80, Q waves in II, III, and
F, flipped Ts in II, III, F, V5 and 6.
HOSPITAL COURSE: As stated previously, the patient was a
direct admission to the Operating Room on [**2161-10-5**]. Please
see the Operating Room report for full details and summary.
The patient had a coronary artery bypass graft times four
with a left internal mammary artery to the left anterior
descending, saphenous vein graft to diagonal, saphenous vein
graft to obtuse marginal, and saphenous vein graft to right
coronary artery. His bypass time was 84 minutes with a cross-
clamp time of 71 minutes. He tolerated the operation well
and was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit. At the time of transfer
the patient was A paced at 90 beats per minute. He had a
mean arterial pressure of 74 with a CVP of 5. He had Neo-
Synephrine at 0.2 mcg/kg/minute as well as propofol at 20
mcg/kg per minute. Patient did well in the immediate
postoperative period. His anesthesia was reversed. He was
weaned from the ventilator and successfully extubated. He
remained hemodynamically stable throughout the remainder of
his operative day only requiring Neo-Synephrine for blood
pressure support.
Patient remained hemodynamically stable throughout
postoperative day 1. However, he was able to be weaned off
of his Neo-Synephrine drip during that period of time. On
postoperative day 2 the patient remained hemodynamically
stable. His chest tubes were removed and he was transferred
to the floor for continuing postoperative care and cardiac
rehabilitation.
[**Hospital **] hospital course on the floor was uneventful. With
the assistance of the nursing staff and Physical Therapy
staff his activity was advanced on a daily basis. On
postoperative day 3 his temporary pacing wires were removed,
and on postoperative day 4 it was decided that the patient
was stable and ready to be discharged to home. At this time
the patient's physical exam is as follows: Temperature 97,
heart rate 83 sinus rhythm, blood pressure 100/60,
respiratory rate 18, O2 sat 96 percent on room air, weight
today 74.9, preoperatively 75.
LABORATORY DATA: White count 9, hematocrit 26.7, platelets
179, sodium 138, potassium 3.9, chloride 100, CO2 29, BUN 25,
creatinine 1.1, glucose 104.
PHYSICAL EXAMINATION: Neurologically alert and oriented
times three. Moves all extremities, follows commands.
Respiratory: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm; S1, S2 with no
murmurs. Sternum is stable. Incision with Steri-Strips,
open to air, clean and dry. Abdomen is soft, nontender,
nondistended with normoactive bowel sounds. Extremities are
warm, well perfused with no edema. Left leg endoscopic
harvest site with Steri-Strips open to air, clean and dry.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES: Coronary artery disease status post
coronary artery bypass grafting times 4 with a left internal
mammary artery to the left anterior descending, saphenous
vein graft to diagonal, saphenous vein graft to obtuse
marginal, and saphenous vein graft to right coronary artery.
Hypertension.
Hypercholesterolemia.
Osteoarthritis of back and hip.
Status post right shoulder surgery.
DISPOSITION: Discharged to home.
FOLLOW UP: He is to have follow up with Dr. [**Last Name (STitle) **] in 2 to 3
weeks.
Follow up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] 2 to 3 weeks.
Follow up with Dr. [**Last Name (STitle) **] in 4 weeks.
DISCHARGE MEDICATIONS:
1. Aspirin 325 q.d.
2. Crestor 10 mg q.d.
3. Metoprolol 25 b.i.d.
4. Percocet 5/325 1 to 2 tabs q. 4 to 6 h. as needed.
5. Additionally, the patient can resume his Celebrex 200 mg
q.d.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2161-10-9**] 12:54:26
T: [**2161-10-9**] 14:42:17
Job#: [**Job Number 58221**]
ICD9 Codes: 4111, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4193
} | Medical Text: Admission Date: [**2144-3-10**] Discharge Date: [**2144-3-27**]
Date of Birth: [**2082-1-26**] Sex: F
Service: #58
CHIEF COMPLAINT: Abdominal pain, nausea, vomiting, diarrhea.
HISTORY OF PRESENT ILLNESS: This patient was transferred
from the medical service to the surgical service on [**2144-3-19**],
postoperatively. She is a 62 year old female with a history
of sarcoidosis with pulmonary involvement and hepatic
involvement who was initially admitted to the medical service
on [**2144-3-10**], with a five day history of nausea, vomiting and
diarrhea and a one day history of epigastric pain.
Right upper quadrant ultrasound showed at the time showed a
thickened gallbladder with a common bile duct of 1.2
centimeters and elevated liver enzymes. Of note, her liver
enzymes have been elevated in the past. She underwent an
endoscopic retrograde cholangiopancreatography which showed
portal hypertensive gastropathy and compression of the portal
vein by the common bile duct without any stones.
She was treated with antibiotics and then underwent a MRCP.
She continued to have crampy abdominal pain and a CT scan of
the abdomen was performed on [**2144-3-12**], which showed ascites
and a large ventral hernia.
She was seen by the hepatology service at this point
regarding operative risks for possible hernia repair. The
hepatology consult suggested 30% risk mortality and also
suggested conservative treatment with Actigall, Aldactone and
paracentesis.
She continued to have emesis and a nasogastric tube was
placed by Dr. [**Last Name (STitle) 519**] on [**2144-3-13**]. She continued to have high
nasogastric output and pain and nausea and then underwent an
upper gastrointestinal and small bowel follow through on
[**2144-3-18**], which revealed high grade ileal obstruction. At
this point, the decision was made to operate on her and she
was subsequently transferred to the surgical service
postoperatively.
PAST MEDICAL HISTORY:
1. Sarcoidosis with pulmonary and hepatic involvement
diagnosed in [**2137**], and treated with steroids.
2. Cirrhosis diagnosed [**10-30**], by CT with grade II esophageal
varices.
3. Osteoporosis.
4. Cholelithiasis diagnosed [**10-30**], on CT.
5. Hypertension.
6. Hypercholesterolemia.
7. Aortic stenosis with left ventricular dysfunction.
8. Status post umbilical hernia repair.
9. Hip fracture, status post open reduction, internal
fixation on [**2142**].
10. Right total knee replacement [**2141**].
11. Right total hip replacement in [**2133**].
12. Status post total abdominal hysterectomy with bilateral
salpingo-oophorectomy.
13. Bilateral cataracts.
MEDICATIONS ON TRANSFER TO SERVICE:
1. Actigall 300 mg p.o. t.i.d.
2. Aldactone 50 mg p.o. q.d.
3. Hydrocortisone 25 mg b.i.d.
4. Protonix 40 mg p.o. q.d.
5. Toradol.
6. Zofran.
MEDICATIONS AS OUTPATIENT.
1. Evista.
2. Prednisone 10 mg p.o. q.d.
HOSPITAL COURSE: The patient underwent an exploratory
laparotomy with ventral herniorrhaphy with competent
separation and lysis of adhesions on [**2144-3-19**].
Postoperatively, she was transferred to the Intensive Care
Unit intubated because of her prior history. She was stable
overnight and was extubated in the early a.m. of [**2144-3-20**].
She continued to be stable and was deemed ready for discharge
to the regular floor on [**2144-3-21**].
Subsequently, her postoperative course has been
uncomplicated. She was started on sips on [**2144-3-23**], after
passing flatus and having a bowel movement. She tolerated
the sips well. She was on peripheral nutrition during this
time. She was slowly advanced over the next couple of days
to a regular diet which she tolerated well.
She did have some ascites which had slightly increased in
size postoperatively. She has two [**Location (un) 1661**]-[**Location (un) 1662**] drains in
the abdomen which have been draining probable ascitic fluid.
She continues to be followed by the liver service while on
the floor postoperatively.
She was deemed ready for discharge by both services on
[**2144-3-27**]. She was discharged home with the [**Location (un) 1661**]-[**Location (un) 1662**] in
situ with a plan to discontinue them during the postoperative
visit. She had a visiting nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 1661**]-[**Location (un) 1662**] care.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. q.d.
2. Lopressor 12.5 mg p.o. b.i.d.
3. Aldactone 50 mg p.o. b.i.d.
4. Prednisone 10 mg p.o. b.i.d. times two days and then 10
mg p.o. q.d.
5. Protonix 40 mg p.o. q.d.
6. Actigall 300 mg p.o. t.i.d.
TREATMENT: She is to have q.d. dressing changes to
[**Location (un) 1661**]-[**Location (un) 1662**] sites by VNA. Record [**Location (un) 1661**]-[**Location (un) 1662**] output.
FOLLOW-UP:
1. Dr. [**Last Name (STitle) 519**] on [**2144-4-10**], at 9:45 a.m.
2. Follow-up with the liver service, appointment set up.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2144-3-28**] 09:18
T: [**2144-3-29**] 10:46
JOB#: [**Job Number 12568**]
ICD9 Codes: 5715, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4194
} | Medical Text: Admission Date: [**2156-2-1**] Discharge Date: [**2156-2-3**]
Date of Birth: [**2071-4-16**] Sex: M
Service: SURGERY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 year-old male h/o COPD, HTN who presented to [**Hospital3 417**]
Hospital with sudden onset back pain on [**2156-1-31**]. He reports that
he was answering the phone
yesterday at approximately 10AM when there was sudden severe
midline upper back. The pain resolved, however, recurred 2
hours later. He notified his primary care, who is also a
cardiologist, who sent him to [**Hospital3 417**] Hospital. He
underwent a CT scan there which showed a type B dissection
starting that the takeoff of the left subclavian enxtending to
the origin of the celiac trunk, with it originating off the true
axis. He was transferred to [**Hospital1 18**] on [**2156-2-1**] for further
management.
Currently, he reports resolution of his pain symptoms. HE has
no
other complaints. His initial presenting blood pressure here
was
162/91.
Past Medical History:
Hypertension
Hyperlipidemia
Chronic Obstructive Pulmonary Disease
Right Total knee replacement
[**2119**] sigmoidectomy for diverticulitis
TURP
Social History:
SOCIAL HISTORY:
EtOH use: wine 3x/day
Tobacco use: Denies
Previous smoker: Last smoked when cigarettes were 50cents per
pack.
Recreational drugs (marijuana, heroin, crack pills or
other):Denies
Marital status: Lives alone but has 4 daughters who assist.
Occupation: Previously a teamster.
Family History:
Non-contributory
Physical Exam:
Admission:
PHYSICAL EXAM
Temp: 97.0 75 99/56 22 97% on 2 liters nasal cannula
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, No
hepatosplenomegally, No hernia, No AAA. Well-healed midline
abdominal incision.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, No skin changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P. Ulnar: P.
LUE Radial: P. Ulnar: P.
RLE Femoral: P. Popiteal: P. DP: P. PT: P.
LLE Femoral: P. Popiteal: P. DP: P. PT: P.
Discharge:
Pertinent Results:
[**2156-2-1**] 04:45AM BLOOD WBC-12.9* RBC-4.32* Hgb-13.4* Hct-37.1*
MCV-86 MCH-30.9 MCHC-36.0* RDW-13.4 Plt Ct-195
[**2156-2-2**] 02:20AM BLOOD WBC-10.3 RBC-3.76* Hgb-11.8* Hct-33.1*
MCV-88 MCH-31.4 MCHC-35.7* RDW-13.3 Plt Ct-176
[**2156-2-3**] 07:40AM BLOOD WBC-10.2 RBC-3.89* Hgb-11.9* Hct-34.2*
MCV-88 MCH-30.5 MCHC-34.8 RDW-13.5 Plt Ct-173
[**2156-2-1**] 04:45AM BLOOD Neuts-82.7* Lymphs-11.3* Monos-5.7
Eos-0.1 Baso-0.2
[**2156-2-1**] 04:45AM BLOOD PT-15.5* PTT-25.3 INR(PT)-1.4*
[**2156-2-1**] 04:45AM BLOOD Plt Ct-195
[**2156-2-3**] 07:40AM BLOOD Plt Ct-173
[**2156-2-1**] 04:45AM BLOOD Glucose-163* UreaN-17 Creat-1.0 Na-136
K-4.2 Cl-97 HCO3-28 AnGap-15
[**2156-2-2**] 02:20AM BLOOD Glucose-155* UreaN-24* Creat-1.5* Na-134
K-4.2 Cl-97 HCO3-26 AnGap-15
[**2156-2-2**] 05:35PM BLOOD Glucose-128* UreaN-31* Creat-1.4* Na-135
K-4.3 Cl-96 HCO3-29 AnGap-14
[**2156-2-3**] 07:40AM BLOOD Glucose-153* UreaN-27* Creat-1.2 Na-137
K-4.3 Cl-96 HCO3-30 AnGap-15
[**2156-2-1**] 01:27PM BLOOD CK(CPK)-54
[**2156-2-1**] 08:09PM BLOOD CK(CPK)-54
[**2156-2-2**] 02:20AM BLOOD CK(CPK)-62
[**2156-2-1**] 04:45AM BLOOD cTropnT-0.01
[**2156-2-1**] 01:27PM BLOOD CK-MB-3 cTropnT-0.03*
[**2156-2-1**] 08:09PM BLOOD CK-MB-3 cTropnT-0.03*
[**2156-2-2**] 02:20AM BLOOD CK-MB-3 cTropnT-0.02*
[**2156-2-3**] 07:40AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.2
[**2156-2-2**]:FINDINGS:
CT CHEST: Within the lung parenchyma, there is a small left
pleural effusion as well as associated compressive atelectasis.
Dependent atelectasis on the right is also present. Several
pleural-based calcifications are noted posteriorly. No
pneumothorax is seen. The airways are patent to the segmental
level. No pathologically enlarged lymph nodes are seen. There
are aortic and coronary artery vascular calcifications. No
pericardial effusion is seen. Please see below for CT
angiography.
CT ABDOMEN AND PELVIS: There is fatty deposition within the
liver. The
patient is status post cholecystectomy. The spleen, pancreas,
and adrenal
glands appear grossly normal. The kidneys contain multiple
hypodensities,
incompletely characterized on this examination. A 2.8 cm
hypodensity in the right kidney (4:136) is most compatible with
a simple cyst. Multiple
additional hypodensities are incompletely evaluated. Loops of
small and large bowel are of normal size and caliber.
Within the pelvis, distal loops of large bowel and rectum appear
grossly
unremarkable. There is colonic diverticulosis. The bladder and
distal
ureters are normal. The prostate gland is enlarged measuring up
to 5.5 cm in diameter. No free air, free fluid, or
lymphadenopathy is seen. There is a fat-containg right inguinal
hernia.
BONE WINDOWS: No concerning osseous lesion is seen.
CTA: Again seen is a thoracic aortic aneurysm beginning distal
to the origin of the left subclavian artery (type B). Multiple
mural calcifications are noted at the origin of the dissection
and along the true lumen. The dissection extends to the level of
the origin of the celiac artery. The celiac artery itself has
several calcifications with some narrowing at the origin;
however, appears to opacify with contrastand likely originates
from the true lumen.
The superior mesenteric artery, bilateral renal arteries, and
inferior
mesenteric artery are patent and are supplied by the true lumen.
There is
mild narrowing of the right renal artery due to atherosclerosis
at the origin. The false lumen does opacify with contrast,
though to a lesser extent. At the level of the aortic hiatus,
there is non-opacification of the false lumen suggesting the
presence of thrombus. The overall diameter of the aorta at the
level of the hiatus measures 3.9 x 3.9 cm (4:95), aneurysmal.
Vascular calcifications extend throughout the aorta into the
bilateral iliac arteries. The iliac arteries measure up to 1.6
cm bilaterally, mildly aneurysmal.
Incidental note is made of a common origin of the
brachiocephalic artery and left common carotid artery (bovine
arch configuration). The origin of the common hepatic artery is
off the superior mesenteric artery.
IMPRESSION: Type B aortic dissection extending from just distal
to the origin of the left subclavian artery to the level of the
celiac artery, which appears mildly narrowed. Partial thrombosis
of the false lumen. Mild narrowing of right renal artery due to
atherosclerosis.
Brief Hospital Course:
Mr. [**Known lastname 90109**] was admitted to the ICU on [**2156-2-1**] for Type B
dissection of the aorta without aortic leak (takeoff of left
subclavian to celiac axis) for blood pressure control. He was
initially started on Esmolol and Nipride drips in the Emergency
Room, which were weaned off and changed to labetolol drip for
goal SBP less than 120. A radial A-line was placed and his blood
pressure was closely monitored. He ruled out for a myocardial
infarction. He was started on an increased dose of metoprolol,
in an addition to his home medications and the labetolol was
weaned off. On HD 2, his creatinine peaked at 1.5. There was
concern for extension of dissection to renal arteries, so repeat
CTA was performed. Repeat CTA was unchanged. His renal
insuffiency was then thought to be due to dye load for CTA, so
he received sodium bicarbonate, mucomyst, and IV fluid and
creatinine trended down to 1.2. His diet was advanced and he was
transferred to the floor on [**2-2**] for further monitoring. At the
time of discharge on HD 3, his systolic blood pressure ranged
between 120-140 and creatinine was stable at 1.2.
Medications on Admission:
Pravastatin 40mg daily
Accupril 40mg daily
Metoprolol 75mg [**Hospital1 **]
Flexeril 10mg daily
Lasix 20mg daily
Vicodin 500-5mg prn
Discharge Medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Accupril 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Blood Pressure Machine
Please check your blood pressure once or twice a day with a home
machine. Your systolic blood pressure (the top number) should be
less than 140. Please call your primary care doctor if it is
greater than 140, as your medications may need to be changed.
5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO three
times a day.
Disp:*135 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Type B Aortic Dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Discharge Instructions
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower
?????? No heavy lifting, pushing or pulling (greater than 5 lbs),
exercise, or shoveling until you follow up with Dr. [**Last Name (STitle) 1391**].
When you see him, you need to re-address your weight lifting/
and exercise restrictions with Dr. [**Last Name (STitle) 1391**]
?????? Call and schedule an appointment to be seen in 4 weeks for
follow up visit and repeat CTA
What to report to office:
?????? Pain in your jaw, neck, upper back (or other part of your
back), or chest
?????? Coughing, hoarseness, or trouble breathing
?????? Numbness, coldness or pain in lower extremities
?????? Blood Pressure greater than 140. It is important to keep your
systolic Blood pressure(top number)less than 140 to prevent
further dissection or rupture.
Followup Instructions:
Please make an appointment to see Dr. [**Last Name (STitle) **] in [**12-14**] weeks.
Please call to make an appointment to see Dr. [**Last Name (STitle) 1391**] in one
month-[**Telephone/Fax (1) 1393**]. His office will also set you up to have a
CAT scan prior to that visit.
Completed by:[**2156-2-3**]
ICD9 Codes: 4019, 2724, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4195
} | Medical Text: Admission Date: [**2180-3-29**] Discharge Date: [**2180-4-13**]
Date of Birth: [**2110-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Dyspnea, Acute Renal Failure
Major Surgical or Invasive Procedure:
Temporary Dialysis Catheter Placement
Tunneled Dialysis Catheter Placement
Central Venous Line Placement
History of Present Illness:
Mr. [**Known lastname **] is a 69 yo M with h/o CKD stage IV, HTN, DM2,
Hyperlipidemia presented to [**Location (un) **] ED with weakness, nausea for
several days. Also noted poor appetite, shortness of breath
worsened by exertion, chest pain and cough prodcutive of clear
sputum. Also with two loose stools and abdominal pain. reported
fever to 103.
At [**Location (un) **] VS T 98.4, pulse 77, RR 18, BP 167/77, O2 sat 93%/RA.
CXR demonstrated RLL/RML infiltrate. Given vanc 1g, ceftriaxone
1g and levofloxacin 500mg IV for PNA. ABG 7.24/31/63/88,
admitted to ICU and intubated. Put on vent at AC Vt 600, RR 20,
FiO2 50, PEEP 5, on propofol for sedation. Lytes demonstrated Cr
8.8, BUN 133, K 5.7. ECG demonstrated no peaked T waves. Given
calcium gluconate, kayexalate. Given 200mg IV lasix and put out
200cc urine. OG output "coffee grounds materials" and he was
started on pantoprazole 40mg IV q12. Transferred to [**Hospital1 18**] for
consideration of urgent hemodialysis.
Past Medical History:
- HTN
- DM2
- CKD Stage IV (Baseline Cr 4.55)
- Atrophic left kidney
Social History:
Lives with partner in [**Name (NI) 22022**] MA, current smoker. Denies EtOH,
illicit drugs.
Family History:
Noncontributory
Physical Exam:
Admission
Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 62 (59 - 65) bpm
BP: 114/57(72) {112/57(72) - 114/59(73)} mmHg
RR: 25 (22 - 25) insp/min
SpO2: 95%
Heart rhythm: SB (Sinus Bradycardia)
Height: 72 Inch
General Appearance: Well nourished, intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Bronchial: RML)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
On discharge:
Tmax: 97.6
Tcurrent: 97.6
HR: 82 (68-82) bpm
BP: 144/83 {136/80 - 152/86} mmHg
RR: 18 (18 - 20) insp/min
SpO2: 96% RA
Heart rhythm: Irregular
Height: 72 Inch
General Appearance: Obese, edematous, but aware and appropriate
Eyes / Conjunctiva: PERRL
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), GII holosystolic
murmur RUSB
Pulmonary: no increased work of breathing, wheezes at upper lung
[**Last Name (un) 8434**], good movement of ir throughout.
Abdominal: Protuberant, soft, Non-tender, Bowel sounds present
Extremities: Diffuse edema but decreased from yesterday,
strength 4/5 throughout.
Pertinent Results:
Admission Labs:
[**2180-3-29**] 12:00AM BLOOD WBC-31.6* RBC-3.35* Hgb-10.6* Hct-31.1*
MCV-93 MCH-31.5 MCHC-34.0 RDW-14.4 Plt Ct-267
[**2180-3-29**] 12:00AM BLOOD PT-15.3* PTT-31.9 INR(PT)-1.3*
[**2180-3-29**] 12:00AM BLOOD Glucose-176* UreaN-137* Creat-9.7*
Na-130* K-5.6* Cl-97 HCO3-13* AnGap-26*
[**2180-3-29**] 12:00AM BLOOD ALT-34 AST-57* AlkPhos-85 TotBili-0.7
[**2180-3-29**] 12:00AM BLOOD Albumin-2.4* Calcium-8.9 Phos-11.7*
Mg-2.3
[**2180-3-29**] 01:00AM BLOOD Type-ART Temp-36.8 Rates-14/13 Tidal
V-500 PEEP-5 FiO2-50 pO2-87 pCO2-34* pH-7.21* calTCO2-14* Base
XS--13 Intubat-INTUBATED
Legionella Antigen positive - [**2180-3-30**]
Imaging:
CXR on admission:
An endotracheal tube lies with its tip approximately 4 cm from
the carina. An NG tube lies with its tip below the diaphragm
although the tip is not
visualized on this study. There is increased opacity at the
right base with homogenous opacification consistent with a
pleural effusion. This makes assessment of the right lung base
difficult. There are air bronchograms evident in the right lower
lung; however, this may be related to either compressive
atelectasis or pneumonia
CT Abdomen:
1. Endotracheal tube is seen 5 cm above the carina. The right
internal
jugular line is seen with the distal tip in the proximal
superior vena cava. The nasogastric tube is seen coiled with
the tip within the antrum of the stomach.
2. Complete opacification of the right lower lung lobe with a
moderate-sized pleural effusion. There is a smaller
consolidation and tiny pleural effusion at the base of the left
lung.
3. No intra-abdominal or intrapelvic source of infection. There
is
perinephric stranding seen around the right kidney as well as
free fluid
within the pelvis from likely from aggressive hydration or poor
nutritinoal status.
4. Several hypodensities seen bilaterally and a soft tissue
density lesion
seen in the inferior pole of the right kidney. This right kidney
lesion can be further evaluated with ultrasound after the
patient's acute clinical condition resolves.
CT Chest:
1. Endotracheal tube is seen 5 cm above the carina. The right
internal
jugular line is seen with the distal tip in the proximal
superior vena cava. The nasogastric tube is seen coiled with
the tip within the antrum of the stomach.
2. Complete opacification of the right lower lung lobe with a
moderate-sized pleural effusion. There is a smaller
consolidation and tiny pleural effusion at the base of the left
lung.
3. No intra-abdominal or intrapelvic source of infection. There
is
perinephric stranding seen around the right kidney as well as
free fluid
within the pelvis from likely from aggressive hydration or poor
nutritinoal status.
4. Several hypodensities seen bilaterally and a soft tissue
density lesion
seen in the inferior pole of the right kidney. This right kidney
lesion can be further evaluated with ultrasound after the
patient's acute clinical condition resolves.
Pertinent labs on discharge:
Hemoglobin 7.5 Hct 22.6. Final urine culture on [**2180-4-11**] was
negative for growth.
Brief Hospital Course:
Mr. [**Known lastname **] is a 69 y/o M with Stage IV CKD (Cr 4.5), HTN, DM2, p/w
weakness & SOB x 3 days, found to have RML/RLL PNA and acute on
chronic renal failure, transferred for consideration of urgent
hemodialysis.
#. Hypoxemia/Pneumonia: Patient arrrived intubated and sedated
on mechanical ventilation. He was treated initially for
community acquired pneumonia with azithromycin and ceftriaxone,
but switched to vancomycin and cefepime as he did not intially
improve. Urine legionella antigen was positive and antibiotics
were narrowed to levofloxacin. His WBC count continued to rise,
infectious disease was consulted and coverage was broadened to
tigecycline on [**2180-3-31**]. He was extubated initially on [**2180-4-3**],
but became acute hypoxic due to mucous plugging and suffered PEA
arrest. He was emergently reintubated, and put back on the
ventilator. On [**2180-4-7**], he passed a spontaneous breathing trial
and was extubated without complication. His white count trended
down to 12 on transfer to the floor. He was continued on
levofloxacin with a planned total course of 21 days (Day #15 at
discharge).
# Cardiac Arrest: On [**2180-4-3**] patient was extubated, became
acutely hypoxic and suffered PEA arrest. Chest compressions
were started promptly, he received epinephrine, atropine and
received one electrical defibrillation for ventricular
fibrillation. He received adenosine for SVT, then switchedinto
atrial fibrillation with RVR. Restoration of sponteous
circulation was achieved in 8 minutes.
He was give amiodarone 150mg IV, followed by an infusion at
1mg/hr for six hours, then 0.5 mg/hr for 18 hours. His rate was
stable in the 80s.
#. Sepsis: On hospital day 2, patient became progressively
tachycardic and hypotensive responsive to fluid boluses and
briefly required norepinephrine.
#. Acute on Chronic Renal Failure: On arrival patient had
increased BUN and creatinine (4.5 -> 8.8) from baseline, mild
hyperkalemia (5.7) and metabolic acidosis. He was initially
treated with kayexalate, and IV bicarbonate. A temporary
dialysis catheter was placed and CVVH was initiated. His
electrolyte abnormalities gradually improved. A left internal
jugular tunneled catheter was placed, and he was started on
intermittent hemodialysis. He was started on Aluminum
Hydroxide, this was changed to calcium acetate on discharge.
Mr. [**Known lastname **] will likely require longterm hemodilaysis from this
point on. He was noted to be severely anemic (Hct 22-25) and
possibility of transfusion was discussed, but patient refused.
# Atrial Fibrillation. On hospital day two, patient was noted
to be in atrial fibrillation. Anticoagulation was initially
held. After completing his course of amiodarone post arrest, he
was started on diltiazem 30mg PO qid with fair to good rate
control (80s to 100s). He was started on a heaprin drip and
warfarin. As his platelets trended down from 267 to 110, there
was concern for HIT. Heparin dependent antibodies were sent and
he was initially switched to argatroban; antibodies returned
negative. Once his INR was > 2.0, argatroban was stopped. INR
was initially therapeutic on 4 mg warfarin, but then became
supratherapeutic. Dose was decreased to 2.5 mg on [**2180-4-11**] and
should be held on [**2180-4-13**]. He will require INR checks on [**2180-4-14**]
and [**2180-4-17**] with further adjustments as needed. He should follow
up with his PCP at discharge to discuss cardiology referral for
evaluation/management of his atrial fibrillation. His blood
pressures have been very stable on his current dose of
diltiazem, which may be titrated up if his heart rate persists
above 90s. If he maintains good rate control, a long-acting form
of diltiazem may be appropriate at discharge from rehab to aid
with compliance.
# Abdominal Pain: Patient had tenderness to palpation of the
abdomen on exam. Given rising white count and question of
perinephric fluid collection on the outside CT, an abdominal
ultrasound was performed that were unremarkable. He was treated
empirically for possible abodminal infection with tigecycline
from [**2180-3-31**] to [**2180-4-6**] and his pain resolved.
#. DM2: Fingerstick blood glucose was checked daily. Mr. [**Known lastname **]
did not require insulin therapy upon discharge.
# Elevated Alkaline Phosphatase: Alk phos increased after
admission to 500s. This was thought to be secondary to
levofloxacin therapy.
TRANSITIONAL CARE ISSUES:
- Patient will need nephrology follow up after discharge from
rehab, either with his prior nephrologist or a new provider.
[**Name Initial (NameIs) **] [**Name11 (NameIs) **] will need to arrange for regular INR checks while on
warfarin after discharge. He should see his PCP to discuss
cardiology referral for his atrial fibrillation.
- Patient will need INR monitored tomorrow and Monday and
warfarin dose adjusted accordingly.
- Patient will need to be monitored for heart rate control
(diltiazem may be increased as needed).
- Patient will complete his course of levofloxacin after 3
additional doses Q48H (next dose [**2180-4-14**]).
- CBC/hematocrit should be checked on Monday (patient may
require transfusion for Hct < 21).
Medications on Admission:
Atenolol 50mg PO daily
Lasix 40mg PO daily
Sodium Bicarbonate 2 tabs PO bid
minitran patch
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for pain, fever.
Disp:*90 Tablet(s)* Refills:*0*
4. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: PLEASE HOLD TODAY [**2180-4-13**] for INR of 4.6.
Disp:*30 Tablet(s)* Refills:*2*
5. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours).
Disp:*3 Tablet(s)* Refills:*0*
6. PhosLo 667 mg Capsule Sig: As directed Capsule PO twice a
day: Take 1 tab after breakfast, 1 tab after lunch, 2 tab after
dinner.
Disp:*120 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
St. [**Hospital 11042**] Hospital rehab
Discharge Diagnosis:
Primary:
Legionella pneumonia
Acute renal failure necessitating dialysis
Pulseless electrical activity cardiac arrest
Atrial fibrillation/flutter (new)
Anemia
Secondary:
Type II diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname **] you presented to the [**Hospital1 18**] on [**2180-3-29**] in severe
respiratory distress due to pneumonia illness. This illness
required an admission to the medical intensive care unit and for
you to be intubated and placed on a respirator. During this time
you were diagnosed with pneumonia due to legionella infection
and were begun on Levofloxacin IV antibiotics. However, during
this time you stopped making urine and required dialysis. Your
ICU course was complicated by an arrhythmia called atrial
flutter/fibrillation. You were started on warfarin
anticoagulation therapy to minimize your risk of stroke. This
will require following INR on a regular basis. You also had an
episode where your heart stopped (lost pulse) and you required
rescusitation, which was successful.
You improved on antibiotics and were transfered to the medical
floor where your respiratory status improved and you defervesed.
You were continued on dialysis 3x per week. You also
demonstrated significant weakness likely due to the long
admission in the intensive care unit. However your strength
improved somewhat during your stay.
Your renal failure requires hemodialysis at this time. You will
need to copntinue hemodialysis as an outpatient with a renal
physician following your care.
We have made the following changes to your medication regimen:
- STOP TAKING atenolol while using the diltiazem.
- STOP TAKING minitran patch while using the diltiazem.
- STOP TAKING furosemide until/unless instructed to resume by
your doctors.
- STOP TAKING sodium bicarbonate until/unless instructed to
resume by your doctors.
- BEGIN TAKING diltiazem 30 mg PO every 6 hours for heart rate
control (your doctor may wish to change you to a once-daily
formula once you are stable on this regimen)
- BEGIN TAKING warfarin 2.5 mg PO daily (your doctor will need
to monitor your INR and may need to adjust your dose)
- BEGIN TAKING Phos-Lo to control your phosphate levels (total 4
tablets daily or as directed by your nephrologist)
- BEGIN TAKING aspirin 81 mg PO daily
- TAKE AS NEEDED acetaminophen for fever or pain
- COMPLETE COURSE of levofloxacin (antibiotic) for your
pneumonia (3 more doses over 6 days)
Please continue to take your medications as prescribed.
Followup Instructions:
Please have make an appointment with your primary care physician
on discharge from rehab. You should review your medications with
your doctor and discuss referral to a cardiologist for your
atrial fibrillation. You will also need to have your INR
monitored regularly while on anticoagulation therapy with
warfarin.
You will need to follow up with a nephrologist at discharge from
rehab (either your prior nephrologist or a new provider) to
monitor your kidney function and need for dialysis.
Completed by:[**2180-4-13**]
ICD9 Codes: 0389, 4275, 5856, 5849, 5990, 2762, 2875, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4196
} | Medical Text: Admission Date: [**2179-4-27**] Discharge Date: [**2179-4-30**]
Date of Birth: [**2120-6-4**] Sex: M
CHIEF COMPLAINT: Mental status changes.
HISTORY OF PRESENT ILLNESS: This is a 57-year-old male with
multiple medical problems including cardiomyopathy, heart
Staphylococcus aureus, acquired immunodeficiency syndrome,
chronic obstructive pulmonary disease, and pulmonary embolism
who was admitted via the Emergency Department for hypercarbic
and anoxic respiratory distress.
In the Emergency Department, he was found to have a blood gas
of 7/121/115, and for this he admitted to the Medical
REVIEW OF SYSTEMS: Positive headache, lightheadedness,
shortness of breath, abdominal pain, constipation. No visual
changes, sore throat, dysphagia, chest pain, fevers, or
chills.
PAST MEDICAL HISTORY:
1. Right-sided heart failure.
2. Acquired immunodeficiency syndrome complicated by
candidal esophagitis; on antiretroviral therapy.
3. Intravenous drug use; the patient is on methadone.
4. Chronic lung disease and hypoventilation syndrome with
oxygen saturation on room air typically in the low 80s. He
is on chronic oxygen therapy.
5. Pulmonary embolism and deep venous thrombosis; the
patient on Coumadin.
6. Hepatitis C.
7. Central and peripheral sleep apnea.
8. Renal failure; on dialysis.
9. Hemorrhoidal bleeding.
10. Splenomegaly.
11. Multiple episodes of pneumonia with respiratory
failure and intubation.
12. Benign prostatic hyperplasia.
13. Anemia.
14. Depression.
15. Chronic pancreatitis of unclear etiology.
16. Hepatitis B.
FAMILY HISTORY: Father died of unknown causes. Mother died
of a myocardial infarction at the age of 75. Brother died in
[**Country 3992**]. His sister is alive and well with three children.
SOCIAL HISTORY: He lives with his wife and has a
100-pack-year history of smoking; he quit in [**2166**]. He has a
long history of alcohol and heroin use and has been on
methadone since [**2162**]. For the past several years prior to
admission, he has been on dialysis. His physical condition
has markedly deteriorated, and he is unable to ambulate
without assistance.
ALLERGIES: HALDOL, STELAZINE, THORAZINE, CODEINE, H2
BLOCKERS, CLINDAMYCIN.
MEDICATIONS ON ADMISSION: Albuterol meter-dosed inhaler
2 puffs q.i.d. p.r.n., Atrovent meter-dosed inhaler 2 puffs
q.8h. p.r.n., methadone 50 mg p.o. q.d., zinc sulfate 220 mg
p.o. q.d., Coumadin 2.5 mg p.o. q.h.s., stavudine 20 mg p.o.
q.d., Zoloft 50 mg p.o. q.d., Protonix 40 mg p.o. q.d.,
lamivudine 25 mg p.o. q.d., vitamin C 500 mg p.o. b.i.d.,
amiodarone 200 mg p.o. q.d., Colace 100 mg p.o. b.i.d.,
Bactrim-DS one tablet p.o. three times per week (Tuesday,
Thursday, and Saturday), Renagel 1600 mg p.o. t.i.d.,
levothyroxine 25 mcg p.o. q.d., Nephrocaps 1 mg p.o. q.d.,
Roxicet one to two tablets p.o. q.i.d. p.r.n. for pain, and
Bicitra.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 98.8, heart rate of 80, blood pressure of
98/52, respiratory rate of 16, oxygen saturation of 94% on 3
liters nasal cannula. In general, cachectic. Head, eyes,
ears, nose, and throat revealed mucous membranes were moist.
Pupils were equal, round and reactive to light. Extraocular
movements were intact. Neck revealed no jugular venous
distention appreciated. Chest revealed coarse fibrotic
breath sounds bilaterally with occasional expiratory wheezes.
In addition, there were also some wet crackles. Heart had a
regular rate and rhythm laterally and downward, displaced
point of maximal impulse with a murmur heard at the base of
the heart without radiation to the carotids. Abdomen revealed
positive bowel sounds, scaphoid. Extremities revealed
toenails with evidence of superficial infection.
RADIOLOGY/IMAGING: Electrocardiogram revealed sinus at 73
with left and right atrial abnormalities, left axis
deviation, supraventricular conduction delay.
A chest x-ray revealed no consolidations, no effusions, no
congestive heart failure. Positive interstitial markings.
PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell
count of 4.6, hematocrit of 43.5, platelets of 101, mean cell
volume of 120. INR of 1.7. Sodium of 138, potassium of 4.9,
chloride of 100, bicarbonate of 29, blood urea nitrogen
of 25, creatinine of 8.4, blood glucose of 53. Albumin
of 3.1, calcium of 8.5, phosphate of 6, magnesium of 2.
Blood gas revealed 7/121/115, sputum with 4+ gram-negative rods
and o/p flora.
HOSPITAL COURSE: The patient was admitted for hypercarbic
respiratory failure.
1. CARDIOVASCULAR: The patient was maintained on
amiodarone for a history of ventricular tachycardia. He did
not require pressor support. He did not require diuresis.
2. PULMONARY: The patient required oxygen at baseline, and
he was kept on nasal cannula oxygen throughout his stay. To
correct his hypercarbia and hypoxia, he was initially placed
on noninvasive mask ventilation which resulted in marked
improvement of his respiratory status. A repeat arterial
blood gas was shown to be 7.18/80/64 with a lactate of 0.4.
He was initially given steroids, but then these were
discontinued because it was felt that he was not having a
chronic obstructive pulmonary disease exacerbation. He was
started on levofloxacin and will continue a 10-day course,
finishing on [**2179-5-8**]. He was to be discharged on home
oxygen, and his primary care provider planned to give him a
BiPAP machine at home, hopefully to avoid need for
readmission.
3. RENAL: The patient was maintained on hemodialysis
during his course. He was changed from sodium bicarbonate to
baking soda, and he was given Nephrocaps instead of folate
and multivitamin. He was followed in consultation by the
Renal Service while he was here.
4. INFECTIOUS DISEASE: The patient was treated with
Levaquin 250 mg p.o. q.o.d. beginning on [**2179-4-28**]; to
continue until [**2179-5-8**]. He was also maintained on
lamivudine and stavudine in addition to prophylactic Bactrim.
5. GASTROINTESTINAL: The patient was maintained on
Protonix, and he did not have any liver function tests
abnormalities.
6. HEMATOLOGY: The patient was maintained on Coumadin for
his history of pulmonary embolism. He was therapeutic during
his hospital stay.
7. FLUIDS/ELECTROLYTES/NUTRITION: The patient was
encouraged to take p.o.
8. NEUROLOGY: The patient maintained his mental status
without any changes once he was put on BiPAP. He was
maintained on Zoloft and maintenance methadone.
9. LINES: The patient had a dialysis cathether and a
central line.
10. CODE STATUS: The patient is full code.
MEDICATIONS ON DISCHARGE:
1. Albuterol meter-dosed inhaler 2 puffs q.i.d. p.r.n.
2. Atrovent meter-dosed inhaler 2 puffs q.8h. p.r.n.
3. Methadone 50 mg p.o. q.d.
4. Zinc sulfate 220 mg p.o. q.d.
5. Coumadin 2.5 mg p.o. q.h.s. (titrate to INR 2 to 3).
6. stavudine 20 mg p.o. q.d.
7. Zoloft 50 mg p.o. q.d.
8. Protonix 40 mg p.o. q.d.
9. Lamivudine 25 mg p.o. q.d.
10. Vitamin C 500 mg p.o. b.i.d.
11. Amiodarone 200 mg p.o. q.d.
12. Colace 100 mg p.o. b.i.d.
13. Bactrim-DS one tablet p.o. three times per week
(Tuesday, Thursday, and Saturday).
14. Renagel 1600 mg p.o. t.i.d.
15. Levofloxacin 250 mg p.o. q.o.d. (from [**2179-4-28**] to
[**2179-5-8**]).
16. Levothyroxine 25 mcg p.o. q.d.
17. Nephrocaps 1 capsule p.o. q.d.
18. Roxicet one to two tablets p.o. q.i.d. p.r.n. for pain.
19. Baking soda 0.5 teaspoon in 8 ounces of water p.o.
b.i.d.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) **] (who is his primary care doctor).
DISCHARGE DIAGNOSES:
1. Human immunodeficiency virus.
2. Cardiomyopathy.
3. End-stage renal disease.
4. Hepatitis B.
5. Hepatitis C.
6. Hypoventilation syndrome.
7. Intravenous drug use.
8. Chronic pancreatitis.
9. Depression.
10. Anemia.
11. Ventricular tachycardia.
12. Pneumonia.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 9336**]
MEDQUIST36
D: [**2179-4-30**] 20:35
T: [**2179-5-4**] 09:34
JOB#: [**Job Number 35105**]
ICD9 Codes: 4280, 4254, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4197
} | Medical Text: Admission Date: [**2130-4-7**] Discharge Date: [**2130-4-12**]
Date of Birth: [**2051-7-16**] Sex: F
Service: [**Year (4 digits) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Slurred speech and L weakness
Major Surgical or Invasive Procedure:
MRI MRA brain
CTA brain
History of Present Illness:
HPI: The patient is a 79yo R-handed woman with HTN,
hypercholesterolemia, GERD, glaucoma, brought in per EMS for
L-sided weakness.
The patient was last seen in normal health by her neighbor
around
7 am. Around 2.40pm her neighbor checked in on her and found her
on the floor, being unresponsive. EMS were called. FS 110. BP in
150s. They found her incontinent, with a R-gaze deviation. She
was not moving the L-side. She did respond though it was hard to
understand her. She cannot tell what happened. Denies any pain.
Denies falling. She thinks all is fine with her. In the ED NIHSS
was 20. BP in 150's. FS 110. She appeared a bit more somnolent
towards the end of the exam.
Code stroke was called. NIHSS exam was performed (see below) and
CT head was obtained.
NIHSS: 20
1a. Level of consciousness: 1
1b. LOC questions: 0 (age and month)
1c. LOC commands: 0
2. Best gaze: 2 R-gaze deviation
3. Visual: 2 no response from the L
4. Facial Palsy: 2 L-facial
5. Motor Arm: 0/3 flaccid L
6. Motor Leg: [**3-3**]
7. Limb ataxia: 0
8. Sensory: 1
9. Best Language: 1 not read
10. Dysarthria: 1
11. Extinction: 2
ROS:
denies any fever, pain or fall.
EXAM
VITALS: T 98 HR64 BP150-160/70-90 RR18 sO2 100 NRB
GEN: face mask, head to the R, obese
HEENT: mmm
NECK: no LAD; no carotid bruits
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
MENTAL STATUS:
Awake and alert, but needs frequent prompting, cooperative with
exam; inattentive thoughout rest of MS exam; follow some
commands
but inconsistently.
Knows she is in the hospital, knows age and date
CRANIAL NERVES:
II: Does not blink to threat from the R, minimal response from
the L. Pupils not able to assess due to scleral abnormalities.
III, IV, VI: R-gaze deviation, does not cross midline No ptosis.
V: Facial sensation intact to light touch and pinprick.
VII: L-facial.
VIII: Hearing intact to finger rub bilaterally.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: -
MOTOR SYSTEM: Able to hold her R-arm antigravity; L-arm flaccid,
no withdrawal. Not able to lift either R or L leg antigravity
REFLEXES:
B T Br Pa Pl
Right2 2 2 1 -
Left 2 2 2 1 -
Toes: down on the R, up on the L
SENSORY SYSTEM: Says she feels LT on both sides; too inattentive
to adequately assess.
COORDINATION: no dysmetria seen on the R.
GAIT: deferred
LABS and IMAGING:
144 105 24
-----------<101 AGap=17
3.3 25 1.1
Comments: K: Hemolysis Falsely Elevates K
estGFR: 48/58 (click for details)
CK: 118 MB: 3 Trop-T: <0.01
Ca: 9.3 Mg: 2.0 P: 3.2
WBC11.5 PLT283 Hct37.8
N:81.5 L:12.5 M:4.4 E:1.5 Bas:0.1
PT: 11.4 PTT: 25.6 INR: 1.0
Head CT: large ICH, R- striatocapsular
ASSESSMENT:
The patient is a 79yo R-handed woman with HTN,
hypercholesterolemia, GERD, glaucoma, brought in per EMS for
L-sided weakness. She denied headache or fall, and cannot
remember what happened. She has R-gaze preference, severe
neglect. Her L-arm is flaccid, and motor function in both legs
in
impaired (L>R). She has an upgoing toe on the L. She was able to
speak full sentences. NIHSS was 20. CT head showed
R-striatocapsular bleed. This may be related to hypertension,
though other etiologies (mass) will need to be ruled out.
PLAN:
-admit to Neuro icu
-q 1 hour neurochecks
-HOB up to >30 degrees
-monitor respiratory status
-Neurosurg consult; follow up recs
-repeat head CT if condition worsens, otherwise in am
-CTA head
-MRI/MRA head once stable
-keep MAP<130
-check A1C, lipid panel in am
-follow up admission labs especially coags, UA and CXR
-continue lipitor
Endo:
-ISS, FSBS
ID:
-UTI, treat with cipro
-treat fever aggressively with tylenol if needed
Glaucoma:
-continue home meds (please verify)
Psych:
-on risperdal per med list; please observe closely
FEN:
-NPO
-NS at 70ml/hr
Proph:
-VD boots
-protonix
[**First Name8 (NamePattern2) 39215**] [**Last Name (NamePattern1) **] MD [**First Name (Titles) **]
[**Last Name (Titles) 878**] R-3
[**Numeric Identifier 90765**]
Disc with stroke fellow, Dr. [**Last Name (STitle) **]
Addendum by [**Name6 (MD) **] [**Name8 (MD) **], MD, [**Name8 (MD) **] on [**2130-4-7**]:
[**Date Range **]/STROKE ATTENDING NOTE
Patient seen and examined with resident and stroke fellow. I
reviewed Dr.[**Name (NI) 12343**] note and agree with her assessment
and
plan. In brief, this is a 79 yo RH woman with HTN,
hypercholeterolemia, GERD, glaucoma, brought to ED by EMS for
new
left sided weakness. She was in her USOH around 7AM. At 2:40PM a
neighbor found her lying on the floor, she was not moving her
left side and did not have understandable verbal output. Her
eyes
were deviated to the right. She was brought to [**Hospital1 18**]. A hCT
showed a large right hem hemorrhage with center in the basal
ganglia region, but extending over 9 slices. Size is
approximately 80-90cc. No significant mass effect yet, no
herniation.
Her exam is significiant severe dsyarthria and mild inattention,
anosognosia, inattention to the left, severe left hemiparesis
(can't move left arm), but lifts up left leg. Upgoing toe.
Decreased sensation in left arm>leg. The etiology of her
hemorrhage is most likely due to hypertension, although vascular
malformation cannot be rule out and an aneurysmal bleeding from
her distal MCA is also a possibility. However, she does not have
any blood in the subarachnoid space which makes an aneurysmal
hemorrhage less likely. An amyloid hemorrhage is a possibility
as
well, although very unlikely.
She will be admitted to the Neuro ICU for monitoring and
neurochecks. We will keep her HOB above 30 degrees, repeat hCT
in
24 hours or if patient worsens. She needs to hve a CTA to rule
out an aneurysm. We will keep her MAPx<130. We will continue
with
Lipitor for now. She will need an EEG in AM to rule out
seizures.
Past Medical History:
-glaucoma
-hypercholesterolemia
-knee surgeries
-hypothyroidism
-GERD
-acute psychosis
-HTN?
Social History:
Mrs [**Known lastname 95604**] has a daughter resident in [**State 15946**] and nephews and
nieces closer by. Prior to this admission she lived alone.
Family History:
Unknown
Physical Exam:
VITALS: T 98 HR64 BP150-160/70-90 RR18 sO2 100 NRB
GEN: face mask, head to the R, obese
HEENT: mmm
NECK: no LAD; no carotid bruits
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
MENTAL STATUS:
Awake and alert, but needs frequent prompting, cooperative with
exam; inattentive thoughout rest of MS exam; follow some
commands
but inconsistently.
Knows she is in the hospital, knows age and date.
CRANIAL NERVES:
II: Does not blink to threat from the R or L. Pupils 3.5 bilat
minimally reactive. Corneal opacification on L. Red reflex
present on R. Eyelid apraxia- tends to keep closed.
III, IV, VI: R-gaze deviation, does not cross midline. No
ptosis.
V: Facial sensation intact to light touch and pinprick.
VII: L-facial.
VIII: Hearing intact to finger rub bilaterally.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: -
MOTOR SYSTEM: Able to hold her R-arm antigravity; L-arm flaccid,
no withdrawal. Not able to lift either R or L leg antigravity
REFLEXES:
B T Br Pa Pl
Right2 2 2 1 -
Left 2 2 2 1 -
Toes: down on the R, up on the L
SENSORY SYSTEM: Says she feels LT on both sides but variable
responses, inattentive to L at times
COORDINATION: no dysmetria seen on the R.
GAIT: deferred
At discharge:
Slow to rouse in mornings. Becoming more alert and providing few
additional details including comment about tenderness from
bruises due to fall. States in hospital for heart problems.
Answers simple questions about family appropriately.
L facial weakness.
Right side strong, L deltoid and triceps at least 4+ (give way
weakness), [**3-5**] at finger extension on L.
at least antigravity movement both legs at hips and wiggling
toes on both sides. Formal testing remains difficult.
Pertinent Results:
Admission details:
URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-0 WBC-0-2
BACTERIA-MOD YEAST-NONE EPI-0-2
GLUCOSE-101 UREA N-24* CREAT-1.1 SODIUM-144 POTASSIUM-3.3
CHLORIDE-105 TOTAL CO2-25 ANION GAP-17
CK-MB-3 cTropnT-<0.01
CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-2.0
WBC-11.5* RBC-4.55 HGB-12.9 HCT-37.8 MCV-83 MCH-28.4 MCHC-34.2
RDW-13.7
NEUTS-81.5* LYMPHS-12.5* MONOS-4.4 EOS-1.5 BASOS-0.1
PLT COUNT-283
PT-11.4 PTT-25.6 INR(PT)-1.0
A1c 5.8
Chol 174 Triglyc 220 HDL 38 Chol/HDL 4.6 LDL 92
TSH 1.1
CT head [**2130-4-7**]
Large intraparenchymal right basal ganglia hemorrhage with
surrounding edema and mass effect. Patent basal cisterns with no
shift of normally midline structures at this time. Size is
approximately 80-90cc.
CT/CTA head [**2130-4-8**]
Bilateral chronic occlusive disease involving the middle
cerebral arteries with multiple small collaterals giving a
moyamoya appearance. No evidence of an aneurysm identified.
Fetal left posterior cerebral artery is not incidentally noted.
Right basal ganglia hematoma is again visualized unchanged from
the previous CT obtained on [**2130-4-7**].
CT head [**2130-4-11**]
No change from the prior examination in the large right basal
ganglia hemorrhage.
CXR [**2130-4-7**]
The cardiac size is normal. Some tortuosity of the aorta is
present. The lung fields are clear. There is no evidence
aspiration or failure.
ECG normal
Brief Hospital Course:
79 yo RH woman with HTN, hypercholeterolemia, GERD, glaucoma,
brought to ED by EMS for new left sided weakness. A neighbor
found her lying on the floor, she was not moving her left side
and did not have understandable verbal output. Her eyes
were deviated to the right. She was brought to [**Hospital1 18**]. A hCT
showed a large right hem hemorrhage with center in the basal
ganglia region, approximately 80-90cc. No significant mass
effect or
herniation. Her exam was significiant for severe dsyarthria and
mild inattention,
anosognosia, inattention to the left, severe left hemiparesis
affecting arm with significantly less weakness of left leg. L
upgoing toe.
Decreased sensation in left arm>leg. The etiology of her
hemorrhage is most likely due to hypertension, or amyloid
angiopathy.
Neuro: She was admitted to the Neuro ICU for monitoring and no
significant decompensation occurred. Neurosurgery consultation
was obtained and no surgical intervention recommended. Blood
pressure was closely monitored. She was transferred to the
floor by [**2130-4-9**]. Repeat head CT has been stable. No aneurysm was
seen on CTA, but abnormal vessels seen (see report), not thought
to be explanation for bleed. MRI was limited due to movement
artefact. There is no florid amyloid angiopathy seen but note
poor quality study.
Triglycerides were significantly elevated in addition to LDL.
Statin was continued.
CVS: Blood pressure has not been significantly elevated in
hospital, and antihypertensives not restarted as yet.
ID: UTI was treated with ciprofloxacin for 3 days. Culture
E.coli sensitive to ciprofloxacin. Repeat culture negative.
FEN: Swallow evaluation recommended pureed solids and nectar
thick fluids.
Glaucoma:
Home medications were continued. Known significant visual
impairment affecting L eye. The patient has longstanding history
of glaucoma and previously some functional vision on the right
according to family. Examination during this admission shows
significant impairment of R visual acuity, thought likely due to
visual field defect associated with stroke superimposed on
previous disease.
Psych:
Psychotropic medications have been held during hospitalisation
and may need to be restarted on discharge as the patient has a
history of previous acute psychosis.
DVT and GI tract prophylaxis were provided during
hospitalisation.
Please note Mrs[**Known lastname 95605**] daughter wishes to be kept informed of
significant events. Please continue communication ph [**Telephone/Fax (3) 95606**].
Medications on Admission:
-hyoscyamine sluphate ER 375mg [**Hospital1 **]
-triamterene HCTZ 37.5/25 daily PO
-detrol LA 4mg qHS PO
-Levothyroxine 100mcg PO daily
-risperdal 1mg in am, 2mg at night
-omeprazole DR 10mg PO daily
-lipitor 20mg PO daily
-ambien 5mg PO daily
-cosopt 1 drop in R eye [**Hospital1 **]
-travatan 1 drop in R eye q HS
-tobraden 35gm?
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic qHS ()
as needed for glaucoma.
4. Tobramycin-Dexamethasone 0.3-0.1 % Drops, Suspension Sig: One
(1) Drop Ophthalmic [**Hospital1 **] (2 times a day).
5. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12 hr
Sig: One (1) Capsule, Sust. Release 12 hr PO BID (2 times a
day).
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
7. Omeprazole 10 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
R temporal lobe hemorrhage
Discharge Condition:
Stable. L hemiparesis (arm>leg) and slurred speech. Visual
impairment.
Discharge Instructions:
Please keep all follow up appointments and take medications as
prescribed. Please discuss with your doctors [**Name5 (PTitle) 691**] [**Name5 (PTitle) **] [**Name5 (PTitle) **] of
confusion, worsening speech difficulty, weakness or clumsiness
or any other concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2130-5-24**]
12:15 [**Hospital1 18**] [**Hospital Ward Name 23**] [**Location (un) 861**]
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2130-7-4**] 1:00 [**Hospital1 18**] [**Hospital Ward Name 23**] Floor 8 (on wait list for
earlier appointment)
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 2449, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4198
} | Medical Text: Admission Date: [**2133-3-25**] Discharge Date: [**2133-4-20**]
Date of Birth: [**2090-5-28**] Sex: F
Service: CARDTHOR SURGERY
HISTORY OF PRESENT ILLNESS: This is a 42 year old woman with
a history of multiple medical problems starting with the
following:
1. Congenital hepatic fibrosis.
2. Hepatitis C with demonstrated liver lesions.
3. End-stage renal disease on hemodialysis.
4. History of bilateral deep venous thromboses and status
post placement of an IVC filter.
5. History of Streptococcal infection of a dialysis
catheter.
6. History of aortic insufficiency and mitral regurgitation.
7. Status post splenectomy.
8. History of intraperitoneal bleed.
9. History of Klebsiella sepsis in [**2132-1-11**].
10. Asthma.
The patient had multiple medical admissions over the year;
the most recent one of note was for increasing shortness of
breath in [**2132-12-11**], for which she saw Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **].
The patient also had a history of VRE.
ALLERGIES:
1. Metronidazole.
2. Neomycin.
3. Penicillin.
4. Sulfa.
MEDICATIONS ON ADMISSION:
1. Ambien 5 mg p.o. q. h.s.
2. Colace 100 mg p.o. twice a day.
3. Folate 1 mg p.o. q. day.
4. Protonix 40 mg p.o. twice a day.
5. Nephrocaps 1 tablet q. day.
6. Renagel 800, four tablets three times a day.
7. Coumadin 2.5 mg p.o. q. day.
8. Zyrtec 10 mg p.o. q. day
9. Lactulose 30 cc twice a day and three times a day.
The patient was admitted on the 13th for a work-up of her
aortic murmur and her known four plus aortic insufficiency
and three plus mitral insufficiency. Her exercise tolerance
test had shown no perfusion defects and an ejection fraction
of 72%. She was admitted to the Cardiology Service for
elective catheterization prior to her double-valve surgery.
Also of note was the notation that the patient's
glomerulonephritis was probably status post a Streptococcal
infection that ultimately results in end-stage renal disease
and hemodialysis. She then developed a line infection that
gave her the endocarditis and, hence, the increasing murmurs
and insufficiency of her heart valves.
PHYSICAL EXAMINATION: When she was admitted to Cardiology
she was noted to be thin with a blood pressure of 124/53,
saturating 98% on room air with a heart rate in sinus at 81;
respiratory rate of 20. Her carotids had no bruits. She had
no jugular venous distention. Lungs were clear anteriorly.
She did have both systolic and diastolic murmurs. Her
abdomen was soft and nontender with good bowel sounds. She
had no extremity edema and had bilateral distal pulses. She
was alert and oriented.
Prior work-up had also shown an echocardiogram in [**2132-12-11**], which showed mild left atrial enlargement, symmetric
left ventricular hypertrophy and a normal ejection fraction.
Her aortic valve gradient was 23 with a peak of 44 at that
time.
Her pulmonary function tests in [**Month (only) **] also of [**2132**], were
done.
On [**2133-3-18**], she had a CT scan of the chest which
showed stable tree and [**Male First Name (un) 239**] opacities and the right apex was
consistent with bronchiolitis.
LABORATORY: Prior to admission were white blood cell count
of 6.8, hematocrit of 36.6, platelet count of 348,000.
Sodium 138, potassium 5.1, chloride 104, CO2 21, BUN 26,
creatinine 8.3 with a platelet count of 73,000. INR was 1.4.
She did also, as noted in Past History, have a history of
hepatic encephalopathy that had resolved. She also had a
prior history of infection with Clostridium difficile.
HOSPITAL COURSE: Cardiac catheterization was done which
showed normal coronary arteries, aortic insufficiency, mitral
regurgitation. The patient had hemodialysis one day
preoperatively while also on the Cardiology Service and was
followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**], the Renal attending, for
monitoring of her renal status. She did have a left arm AV
fistula in place and she was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) 411**] of Cardiothoracic Surgery for her valve replacement.
She was also seen by Dr. [**Last Name (STitle) 11442**], the Chief Resident.
Her ejection fraction was normal. Her murmurs are radiated
to bilateral neck, Grade III/VI both systolic and diastolic.
Her last set of laboratories prior to the Operating Room was
sodium 138, potassium 4.4, chloride 103, CO2 23, BUN 30,
creatinine 8.6, white count of 5.4, blood sugar of 100,
hematocrit of 34 and platelet count of 190,000.
On[**Last Name (STitle) 32377**]5th, she underwent double valve replacement with a 19
CarboMedics mechanical aortic valve and a [**Street Address(2) 11599**]. [**Male First Name (un) 923**]
mechanical mitral valve by Dr. [**Last Name (Prefixes) **]. She was
transferred to Cardiothoracic Intensive Care Unit in stable
condition on a Neo-Synephrine drip, Propofol drip and a
protenin infusion. She was also treated perioperatively with
Linezolid for her allergies and intolerance of Vancomycin and
penicillin.
[**Last Name (STitle) **], there was concern with increased chest tube
bleeding and Dr. [**Last Name (Prefixes) **] mobilized the Operating Room
team to bring her back to explore her mediastinum to rule out
any sources of bleeding. The patient was brought down to the
Operating Room. A transesophageal echocardiogram was
performed which did not show an effusion and the patient's
bleeding decreased; the patient was returned to the
Cardiothoracic Intensive Care Unit. The patient did, over
the course of the first day, have an increased PR interval
and went into atrial fibrillation. The patient was started
immediately on Amiodarone on postoperative day one and was
extubated. The patient was V-paced for better control of her
rate.
She did well over the first couple of days. She did pick up
some volume and then became a little more lethargic over the
next couple of days. She received intravenous heparin to
cover her valves in preparation for starting her on Coumadin,
but her platelet count continued to drop. HIT antibodies
were sent which were negative. The patient began to require
a little bit of increased amount of pressor support other
than the Neo that the patient had come up on. The patient
was also started on Dopamine on postoperative day six for
blood pressures that waned in the 90s over 50s. The patient
was continually followed every day by the Renal Service. The
Clinical Nutrition Service also saw the patient.
The patient went back into sinus rhythm after the amiodarone
was started and then went back into atrial fibrillation the
following day. On postoperative day seven, of note, the
patient's white count rose acutely from 10.9 to 25.6, and an
Infectious Disease consultation was immediately obtained.
Also of note, the central line was pulled from the right
internal jugular site and there was some purulence at that
site. In addition, the patient was producing some greenish
sputum. Cultures were sent off; urinalysis was sent. E.
coli came back in the urine. The patient was then
immediately started on triple antibiotic therapy,
Ceftazidime, Vancomycin and Gentamicin. The white count
decreased the next day to 17.6. Blood cultures had all been
sent off on day six and came back with Gram negative rods.
The patient's lactate rose over the next couple of days to
7.5 and the patient started to have respiratory symptoms with
increased dyspnea as well as continuing persistent
hypotension. The patient was restarted on CVVH on
postoperative day 10. Pressor requirements were such that
she was now on Neo-Synephrine at 5, Dopamine at 5, and she
continued to be V-paced. She was transfused as needed. Her
lactate came back down slightly to 6.5. Liver enzymes were
all elevated. Approximately day eight, a right upper
quadrant ultrasound was obtained. The patient's mixed venous
was also at 65% at that point.
Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] from General Surgery also saw the
patient on postoperative day nine, and agreed that her
gallbladder probably needed to be drained. This was done
under Radiology. On that day, her total bilirubin was 21.9.
She continued to have increased work of breathing and was
reintubated. Levophed was added in to her pressor regimen.
A bedside echocardiogram showed increasing pleural effusions
with tricuspid regurgitation. As sensitivities came back,
the patient was switched back only to Ceftazidime, then
Amikacin was added in at the recommendation of Infectious
Disease on postoperative day 11.
On postoperative day 11, the hunt continued for other sources
of possible sepsis. The patient had a pericardiocentesis
done by Cardiology which drained 250 cc of fluid. The
patient continued to have a dropped SER with an increasing
cardiac output and cardiac index of approximately 4 with a
growing septic picture. Filling pressures rose to CVP of 24
and PA pressures of 54/30. Bilateral chest tubes were placed
with a decrease in the amount of effusions. The right IJ and
radial A-line cultures came back as E. coli.
Pericardiocentesis fluids were also sent for culture. The
patient also had a CVVHD. All of these volume management and
hemodialysis issues continued to be followed on a daily and
sometimes twice daily basis by the Renal Service.
On postoperative day 12, the patient's lactate rose to 14.2
and the patient was clearly showing signs of jaundice. The
patient, at that point, had a right Quinton catheter and a
left femoral A-line. The patient was continued on Vancomycin
at this point, Ceftazidime and Amikacin. Also of note on
that day was increasing right upper extremity edema.
The patient was also seen by Social Work for discussion with
the family.
The patient's Levophed requirement also increased and was now
at 0.5. Metabolic Service was also consulted. The
Hyperalimentation attending saw the patient and recommended
TPN changes. The patient was on Levophed at 0.6,
Neo-Synephrine at 6.0, and Dopamine at 5.0. Pitressin was
added in to the pressor regimen at 0.04.
The patient showed signs of worsening distal perfusion with
decreased pulses in her extremities and the INR continued to
rise. The patient also had multiple episodes of epistaxis
bleeding also from around the NG tube. On postoperative day
13, the patient had an ultrasound of the belly which showed
ascites in bilateral lower quadrants. All fluids had come
back as E. coli; that included pleural fluid, pericardial
fluid, cultures from urine. Bile fluid proved to have
Vancomycin resistant Enterococcus. The patient was started
on Linezolid again and the Vancomycin was discontinued as it
was resistant. The patient continued to look more grave and
increasingly septic as the antibiotic regimen was shifted
again in an attempt to bring her sepsis under control.
On postoperative day 15, the patient was hypothermic; also,
possibly due to her CVVH, her white count rose to 24.9. She
did develop some metabolic alkalosis which was addressed by
the Renal Team by changing her CVVHD fluid to normal saline
from the bicarbonate included solution that they had been
using. On postoperative day 16, she required continuing
pressor support and was increasingly more jaundiced. She was
on Dopamine at 3.0, Levophed at 0.2, Neo-Synephrine at 0.3
and Pitressin at 0.04. She was receiving maximal pressure
support with aggressive antibiotic therapy and control of her
renal status and volume management by the Renal Service.
On postoperative day 17, the Quinton catheter tip came back
positive for [**Female First Name (un) 564**] albicans. Blood cultures which had also
been sent also came back positive for [**Female First Name (un) 564**]. The patient
continued to be followed very closely by all services,
including the GI Service, General Surgery, Renal, and daily
consultations by the Infectious Disease service for
management of her sepsis and multiple antibiotic therapy.
On postoperative day 20, Amphotericin was added in to the
Amikacin regimen. She also remained on Ceftazidime and
Linezolid. Her lactate was 7.8 and her liver failure was
well documented by enzymes and coagulopathy.
The patient continued to spiral and with a very poor
prognosis. On postoperative day 22, she had increasing
metabolic acidosis, was again dialyzed. She required
platelets and fresh frozen plasma and heart disease
increasingly worse oxygenation. She was passing clotted
blood and frank blood from her NG tube and had a systemic
anasarca picture. Her central line which had also been
withdrawn also came back positive for [**Female First Name (un) 564**] albicans.
On[**Last Name (STitle) 14810**]perative day 23, the patient was clearly dusky, not
oxygenating well and her sepsis continued. She was on
Neo-Synephrine at 4.0, Dopamine at 4.0, Levophed at 0.5. Her
PT on that morning was 43 with an INR of 13.2. Prior to this
day, discussions had been had by the Renal attending and Dr.
[**Last Name (Prefixes) **] as well as the Infectious Disease Services input
as to her prognosis and maximal aggressive therapy had been
attempted to try and reverse her picture, but the patient
expired in the Cardiothoracic Intensive Care Unit at 05:50
a.m. on [**4-20**]. The patient was pronounced by Dr. [**First Name4 (NamePattern1) 6382**]
[**Last Name (NamePattern1) 32378**] in the Cardiothoracic Surgery Unit.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement and mitral valve
replacement.
2. Status post Septicemia with Escherichia coli and [**Female First Name (un) 564**]
albicans.
3. End-stage renal disease with hemodialysis.
4. Congenital hepatic fibrosis.
5. Hepatitis C.
6. Status post Streptococcal infection of dialysis catheter.
7. Status post bilateral deep venous thromboses with
placement of IVC filter.
8. Status post splenectomy.
9. Status post intraperitoneal bleed.
10. Status post Klebsiella sepsis in [**2133-1-10**].
11. Asthma.
DISPOSITION: The patient was discharged and expired in the
Cardiothoracic Intensive Care Unit on [**2133-4-20**].
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2133-4-22**] 11:47
T: [**2133-4-22**] 12:00
JOB#: [**Job Number 32379**]
ICD9 Codes: 9971, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4199
} | Medical Text: Admission Date: [**2160-3-12**] Discharge Date: [**2160-3-15**]
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]M h/o autoimmune hemolytic anemia, recurrent GIB, mechanical
aortic valve on coumadin and multiple similar admissions, most
recently [**2160-1-2**], presenting from [**Hospital 100**] Rehab with
anemia, HCT 19.4 from recent baseline 28 in setting of
therpaeutic INR. Patient is a relatively poor historian but
reports onset of fatigue and feeling weak and pale today with
DOE. He denies BRBPR, melena, hematemesis, N/V/D, abdominal
pain. Denies lightheadedness, dizziness, SOB, palpitations. He
denies CP currently but states he had chest pressure several
days ago on his way to breakfast in a wheelchair. Has never had
pressure like this before.
.
In ED, initial VS: 97.5 88 95/64 16 97% 2L NC. Exam was
significant for guaiac positive dark stool. Labs significant for
HCT 19.4 (28.5 [**2160-2-25**]) and INR 2.9. SBP remained in the 90s but
did not drop <90. GI was consulted. He was typed and crossed and
transfused 1 units PRBCs via PICC. He was initially going to be
admitted OMED but due to low HCT and borderline low BPs, he was
admitted to MICU. VS prior to transfer: 98.5 89 95/72 18 100%2L.
.
ROS: + dysuria, unclear duration. Denies cough, fever, chills,
SOB, diaphoresis, joint pains, headache, visual changes, rash.
Past Medical History:
# Anemia, multifactorial as below, baseline HCT 28
# Autoimmune hemolytic anemia (Coomb's +, warm autoantibody),
on prednisone 10mg Po daily
# Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped
due to hemolytic anemia
# Aortic mechanical valve, recently Coumadin resistant so
intermittently on Lovenox bridge, followed by Dr. [**Last Name (STitle) **]
# hx recent GI bleeds: colonoscopy [**1-10**]: noted normal colon
with melanotic stool in terminal ileum
# GERD: EGD [**12/2159**] Polyp in the area of the papilla; found on
the wall opposite the ampulla. Small hiatal hernia. Otherwise
normal EGD to third part of the duodenum.
# H/o presyncope
# CKD Cr 1.6-2.0 Stage III
# CAD s/p NSTEMI [**7-10**]
# Chronic CHF, likely diastolic, ([**9-9**] EF=50%)
# Hyperlipidemia
# Hypertension
# Depression vs adjustment disorder after death of brother
# Prostate cancer- s/p radiation
# Bladder/bowel incontinence
# Right lateral malleolus stage 1 pressure ulcer
# Dementia
Social History:
Never smoked, no EtOH or other drugs. Currently living at
[**Hospital 100**] Rehab. Uses wheelchair typically. Requires a
significant degree of assistance in all his ADLs and IADLs. Has
2 sons and 4 grandchildren.
Family History:
No bleeding diatheses. Father had stomach cancer. No other
cancers including colon.
Physical Exam:
VS: Afeb 115/55 76 100%2L
GEN: pleasant, pale appearing, comfortable, NAD
HEENT: PERRL, EOMI, + conjuctival pallor, anicteric, MM slightly
dry, OP without lesions, no supraclavicular or cervical
lymphadenopathy, no jvd, no carotid bruits
RESP: Faint crackles L base. Otherwise CTA with good air
movement throughout.
CV: RRR, S1 and S2 wnl, mechanical click. No rubs or [**Last Name (un) 549**].
CABG scar well healed.
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e. Slight mottling. 1+ DP/PT
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3 (month, date, ICU at [**Hospital1 18**]). Cn II-XII intact with
R ptosis (old per pt).
RECTAL: Dark brown guaiac positive stool
Pertinent Results:
Admission Labs
[**2160-3-12**] 04:00PM WBC-10.0# RBC-1.89*# HGB-6.6*# HCT-19.0*#
MCV-101* MCH-35.1* MCHC-34.8 RDW-22.4*
NEUTS-79* BANDS-5 LYMPHS-6* MONOS-6 EOS-0 BASOS-0 ATYPS-0
METAS-3* MYELOS-1*
ALT(SGPT)-12 AST(SGOT)-19 LD(LDH)-192 ALK PHOS-42 TOT BILI-0.3
GLUCOSE-130* UREA N-48* CREAT-1.6* SODIUM-139 POTASSIUM-4.5
CHLORIDE-107 TOTAL CO2-25 ANION GAP-12
[**Hospital3 **]
[**2160-3-12**] 04:00PM BLOOD Hapto-33
[**2160-3-13**] 02:19AM BLOOD WBC-6.3 RBC-2.65*# Hgb-8.8*# Hct-25.2*#
MCV-95 MCH-33.1* MCHC-34.8 RDW-22.0* Plt Ct-147*
[**2160-3-14**] 04:16AM BLOOD WBC-4.3 RBC-2.87* Hgb-9.4* Hct-25.9*
MCV-90 MCH-32.6* MCHC-36.1* RDW-21.7* Plt Ct-131*
[**2160-3-14**] 03:09PM BLOOD Hct-27.4*
[**2160-3-14**] 04:16AM BLOOD PT-25.2* PTT-30.2 INR(PT)-2.4*
[**2160-3-13**] 02:19AM BLOOD Glucose-109* UreaN-46* Creat-1.5* Na-138
K-4.3 Cl-105 HCO3-22 AnGap-15
[**2160-3-13**] 02:19AM BLOOD CK-MB-8 cTropnT-0.20*
[**2160-3-13**] 10:19AM BLOOD CK-MB-6 cTropnT-0.19*
[**2160-3-13**] 07:55PM BLOOD cTropnT-0.13*
Discharge Labs
[**2160-3-15**] 04:37AM BLOOD WBC-4.5 RBC-2.78* Hgb-9.2* Hct-26.5*
MCV-95 MCH-33.2* MCHC-34.9 RDW-21.4* Plt Ct-143*
[**2160-3-15**] 04:37AM BLOOD PT-22.0* PTT-29.4 INR(PT)-2.1*
[**2160-3-15**] 04:37AM BLOOD Glucose-101* UreaN-38* Creat-1.5* Na-141
K-4.0 Cl-108 HCO3-24 AnGap-13
[**2160-3-15**] 04:37AM BLOOD ALT-11 AST-19 LD(LDH)-208 AlkPhos-39*
TotBili-0.5
[**2160-3-15**] 04:37AM BLOOD Calcium-7.7* Phos-2.6* Mg-2.3
Brief Hospital Course:
[**Age over 90 **]M with autoimmune hemolytic anemia, mechanical aortic valve on
coumadin and recurrent GIB and admissions for anemia presenting
from rehab with anemia, HCT 19 and guaiac positive stool.
.
#. Anemia: Most likely related to recurrent ongoing GIB given
dark guaiac positive stool and negative hemolysis labs.
Continued prednisone for AIHA. He has had work up in past
including colonoscopy and capsule endoscopy without finding
source of bleed. Guaiac positive although remained
hemodynamically stable. Received 4 units of pRBC. The patient
declined any further work up such as endoscopy. Discussed with
Dr. [**Last Name (STitle) **] (outpatient hematologist) and will plan to monitor
and transfuse as needed as an outpatient. He was discharged to
his nursing home with instructions to monitor HCTs and INR q2-3
days. He will continue on PO PPI [**Hospital1 **]. His carvedilol was held
due to BPs in 100s/60s and HR 70s.
.
#. Mechanical Aortic valve: The patient has a goal INR of [**3-5**].5
per Dr. [**Last Name (STitle) **]. He wishes to be closer to 2. Currently on
coumadin 4mg dailiy. This will need to be followed as an
outpatient adn adjusted for INR goal of 2.
.
#. Chest pressure/Elevated trop: Resolved. Also has slight ST
depressions on ECG. Likely demand ischemia in setting of anemia
and GIB. Patient ruled out for acute myocardial infarction and
troponins trended down. He had no further episodes of chest
pressure during hospital stay.
.
#. Dysuria: Patient had reports of dysuria but denied UA or
foley at this time. He remained afebrile and without
leukocytosis.
.
#. GERD: PO PPI.
.
#. CAD/Hyperlipidemia/HTN: Continued statin. Held carvedilol in
setting of GIB and stable blood pressures. Can restart as
outpatient as necessary.
.
Medications on Admission:
Carvedilol 3.125 mg Tablet 1 (One) Tablet(s) by mouth twice a
day
Folic acid 1 mg Tablet 4 (Four) Tablet(s) by mouth daily
Levothyroxine 75 mcg Tablet 1 Tablet(s) by mouth once a day
Omeprazole 40 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by
mouth twice a day
Prednisone 10 mg Tablet 1 (One) Tablet(s) by mouth daily.
Simvastatin 40 mg Tablet 1 Tablet(s) by mouth every evening
Bactrim 400 mg-80 mg Tablet 1 Tablet(s) by mouth once a day
Warfarin 4.5 mg by mouth daily
Acetaminophen 650 mg Tablet 1 Tablet(s) by mouth every 6 hours
as needed for pain
Bisacodyl [Dulcolax] 5 mg Tablet, Delayed Release (E.C.)
2 Tablet(s) by mouth every two days
Cyanocobalamin (vitamin B-12) [Vitamin B-12] 1,000 mcg Tablet
2 (Two) Tablet(s) by mouth daily [**2159-6-4**]
Docusate sodium [Colace] 100 mg Capsule 1 Capsule(s) by mouth
twice a day (Prescribed by Other Provider)
Senna 8.6 mg Tablet 2 Tablet(s) by mouth at bedtime
nr zinc oxide 40 % Ointment topical as needed for prn .
Discharge Medications:
1. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
7. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Four (4)
Tablet PO DAILY (Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis: GI bleed; Anemia
Secondary Diagnosis: Autoimmune hemolytic anemia, Mechanical
aortic valve on coumadin, recurrent GI bleeds, GERD
Discharge Condition:
Mental Status: Confused - sometimes.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with anemia and low blood
counts related to GI bleeding. You were seen by the GI doctors
who discussed [**Name5 (PTitle) 19824**] and benefits of different options with you
and you and yoru family decided not to pursue further invasive
prcedures to look for the source of the bleeding. You were
transfused 4 units of blood with improvement in your blood
counts.
We made the following changes to your medications
1. We held your carvedilol. This can be restarted if your blood
pressure remains stable.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
You should have your blood counts and coumadin level checked as
detailed.
Followup Instructions:
Please follow up with your physicians at [**Hospital 100**] rehab as well as
with your hematologist, Dr. [**Last Name (STitle) **].
Call ([**Telephone/Fax (1) 6179**] for an appointment with Dr. [**Last Name (STitle) **] next
week.
ICD9 Codes: 5789, 2851, 4280, 412, 2724 |
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