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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4200
} | Medical Text: Admission Date: [**2142-10-4**] Discharge Date: [**2142-10-14**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
R knee replacement c/b postop hypotension
Major Surgical or Invasive Procedure:
OR [**10-4**]: R TKA.
OR [**10-8**]: L TKA.
History of Present Illness:
ORTHO HPI: 86M w/ severe b/L OA, admitted to ortho for
sequential bilateral TKA. Pt was admitted to ICU for hypotension
and tachycardia x 3 which subsequently resolved and was
transferred to the floor. Pt ultimately underwent bilateral TKA
w/o complications.
ICU HPI: 86 y/o M with PMHx of arthritis, BPH & osteoporosis s/p
elective right total knee replacement c/b post-op hypotension.
Pt was not intubated, he received spinal anesthesia with
superifical femoral block and EBL was 160cc. After one
uneventful pain-free hour in PACU, patient began "rigoring", SBP
climbed into 200s and HR into 150s. Pt denied CP/SOB. After
receiving Labetalol 5mg IV with Metoprolol 2mg IV, SBP dropped
to 160. An EKG revealed sinus tachycardia with HR 103, and PACs.
AFter a second dose of Metoprolol 2.5mg IV, the pt's SBPs
dropped into 70s and the pt became lethargic and ashen [**Doctor Last Name 352**]. SBP
recovered to 100s after a neosynephrine bolus (100mcg); and the
SBP subsequently recovered to the 170s. An A-line was placed.
On arrival to ICU, the pt's SBP was measured to be elevated at
170/70 by the arterial line. The pt denied SOB and CP, but
complained of nausea that he attributed to not eating for 24hrs.
During an attempted PIV placement, the SBP suddenly dropped to
70/40s, HR remained in the 80s (T stable at 98.7, and BS 167).
Pt complained of lightheadedness, diaphoresis & nausea. After an
IVF bolus, the SBP recovered to 140s within minutes and symptoms
resolved.
.
ROS: Pt denied any recent fevers, chills, weight change, nausea,
vomiting, abdominal pain, diarrhea, constipation, melena,
hematochezia, chest pain, shortness of breath, cough, urinary
frequency, urgency, dysuria, lightheadedness, syncopal episodes.
Past Medical History:
Osteoporosis
Anemia (family h/o G6PD deficiency)
BPH
Osteoarthritis
Cataracts
s/p bilateral inguinal hernia repair
Social History:
Social History: Pt lives with daughter who is an internist and
denies any smoking, ETOH abuse
Living Situation: He lives with his wife in a single family home
in [**Country **]. He has one daughter who lives in [**Country **]. His other
daughter and son live here in [**Name (NI) 86**]. He is currently staying
with his daughter since [**Name (NI) 205**] for surgery.
Background: The patient is retired from working as an engineer.
Habits: No ETOH, Substance use, Quit smoking in [**2104**], 30
pack-years
Nutrition: 3 meals/day, no weight loss
Family History:
Family Medical History: Non-contributory
Physical Exam:
Vitals: T: 96 BP: 179/77 HR: 84 RR: 18 O2Sat: 100% on 2L
GEN: WDWN, pale but in no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, mucous membranes dry
COR: RRR, no appreciable M/G/R, normal S1 S2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E +DP/PT bilaterally, moving distal extremities well
Right knee drain with serosanguinous fluid, brace in place
NEURO: alert, oriented to hospital & month. CN II ?????? XII grossly
intact. Moves all 4 extremities. Strength 5/5 in upper and lower
extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
MS EXAM: wound c/d/i; no erythema; no SSD; [**Last Name (un) 938**]/TA/GS intact.
Pertinent Results:
[**2142-10-12**] 05:52AM BLOOD WBC-12.3* RBC-4.01* Hgb-9.0* Hct-28.0*
MCV-70* MCH-22.4* MCHC-32.1 RDW-19.1* Plt Ct-425
[**2142-10-11**] 06:50AM BLOOD WBC-11.5* RBC-4.41* Hgb-10.0* Hct-30.7*
MCV-70* MCH-22.7* MCHC-32.6 RDW-18.9* Plt Ct-358
[**2142-10-10**] 07:10AM BLOOD WBC-8.4 RBC-4.30* Hgb-10.1* Hct-29.8*
MCV-69* MCH-23.5* MCHC-33.9 RDW-18.6* Plt Ct-297
[**2142-10-9**] 08:14PM BLOOD WBC-9.1 RBC-4.42* Hgb-10.4* Hct-30.6*
MCV-69* MCH-23.5* MCHC-33.9 RDW-18.5* Plt Ct-297
[**2142-10-5**] 12:21AM BLOOD Neuts-84.2* Lymphs-10.4* Monos-5.1
Eos-0.2 Baso-0
[**2142-10-4**] 08:54PM BLOOD Neuts-70.2* Lymphs-24.3 Monos-4.5 Eos-0.8
Baso-0.2
[**2142-10-12**] 05:52AM BLOOD Plt Ct-425
[**2142-10-11**] 06:50AM BLOOD Plt Ct-358
[**2142-10-10**] 07:10AM BLOOD Plt Ct-297
[**2142-10-9**] 08:14PM BLOOD Plt Ct-297
[**2142-10-9**] 02:00AM BLOOD Plt Ct-252
[**2142-10-10**] 07:10AM BLOOD Glucose-108* UreaN-14 Creat-0.9 Na-133
K-4.5 Cl-99 HCO3-26 AnGap-13
[**2142-10-9**] 08:14PM BLOOD Glucose-154* UreaN-15 Creat-0.9 Na-138
K-4.2 Cl-103 HCO3-22 AnGap-17
[**2142-10-9**] 02:00AM BLOOD Glucose-96 UreaN-15 Creat-0.8 Na-137
K-3.7 Cl-104 HCO3-24 AnGap-13
[**2142-10-5**] 03:49PM BLOOD CK(CPK)-109
[**2142-10-5**] 12:21AM BLOOD CK(CPK)-69
[**2142-10-4**] 08:54PM BLOOD CK(CPK)-68
[**2142-10-5**] 03:49PM BLOOD CK-MB-3 cTropnT-<0.01
[**2142-10-5**] 12:21AM BLOOD CK-MB-3 cTropnT-<0.01
[**2142-10-4**] 08:54PM BLOOD CK-MB-3 cTropnT-<0.01
[**2142-10-5**] 12:21AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.3
[**2142-10-4**] 08:54PM BLOOD Calcium-7.2* Phos-3.4 Mg-1.3*
Brief Hospital Course:
ICU COURSE:
Assessment & Plan: 86 y/o M with PMhx of osteoarthritis and BPH
presentd for elective TKR today and has developped transient
recurrent episodes of hypotension with diaphoresis/nausea that
resolve with small IVF bolus.
.
# Hypotension: [**3-17**] spinal anesthesia +/- autonomic dysfunction
given recovery with IVfs and discontinuation of anesthetic. No
evidence of wound infection, sepsis, inferior MI, hypovolemia
2/2 blood loss given minimal EBL, or adverse reaction to beta
blockers. Empiric vancomycin and ceftriaxone for possible UTI
were initiated. All antihypertnesives were held, and SBP
recovered. A rule-out MI with 3x cardiac enzymes/ECGs was
negative.
- monitor sbps & bolus IVF prn
- f/u blood/urine cultures
- Trend WBC count fever curve
- NPO for now
.
# s/p TKR: Pain was well controlled by femoral block. Lovenox
was held post op until POD1.
- lovenox till am per ortho recs
- f/u ortho recs
- monitor drainage and distal pulses
.
# FEN: NPO for now except meds/ice chips
- monitor lytes & replete prn
.
# Access: 2 x PIVs
.
# PPx: Pneumoboots, PPI, bowel regimen
- per ortho, lovenox to start in am
.
# Code: FULL confirmed with HCP
.
# Dispo: oRtho
.
# Comm: with patient & daughter/HCP
FLOOR TRANSFER
Once patient was transferred to the floor after 24hrs of
observation, pt had no similar episodes of hypotension. Pt
remained slightly tachycardic at 100-110. He did have an episode
of tachycardia to 140-150s without any stimulus, but no reasons
were found. Cardiology was consulted who recommended lopressor
100 [**Hospital1 **]. ECHO and EKGs were normal. Troponin were normal. Pt was
ultimately cleared for his R TKA ([**2142-10-4**]) on POD4 from LTKA
([**2142-10-8**]). PT was taken to the operating room by Dr.
[**Last Name (STitle) **] where the patient underwent uncomplicated R TKA. The
procedure was well
tolerated and there were no complications. Please see the
separately
dictated operative report for details regarding the surgery. The
patient was subsequently transferred to the post-anesthesia care
unit
in stable condition and transferred to the floor later that day.
Overnight, the patient was placed on a PCA for pain control. IV
antibiotics were continued for 24 hours postoperatively as per
routine. Lovenox was started the morning of postop day 1 for DVT
prophylaxis. The patient was placed in a CPM machine with range
of
motion set at 0-45 degrees of flexion up to 90 degrees as
tolerated for both knees.
The drain was removed without incident. The patient was weaned
off of
the PCA onto oral pain medications. The Foley catheter was
removed
without incident. The surgical dressing was also removed, and
the
surgical incision was found to be clean, dry, and intact without
erythema nor purulent drainage.
During the hospital course the patient was seen daily by
physical
therapy. Labs were checked both post-operatively and throughout
the
hospital course and repleted accordingly. The patient was
tolerating
regular diet and otherwise feeling well. Prior to discharge the
patient was afebrile with stable vital signs. Hematocrit was
stable
and pain was adequately controlled on a PO regimen. The
operative
extremity was neurovascularly intact and the wound was benign.
The
patient was discharged to rehabilitation in a
stable condition.
CARDIOLOGY A/P: lopressor 100 [**Hospital1 **]; tachycardia likely d/t atrial
tach; can f/u with outpt; ECHO NL; unremarkable EKG; trop neg in
ICU.
GERIATRICS A/P: some crackles in LLL; CXR largely neg w/ some
haziness of LLL; no fever; no respiratory distress -> empiric
augmentin 500 x 10days for PNA coverage.
Medications on Admission:
Fosamax 70 mg qweek
Flomax 0.4 mg daily (inconsistent)
Calcium 500 mg daily,
Multivitamin daily
Tylenol 500 mg p.r.n.
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q 8H (Every 8 Hours).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Multivitamin 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. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once
a day for 3 weeks: after lovenox for 3 wks, start aspirin.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
12. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 10 days.
13. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q4H (every 4
hours) as needed for pain.
14. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
bilateral TKA
Discharge Condition:
stable
Discharge Instructions:
should experience: severe pain not relieved by medication,
increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage at the incision
site,
chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new
medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for your pain control. Please
do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain
medication. This medication can cause constipation, so you
should
drink plenty of water daily and take a stool softener as needed
to
prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or
your primary physician.
6. Please keep your wounds clean. You can get the wound wet or
take a
shower starting 5 days after surgery, but no baths or swimming
for at
least 4 weeks. No dressing is needed if wound continued to be
non-draining. Any stitches or staples that need to be removed
will be
taken out at your 2-week follow up appointment, by your PCP or
at
rehab.
7. Please call your surgeons/doctors office to [**Name5 (PTitle) **] or
confirm
your follow-up appointment.
ANTICOAGULATION: Please take lovenox injections (40mg) once a
day x 3
weeks and then take aspirin 325 mg twice a day x 3 weeks. [**Month (only) 116**]
discontinue all blood thinners 6 weeks post-operatively. Please
call [**First Name9 (NamePattern2) 22369**] [**Doctor Last Name **] at [**Telephone/Fax (1) 22370**] with any questions.
WOUND CARE: Keep your incision clean and dry. Okay to shower
after
POD#5 but do not tub-bath or submerge your incision. Please
place a
dry sterile dressing to the wound each day if there is drainage,
leave
it open to air. Check wound regularly for signs of infection
such as
redness or thick yellow drainage. Staples will be removed by VNA
in 2
weeks. If you are going to rehab, then rehab can remove staples
at 2
weeks.
ACTIVITY: Weight bearing as tolerated bilaterally; RLE can be a
routine TKA pathway, without any strict precautions; LLE must
have [**Doctor Last Name 6587**] brace w/ 5degrees of valgus stress to protect
lateral collateral ligaments, especially when walking; pt can
loose the [**Doctor Last Name 6587**] when in bed for comfort.
VNA (after home): Home PT/OT, dressing changes as instructed,
and
wound checks, staple removal in 2 weeks after surgery.
Physical Therapy:
Weight bearing as tolerated bilaterally; RLE can be a routine
TKA pathway, without any strict precautions; LLE must have
[**Doctor Last Name 6587**] brace w/ 5degrees of valgus stress to protect lateral
collateral ligaments, especially when walking; pt can loosen the
[**Doctor Last Name 6587**] when in bed for comfort.
Treatments Frequency:
should experience: severe pain not relieved by medication,
increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage at the incision
site,
chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new
medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for your pain control. Please
do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain
medication. This medication can cause constipation, so you
should
drink plenty of water daily and take a stool softener as needed
to
prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or
your primary physician.
6. Please keep your wounds clean. You can get the wound wet or
take a
shower starting 5 days after surgery, but no baths or swimming
for at
least 4 weeks. No dressing is needed if wound continued to be
non-draining. Any stitches or staples that need to be removed
will be
taken out at your 2-week follow up appointment, by your PCP or
at
rehab.
7. Please call your surgeons/doctors office to [**Name5 (PTitle) **] or
confirm
your follow-up appointment.
ANTICOAGULATION: Please take lovenox injections (40mg) once a
day x 3
weeks and then take aspirin 325 mg twice a day x 3 weeks. [**Month (only) 116**]
discontinue all blood thinners 6 weeks post-operatively. Please
call [**First Name9 (NamePattern2) 22369**] [**Doctor Last Name **] at [**Telephone/Fax (1) 22370**] with any questions.
WOUND CARE: Keep your incision clean and dry. Okay to shower
after
POD#5 but do not tub-bath or submerge your incision. Please
place a
dry sterile dressing to the wound each day if there is drainage,
leave
it open to air. Check wound regularly for signs of infection
such as
redness or thick yellow drainage. Staples will be removed by VNA
in 2
weeks. If you are going to rehab, then rehab can remove staples
at 2
weeks.
ACTIVITY: Weight bearing as tolerated bilaterally; RLE can be a
routine TKA pathway, without any strict precautions; LLE must
have [**Doctor Last Name 6587**] brace w/ 5degrees of valgus stress to protect
lateral collateral ligaments, especially when walking; pt can
loose the [**Doctor Last Name 6587**] when in bed for comfort.
VNA (after home): Home PT/OT, dressing changes as instructed,
and
wound checks, staple removal in 2 weeks after surgery.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 4599**] [**Last Name (NamePattern1) 9856**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2142-11-9**] 10:40
Cardiology: [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD; [**Hospital1 1170**]
[**Location (un) 830**], E/RW-453
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
ICD9 Codes: 486, 5990, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4201
} | Medical Text: Admission Date: [**2146-3-14**] Discharge Date: [**2146-3-16**]
Date of Birth: [**2102-5-20**] Sex: F
Service: MEDICINE
Allergies:
Dilantin / Penicillins / Dexamethasone / Carbamazepine /
Dilaudid / Doxycycline
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 yr old with hx of left frontal low-grade oligodendroglioma
presenting with severe headache. She suffered at tumoral site
and gross total resection on [**2142-9-26**]. Disease free until this
year with re emergence of mass diagnosed by stereotactic biopsy
[**2146-2-24**] as anaplastic Oligoastrocytoma. She was scheduled for
debulking surgery on thursday and had an MRI 3/ 26/ 09 without
gross change.
.
Reports intermittent low grade headache over the course of two
weeks but with 10/10 throbbing diffuse non radiating headache
since [**46**] AM unrelieved by hydromorphone. No improvement with
increased gabapentin. Given continued headache LP performed [**3-11**]
negative.Given continued pain to [**Hospital 2079**] hospital. There an
CT non con performed with no new change. No focal neurological
deficits. Transferred to [**Hospital1 18**].
.
In ED, vital signs 96.4, 64, 109/66, 18 100%RA. complaining of
severe headache. Compazine 10 mg IV x 1, Morphine 4 mg IV x 3,
Zofran Iv x1 given. Neurosurgery consulted. Felt no acute change
and potential for DC from ED. Given continued pain patient was
admitted.
ROS is negative otherwise.
.
ROS: + headache, photophobia, phonophobia, mild blurry vision
no neck stiffness, fever, chills, weakness, parasthesias,
urinary or bowel incontinence
Past Medical History:
1. Low-grade oligodendroglioma (with secondary seizure disorder)
s/p bleed at tumoral site and gross total resection of a left
frontal low-grade oligodendroglioma by Dr. [**Last Name (STitle) **] on [**2142-9-26**].
It has recurred as an anaplastic Oligoastrocytoma. The treatment
options include surgical debulking followed by temozolomide
chemo-irradiation, or temozolomide chemo-irradiation alone. She
has received a functional head MRI before making a debulking
decision.
2. IBD.
3. Hypothyroidism.
4. Depression.
5. Hysterectomy: menorrhagea
6. MR.
Social History:
She lives alone in an apartment. She previously worked as a
dietary aid, but she is no longer working. She does not use
tobacco or drink alcohol. She is not married. She has no
children. She is close with her parents and her brother. She
lives in [**Location 63146**]
Family History:
Her father has back pain and had a laminectomy. Her mother has
multiple sclerosis. Her brother has "[**Doctor Last Name **]" muscular
dystrophy. Her maternal grandmother had DVT, coronary artery
disease, and [**Doctor Last Name 499**] cancer. Her maternal grandfather had
cirrhosis of the liver and lung cancer. No hx of brain tumors.
Physical Exam:
VS: 96.3, 103/51, 64, 18, 95%RA
GEN: Middle-aged man laying in bed whispering
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP
moist and without lesion
NECK: Supple, no JVD, no neck stiffness
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM
EXT: No c/c/e
SKIN: No rash
NEURO: Alert, oriented x 3. Able to relate history without
difficulty. Normal Affect. Speech fluent, Cranial nerves II-XII
grossly intact. Normal bulk, strength and tone throughout. No
asterixis, sensation intact. No nystagmus, dysarthria, intention
or action tremor.
Pertinent Results:
[**2146-3-13**] 04:50PM BLOOD WBC-5.7 RBC-4.46 Hgb-13.9 Hct-38.8 MCV-87
MCH-31.0 MCHC-35.7* RDW-13.2 Plt Ct-170
[**2146-3-13**] 04:50PM BLOOD Neuts-61.3 Lymphs-31.2 Monos-3.4 Eos-3.6
Baso-0.5
[**2146-3-14**] 06:45AM BLOOD Plt Ct-171
[**2146-3-13**] 04:50PM BLOOD PT-14.0* PTT-25.0 INR(PT)-1.2*
[**2146-3-13**] 04:50PM BLOOD Glucose-89 UreaN-11 Creat-0.8 Na-142
K-3.8 Cl-111* HCO3-23 AnGap-12
[**2146-3-14**] 06:45AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.2
[**2146-3-16**] 07:00AM BLOOD WBC-6.6 RBC-4.56 Hgb-14.0 Hct-38.8 MCV-85
MCH-30.6 MCHC-36.0* RDW-12.6 Plt Ct-193
[**2146-3-16**] 07:00AM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-146*
K-3.8 Cl-111* HCO3-23 AnGap-16
[**2146-3-15**] 07:05AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2
[**3-15**] CT head with and without contrast
IMPRESSION:
Post-surgical sequela at the left frontal lobe with no evidence
of hemorrhage,
abnormal enhancement or herniation. Study is unchanged from that
done two
days earlier.
Brief Hospital Course:
43 yr old with resected low grade oligodendoglioma with
recurrence (anaplastic oligoastrocytoma) presented with
headache.
.
1. Headache: likely secondary to intracranial mass. No focal
neurologic deficits. fMRI on [**3-10**] was unchanged from prior.
Scheduled for tumor debulking on [**3-17**]. Also with recent LP
([**3-11**]) with potential worsening post LP headache. No evidence of
meningitis. Patient was evaluated by neurosurgery, who agreed
with pain control, and no further intervention. CT head with and
without contrast showed no subdural hematoma or evidence of
infection. Pain was controlled with Gabapentin, standing
tyelnol, and MS contin.
Patient was continued on antiseizure medications. Neurosurgery
evaluated the patient. Dr. [**Last Name (STitle) 724**], the patient's primary
neurooncologist was also [**Name (NI) 653**], who agreed with goal of pain
control, and surgical plans on [**3-17**].
Medications on Admission:
GABAPENTIN 300 mg TID- just increased from [**Hospital1 **]
LEVETIRACETAM 1000 mg mouth twice a day
ZONISAMIDE 400 mg qhs
LEVOTHYROXINE 100 mcg daily
PAROXETINE 40 mg daily
QUETIAPINE 75 mg at bedtime
HYDROMORPHONE - 2 to 4 mg every four (4) hours for HA
CALCIUM CARBONATE-VITAMIN D3: 500 mg (1,250 mg)-200 unit qd
MULTIVITAMIN
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Zonisamide 100 mg Capsule Sig: Four (4) Capsule PO QHS (once
a day (at bedtime)).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) for 7 days.
Disp:*56 Tablet(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. Headache secondary to oligodendroglioma.
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a severe headache. This is most likely
due to the oligodendroglioma. You had no changes in your
physical exam, or on recent imaging prior to admission.
Neurosurgery evaluated you and agreed that this pain is likely
secondary to your brain mass. You had a head CT that was
unchanged from prior. We started you on MS contin to control
the pain, in addition to tylenol and gabapentin.
Should you develop any changes in your vision, incontinence,
weakness or numbness in your arms or legs, or any other changes
that concern you please call your primary care doctor or go to
the emergency department.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 63147**] on [**3-21**] at 3:35pm.
The clinic phone number is [**Telephone/Fax (1) **].
Completed by:[**2146-3-16**]
ICD9 Codes: 2449, 4240, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4202
} | Medical Text: Admission Date: [**2191-5-24**] Discharge Date: [**2191-5-28**]
Date of Birth: [**2133-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
58yo M with DM, HTN, CHF, ESRD on peritoneal dialysis, h/o
necrotizing E.coli PNA in [**9-8**] resulting in LUL scar and chronic
volume overload presents with hemoptysis and hypoxia x 1day. Pt
was feeling generally well until 7:30 pm on [**5-23**] when he coughed
up ~ [**1-7**] cup of hemoptysis with some blood clots. Denies any
sob, palpitations, chest pain, no cough prior to hemoptysis,
rhinorrhea, nasal congestion, sore throat, fevers, but felt
somewhat LH and chills/cold. Denies any recent sick contact or
travel. Never been in prison, TB exposure or homeless. Pt still
smokes 1.5pack per day. Had some weight loss but gained it all
back. Denies night sweats.
.
In [**Name (NI) **], pt was afebrile, 90-92% on RA and 97% with 2L via NC. Pt
had another episode of hemoptysis ~[**1-6**] cup.
.
On ROS, denies any chosking/cough after eating, abdomianl pain,
constipation, n/v, nose bleeds, easy bleeding, hematochezia,
melena, diarrhea, orthopnea, PND and recently lost weight which
he gained all his weight back, worsening back pain, or LE
weakness. Denies skipping peritoneal dialysis.
Past Medical History:
1. ESRD: [**2-5**] anti-GBM disease, on HD since [**3-8**], then PD since
[**9-10**]
2. DM2
3. HTN
4. Chronic low back pain [**2-5**] herniated discs
5. diastiolic CHF- TTE [**12-10**] EF 75%, LVH
6. Peripheral neuropathy
7. Anemia
8. h/o nephrolithiasis
9. s/p cervical laminectomy; ?osteo in past
10. h/o depression
11. h/o MSSA bacteremia ([**3-10**]-infected HD catheter), E. coli
bacteremia
12. s/p L AV graft: [**7-8**]
13. h/o [**12-8**] of L4-5 diskitis, osteo, epidural abscess
14. MRSA cath tip infection
15. MSSA peritonitis [**6-11**]
16. thyroid nodule on u/s [**6-11**], recommended f/u 1 yr
17. wheelchair bound due to knee/muscle contraction since had a
PNA and ICU admission in [**2187**]
18. h/o IJ clot
Social History:
Lives w/ wife and son. Daughter-in-law, and three grandchildren
in [**Location (un) 86**] area, has been unemployed [**2-5**] disability, smokes
tobacco 2 ppd x45 years, past alcohol, denies current, no
recreational drug use. Does not walk due to knee contraction,
spinal disease. WC bound since [**2187**]. Wife manages his
medications.
Family History:
NC
Physical Exam:
VS: 98.3 148/78 80 19 100% on 3L, 89-90 on RA. FS 97.
GEN: Appears NAD, no tachypneic, no visible blood around mouth
HEENT: [**Year (4 digits) 3899**], PERRL, no oropharyngeal lesions, erythema.
No LAD, no JVD but difficult to assess
COR: distant HS RR
PULM: diffuse mild expiratory wheezing throughout
ABD: obese NT, BS+, + distension, L PD catheter NT, c/d/i
EXT: [**2-6**]+ edema to knees LEs
NEURO: Alert, oriented. CNs intact. Intact FTN. [**5-9**] UE strength.
Able to lift b/l legs partially, limited by pain.
Pertinent Results:
GLUCOSE-64* UREA N-43* CREAT-11.7* SODIUM-139 POTASSIUM-4.0
CHLORIDE-99 TOTAL CO2-27
CALCIUM-8.5 PHOSPHATE-5.6* MAGNESIUM-1.7
WBC-6.8 RBC-2.74* HGB-8.9* HCT-26.6* MCV-97 MCH-32.3* MCHC-33.4
RDW-16.1*
PLT COUNT-365
PT-13.2 PTT-31.9 INR(PT)-1.1
.
CXR (prelim read): PA AND LATERAL CHEST RADIOGRAPH: Cardiac and
mediastinal contours appear stable allowing for low lung
volumes. Pulmonary vascularity is within normal limits. There
are no focal consolidations or pleural effusions. Persistent
streaky opacity in the left mid lung is again identified, likely
representing
residual scar or atelectasis from the previously seen airspace
disease.
IMPRESSION: No evidence of acute cardiopulmonary process.
Persistent streaky opacity in the left lung likely representing
atelectasis, or scar from prior infection.
.
CTA chest (wet read): No PE. Increased opacity in region of left
upper lobe scar/cavity, concerning for possible superimposed
infection, or scar carcinoma. opacity in left bronchus possibly
blood or secretion. evidence of fluid overload.
[**2191-5-25**] 03:18AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-
Negative
.
[**5-24**] Sputum - [**2191-5-24**] 5:53 am SPUTUM Site: EXPECTORATED
Source: Expectorated.
GRAM STAIN (Final [**2191-5-24**]):
[**10-29**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
SMEAR REVIEWED; RESULTS CONFIRMED IN PAIRS.
RESPIRATORY CULTURE (Final [**2191-5-26**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
.
Time Taken Not Noted Log-In Date/Time: [**2191-5-24**] 3:22 pm
BRONCHIAL WASHINGS
GRAM STAIN (Final [**2191-5-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2191-5-26**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
BETA STREPTOCOCCI, NOT GROUP A. 10,000-100,000
ORGANISMS/ML..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2191-5-25**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
.
[**2191-5-24**] 9:29 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2191-5-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2191-5-27**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Time Taken Not Noted Log-In Date/Time: [**2191-5-25**] 2:21 pm
BRONCHIAL WASHINGS
GRAM STAIN (Final [**2191-5-25**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2191-5-27**]):
~1000/ML OROPHARYNGEAL FLORA.
BETA STREPTOCOCCI, NOT GROUP A. >100,000 ORGANISMS/ML..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2191-5-25**]):
TEST CANCELLED, PATIENT CREDITED.
Brief Hospital Course:
A/P: 58yo M with ESRD on PD, h/o E.coli pneumonia resulting in
LUL scar p/w hemotpysis and hypoxia.
.
1) Hemoptysis: The patient was admitted with hemoptysis. He was
admitted to the medical service and was stable overnight. On the
morning of [**5-24**] he had another episode of hemoptysis. He was
taken to the IP suite for bronchoscopy where he was found to
have large clot in the apico-posterior segment of his left upper
lobe. BAL/wash from the LUL was performed and sent for gram
stain & culture, fungal culture, and cytology. No intervention
was performed due to concern for bleeding. He was transferred to
the MICU for closer monitoring. He underwent a embolization of
the artery in LUL under IR and tolerated procedure well. Pt was
stable for transer to medical service. Hematocrit stable at ~29,
compared to most recent value in OMR dated [**3-11**]. In terms of
understanding what may have precipitated bleeding into the
mainstem bronchus, there is some increased opacity in the LUL on
CT scan which may represent superimposed infection vs.
malignancy. Patient also has a history of necrotizing pneumonia
with scarring in LUL; this may be a complication of chronic
scarring of this old lesion, causing in erosion of bronchial
artery, similar to [**Doctor Last Name **] aneurysm seen in TB patients. At
time of presentation, patient was notably afebrile with normal
WBC, prompting some concern for malignancy in this gentleman
with a long smoking history. Gram stain from BAL with GPC and
GNR, also sputum culture with GPC so pt started on vanco and
levofloxacin-in setting of changes on CT asl well. The patient
stable and was discharged home to complete a course of
levafloxacin. He was schedued to follow up in Pulmonary Clinic
for a repeat CT chest.
.
2) ESRD on PD: On admission the pt had abdominal tenderness on
exam and a sample of peritoneal fluid was sent for evaluation
revealing 2 WBC, no evidence for infection. He was continued on
PD with a 2.5 L/exchange, 6 exchanges/day, dwell time 4 hours
each. He was also continued on sevelamer, cinecalcet,
calcitriol.
.
3) DM: he was continued on neurontin for peripheral neuropathy
.
4) Hypertension: BP well controlled with PD.
.
5) Pain: Continued with management of chronic back pain on q4
hour methadone with PRN oxycodone.
.
6) Depression: Continued Paxil.
.
Medications on Admission:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
3. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO Qdinner.
Disp:*180 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours).
7. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Atorvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
12. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO EVERY
OTHER DAY (Every Other Day).
13. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
14. Nifedical 60mg qday
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 8 days: First day = [**5-24**].
Disp:*2 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours.
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO WITH LUNCH
AND DINNER ().
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours).
9. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for breakthrough pain.
12. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
13. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Hemoptysis
Secondary:
1. ESRD on Peritoneal Dialysis
Discharge Condition:
Afebrile, VSS
Discharge Instructions:
You were admitted after coughing up blood and were found to have
a scar and bleeding blood vessel in your left upper lung. You
underwent a bronchoscopy and cultures were taken to rule out
infection. You are being treated with levaquin for a lung
infection. Please complete your course of antibiotics as
directed.
.
It is very important that you undergo a CT scan of your chest to
monitor for resolution of your infection. You should follow up
in Pulmonary Medicine as scheduled.
.
Please continue to take your medications as directed.
.
Please return if you develop fever/chills. You should return
immediately if you begin to cough up blood again.
Followup Instructions:
Please follow up for your Chest CT scan on [**2191-7-11**] 10:00am in the
[**Hospital Unit Name 1825**] on the [**Location (un) 470**], on [**Hospital1 18**] [**Hospital Ward Name 516**] Building.
You should fast for three hours prior to your test. Provider:
[**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2191-7-11**] 10:15
.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**] in Pulmonary Medicine on
[**2191-7-13**] at 10:30am.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2191-7-13**] 10:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2191-7-13**] 11:00
.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] in Nephrology on
[**2191-6-29**] at 9:00am. Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D.
Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2191-6-29**] 9:00
.
You need to obtain a new primary care provider at [**Name9 (PRE) 191**]. Please
call [**Telephone/Fax (1) 250**] after [**6-5**] to schedule an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
ICD9 Codes: 5856, 3572, 4280, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4203
} | Medical Text: Admission Date: [**2161-4-22**] Discharge Date: [**2161-4-25**]
Date of Birth: [**2105-11-8**] Sex: F
Service: NEUROSURGERY
Allergies:
Taxol
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Brain mass, in need of shunt procedure
Major Surgical or Invasive Procedure:
3rd ventriculostomy
History of Present Illness:
55F with a history of metastatic breast cancer, who has right
and
left cerebellar brain metastases. Her oncological problem
started in [**2146**] when a right breast mass was discovered on
mammogram. She had lumpectomy and T2, N0, and M0 invasive
carcinoma was found. She received chest irradiation with CMF
(cyclophosphamide, methotrexate, and 5-FU), adjuvant
chemotherapy, followed by tamoxifen. In [**2149**], she had
recurrence with chest irradiation followed by tamoxifen. She
stopped tamoxifen in [**2151**]. In [**2156**], she
developed recurrent disease in the left breast. Metastatic work
up revealed metastases in lungs and bone. She received
Adriamycin and cyclophosphamide for 4 cycles, together with one
dose of taxol from which she developed an anaphylactic reaction.
She then completed whole brain cranial irradiation on
[**2160-8-6**].
She was admitted to neurosurgery for 3rd ventriculostomy so that
she could undergo radiation treatment in her brain for
metastases.
Past Medical History:
See above, plus:
hypertension and sarcoidosis.
Past Surgical History: She had breast surgeries, a right
lumpectomy in [**2146**] and a left lumpectomy in [**2149**]. She had a
lung
biopsy in [**2156**].
Social History:
She does not smoke cigarettes or drink alcohol. Has a fiance.
Family History:
Mother died of breast cancer. An aunt from the
maternal side has breast cancer but it is under control. Her
father is healthy. She has 2 uncles, one died of
smoking-related
lung cancer while another is alive with non-smoking-related
cancer. There are other members of her family with diabetes.
Physical Exam:
On discharge:
She is awake, alert, and oriented times 3. Her language is
fluent with good comprehension, naming, and repetition. Her
recent recall is good. Cranial Nerve Examination: Her pupils
are equal and reactive to light, 4 mm to
2 mm bilaterally. Extraocular movements are full. Visual
fields
are full to confrontation. Her face is symmetric. Facial
sensation is intact bilaterally. Her hearing is intact
bilaterally. Her tongue is midline. Palate goes up in the
midline. Sternocleidomastoids and upper trapezius are strong.
Motor Examination: She does not have a drift. Her muscle
strengths are [**6-15**] at all muscle groups. Her muscle tone is
normal. Her reflexes are 2- and symmetric bilaterally. Her
ankle jerks are absent. Her toes are downgoing. Sensory
examination is intact to touch. Coordination
examination does not reveal dysmetria. Her gait is normal. She
does not have a Romberg.
Head: incision CD&I with vertical mattress sutures in place, no
bleeding present
CV: RRR, no murmurs
Chest: CTAB
Abd: S/ND/NT +BS
Ext: wwp
Pertinent Results:
[**2161-4-25**] 07:20AM BLOOD WBC-4.1 RBC-2.98* Hgb-10.9* Hct-32.2*
MCV-108* MCH-36.5* MCHC-33.8 RDW-14.4 Plt Ct-198
[**2161-4-25**] 07:20AM BLOOD PT-12.6 PTT-38.3* INR(PT)-1.1
[**2161-4-25**] 07:20AM BLOOD Plt Ct-198
[**2161-4-24**] 11:00AM BLOOD FacVIII-72
[**2161-4-23**] 05:12AM BLOOD Glucose-109* UreaN-6 Creat-0.8 Na-142
K-3.8 Cl-108 HCO3-27 AnGap-11
[**2161-4-25**] 07:20AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.1
[**2161-4-23**] 05:12AM BLOOD Calcium-9.4 Phos-3.1 Mg-2.1
[**2161-4-23**] 05:12AM BLOOD Glucose-109* UreaN-6 Creat-0.8 Na-142
K-3.8 Cl-108 HCO3-27 AnGap-11
Brief Hospital Course:
Pt was admitted to neurosurgical service for scheduled
procedure. She underwent a head CT for stereotactic planning on
the day of admission. She then was taken to the operating room
and underwent ventriculoscopy. She tolerated this procedure
with no complications. (for full details of procedure, see
dictated operative report.)
Hospital course by system:
Neuro: the patient tolerated the surgery well with no resulting
neurological deficits. She was monitored in the PACU overnight
with hourly neuro checks and then transferred to the floor POD1.
On the day of discharge she was completely neurologically
intact (see exam above).
CV: no issues, pt remained hemodynamically stable throughout
hospitalization
Pulmonary: no issues, pt received incentive spirometry post-op
and lungs were CTA
GI: no issues, tolerating full diet on day of discharge
GU: no issues, pt making adequate urine without foley on day of
discharge
ID: The pt received perioperative antibiotics and post
operative vanc/gent for 3 doses each. on the day of discharge
she was afebrile with no elevated white count.
HEME: Prior to the procedure she received 2000U of Factor 8 per
recommendations of hematology due to her Factor 8 deficiency.
She received 2000U 12hours later and a third dose 12 hours after
the second dose. her followup factor 8 level was 72
postoperatively which was therapeutic. Of note, she did have
some slight oozing from the incision site, this was corrected
easily by over-suturing the incision. On the day of discharge
her HCT had decreased slightly to 33, but was hemodynamically
stable with no bleeding from the wound. she had followup with
heme planned.
Oncology: pt had plans for followup with radiation oncology and
brain tumor clinic provided to her.
on the day of discharge the pt was hemodynamically stable and
good with pain controlled, afebrile with plans for followup.
Medications on Admission:
Tykerb
Diovan
Iron
Vit B6
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: DO NOT DRIVE OR DRINK
ALCOHOL WITH THIS MEDICATION. TAKE A STOOL SOFTENER WITH THIS
MEDICATION.
Disp:*60 Tablet(s)* Refills:*0*
4. Tykerb 250 mg Tablet Oral
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Breast cancer with metastasis to brain
Discharge Condition:
Stable and good
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
You will follow-up with Radiation/oncology Dr. [**Last Name (STitle) 3929**] for
cyberknife planning on Monday [**2161-4-27**] at 9am on [**Hospital Ward Name 23**] 5. Call
[**Telephone/Fax (1) 15755**] for confirmation.
.
You have a Brain [**Hospital 341**] Clinic appointment with Provider: [**Name10 (NameIs) 640**] [**Name8 (MD) 15756**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2161-5-11**] 3:00. This is on
the [**Location (un) 858**] of the [**Hospital Ward Name 23**] Building on the [**Hospital Ward Name 516**].
.
PLEASE RETURN TO THE OFFICE IN 10 DAYS FOR REMOVAL OF YOUR
STAPLES/SUTURES. Please call [**Telephone/Fax (1) **] to arrange.
.
ALSO PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS from today
.
You should also follow-up with hematology. Please call their
office to make an appointment with [**First Name11 (Name Pattern1) 916**] [**Last Name (NamePattern4) **], MD [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 15757**] [**Last Name (NamePattern1) **],MD. Please call their office to make an
appointment: ([**Telephone/Fax (1) 11576**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4204
} | Medical Text: Admission Date: [**2120-7-26**] Discharge Date: [**2120-7-31**]
Date of Birth: [**2061-5-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Tracheobronchomalacia
Major Surgical or Invasive Procedure:
Right thoracotomy, thoracic tracheoplasty w/mesh,
Right main stem bronchus/bronchus intermedius bronchoplasty
w/mesh, Left main stem bronchus bronchoplasty w/mesh
Bronchoscopy with bronchoalveolar lavage
History of Present Illness:
Ms [**Known lastname 80947**] is a 59 y/o female who has had lifelong respiratory
problems given many diagnoses and treatments without true
resolution. She was evaluated with bronchoscopy and noted to
have tracheobronchomalacia, which was also confirmed on CT. She
had a stent placeed with significant improvement of her
breathing. The stent was removed 3 weeks later secondary to
pneumonia. She was evaluated in clinic for a
tracheobronchoplasty.
Past Medical History:
HTN
Hyperlipidemia
Fibromalgia
Right CEA followed by stenting 13 yrs later
Hysterectomy
Recurrent pneumonias
Cataracts
PVD
Social History:
Ex smoker 33pack year history quit in [**2105**]. No ETOH. Silica
exposure: worked in fiber-optics currently retired. Married.
Lives with family.
Family History:
Mother "Breathing problems"
Offspring Daughter with "Breathing problem"
Physical Exam:
VS: 98.1 66 109/53 18 96%RA
Gen: Alert and Oriented x 3. NAD. WD/WN female.
Cardiac: RRR no m/r/g/c
Pulm: CTA Bilaterally (decreased breathsounds in the bases B)
Abdomen: +BS, soft, ND/NT
Ext: Spider bite on medial aspect of left knee improving.
Decreased erythema, no edema, no induration
Pertinent Results:
[**2120-7-29**] 02:34AM BLOOD WBC-9.2 RBC-3.78* Hgb-11.1* Hct-33.3*
MCV-88 MCH-29.3 MCHC-33.2 RDW-14.3 Plt Ct-314
[**2120-7-30**] 09:30AM BLOOD Glucose-134* UreaN-7 Creat-0.8 Na-139
K-3.8 Cl-101 HCO3-30 AnGap-12
[**2120-7-30**] 09:30AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2
Brief Hospital Course:
Mrs. [**Known lastname 80947**] was admitted to the hospital and on [**2120-7-26**] she
had a R thoracotomy and tracheobronchoplasty. The patient
tolerated the procedure well and was extubated immediately
postoperatively. She was taken to the ICU for observation of her
respiratory status postoperatively. Her CT and epidural were
d/ced on POD 2 and her pain was well controlled with PO pain
medications and toradol. Her diet was advanced to regular.
However her BP was sensitive to narcotics so she was kept in the
ICU until her pain was adequately controlled with an acceptable
BP. She did not require pressors. She was transfered to the
floor on POD 3 and her home medications were started. She
continued to do well on the floor, her saturations were within
normal limits on oxygenation, she ambulated without breathing
issues. She was discharged home on POD 6.
Medications on Admission:
Atenolol 50', Benzonatate 100'''prn, Cilostazol 100'',
Cyclobenzaprine 10HS, Lisinopril 20', Ativan 1'', Zantac 150'',
Zoloft 100', Zocor 10', Guaifenesin
Discharge Medications:
Atenolol 50mg', Cyclobenzaprine 10mg qhs, Lisinopril 20mg',
Lorazepam 0.5mg qhs prn insomnia, Pletal 100mg'', Ranitidine
150mg'', Sertraline 100mg', Zocor 10mg', Keflex 500mg qid (Stop
on [**8-3**]), Dilaudid 2-4mg PO q3hrs PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
tracheo-broncho malacia
Discharge Condition:
Stable
Discharge Instructions:
Please Call Dr. [**Last Name (STitle) **] with any questions or concerns
[**Telephone/Fax (1) 3020**].
Call with fevers greater than 101.5
Call with increased cough or secretions
call with increased shortness of breath and or chest pain.
You may shower today. Do not soak/swim x 6 weeks.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2120-8-20**]
10:30am CDC [**Location (un) **] Far Building
Please make an appointment with your primary care physician
[**Name Initial (PRE) 176**] 2 weeks of your discharge.
ICD9 Codes: 4019, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4205
} | Medical Text: Admission Date: [**2144-10-21**] Discharge Date: [**2144-11-6**]
Date of Birth: [**2067-7-11**] Sex: F
Service: VSU
HISTORY OF PRESENT ILLNESS: This is a 77-year-old female
that presented to the emergency room on [**2144-10-21**] with
right foot ulcers over the dorsum of her foot and heel with
associated fevers. The patient, of note, had had a recent
right total hip replacement and total knee replacement and
had suffered a severely comminuted segmental femur fracture
that was periprosthetic in nature in [**Month (only) 216**] of this year.
This had been repaired with open reduction and internal
fixation of the right femur, and she also had had a traction
pin during this time. Now these ulcers were in the area of
this traction pin, and she had noticed that over the last 2-3
days prior to her presentation, she had also experienced some
chills. She also noted increased swelling and redness over
the dorsum of her right foot and toes that was beginning to
extend up her ankles. She had been due to see Dr. [**Last Name (STitle) **]
on [**10-22**], however came to the emergency room due to the
progression of these symptoms. Her family was also able to
provide a significant amount of history and also noted that
they thought the swelling and redness had increased.
Originally, it was contained to the dorsum of her foot near
where the traction had taken placed and had now migrated
slightly up her ankle.
PHYSICAL EXAMINATION ON ADMISSION: Temperature in the
emergency room was 99.8 degrees Fahrenheit, heart rate 90,
blood pressure 110/53, respiratory rate of 16, and she was
93% on room air. She was in no apparent distress and was
comfortable and was well-appearing in general. Her lungs were
clear to auscultation bilaterally without any wheezes, rales
or rhonchi. Her heart was in regular rate and rhythm, with no
murmurs, rubs or gallops. Her abdomen was soft, nontender and
nondistended. She was noted to be obese. On her vascular
exam, she had palpable femoral pulses bilaterally and
Dopplerable popliteals bilaterally, and monophasic dorsalis
pedis and posterior tibialis pulses bilaterally. She was
noted to have a significant eschar over the dorsum and one
over her heel with significant erythema progressing up above
both malleoli with 2+ pitting edema there. There was also
noted to be some malodorous, purulent material that was able
to be expressed from the borders of the ulcer. The area was
also noted to be warm to the touch, and the patient did not
have any tenderness to palpation in these areas. Her affect
and mood were normal.
PAST MEDICAL HISTORY: Consisted of aortic stenosis,
congestive heart failure with EF of 55% on echocardiogram,
atrial fibrillation for which she was on warfarin, chronic
obstructive pulmonary disease, mitral valve regurgitation,
positive [**Doctor First Name **] antibody, osteoporosis, venous stasis,
peripheral neuropathy, history of Clostridium difficile in
the past and spinal stenosis.
MEDICATIONS ON ADMISSION: Amiodarone 200 mg once a day,
Lasix 80 mg every other day p.o., Prilosec 20 mg once daily,
prednisone 10 mg once daily, Toprol 25 mg once daily,
Coumadin 5 mg once daily, ferrous sulfate 325 mg once daily,
ipratropium, Neurontin 600 mg t.i.d., potassium chloride 20
mg b.i.d. and latanoprost eye drops.
PERTINENT LABORATORIES ON ADMISSION: Her white count was
18.4 in the emergency room with hematocrit of 33.4, and a
platelet count of 447. Electrolytes were within normal limits
with a creatinine of 0.8 which was at her baseline, and a
blood sugar of 113. Her urinalysis was negative at this time.
HOSPITAL COURSE: At this time, the patient was admitted to
the vascular service under Dr.[**Name (NI) 5695**] care for further
evaluation and treatment. She was seen also by the orthopedic
service during this time who followed the patient closely.
The patient was started on broad-spectrum antibiotics which
included vancomycin and gentamicin which were dosed
appropriately by levels, and evaluation continued with plain
films of the right foot that showed extensive soft tissue
swelling but no evidence of osteomyelitis. We also assessed
her for deep vein thrombosis at this time and this was
negative.
She was noted to have defervesced by hospital day #2 with her
temperature maximum at 99.3, and she reported that she was
feeling better at this time. On hospital day 3, an angiogram
was performed by Dr. [**Last Name (STitle) **] to evaluate the circulation
in her right leg to evaluate her ability to heal this ulcer.
An abdominal aortogram with right lower extremity runoff was
performed. At this time, the findings included a normal
infrarenal abdominal aorta with patent iliac arteries and
patent common femoral artery on the right side with normal
deep femoral and superficial femoral arteries. The disease
was noted to be localized to the posterior tibialis which
occluded early in the runoff and was noted to be heavily
calcified. No pedal vessels were visualized during this
angiography. The patient was then continued on antibiotics,
however continued to have difficulty healing this wound on
her right heel and over the dorsum of her foot. Microbiology
had now come back from this wound which revealed a growth of
Proteus of moderate amounts and Enterococcus of moderate
amounts. This was done fro the dorsum of the right foot along
with some sparse staph growth. These were sensitive to
everything but ampicillin and ciprofloxacin. The patient was
continued on the antibiotics that she was started on
admission, vancomycin and gentamicin.
It was then determined, based on the patient's lack of
improvement in terms of these ulcers, and the fact that she
now appeared to be having slightly increasing erythema, that
the distal right lower extremity would be unsalvageable. She
had also positive blood cultures at this time which grew back
coagulase-negative staph that was resistant to oxacillin, and
the fact that she was occluded in both her posterior tibial
and dorsalis pedis arteries with no possibility for
reconstruction, so she was brought to the operating room on
hospital day #8, [**2144-10-28**], for a right below-the-knee
amputation which she tolerated well, and in the postoperative
period there were no issues until the morning of
postoperative day 1, when the patient became acutely short of
breath while in the vascular intensive care unit on Far-11.
The patient was, at this point, evaluated, and a chest x-ray
was performed which revealed mild fluid overload. The patient
was not hemodynamically unstable during this time; however,
it was determined that the patient would be best served by
being transferred to the surgical intensive care unit. She
was transferred there, and later that day spiked a
temperature of 102.3 degrees Fahrenheit, for which another
set of pancultures were sent. The patient's antibiotic
coverage was broadened to include vancomycin, levofloxacin
and Flagyl at this time which she remained on until
discharge.
The patient underwent a full work-up at this time because she
briefly required vasopressor agents including Levophed at a
fairly low dose. She was able to be weaned off this without
significant difficulty. She did also have a cortisone stim
test which she passed, and she did not require extra
exogenous steroids. She was, however, given a stress dose of
Solu Medrol 10 mg for 3 days, and then was able to be
transferred back to her regular dose of prednisone. The
patient continued to improve in the postoperative day period,
and after successfully diuresing off some extra fluid, she
was deemed fit for transfer to the floor. By the time she was
discharged, however, she had yet to be moved to the floor,
and of note, further studies during her stay in the intensive
care unit including a CAT scan of the abdomen which revealed
a questionable hypodense lesion at the level of the ampulla
and the head of the pancreas. An MRC was recommended to
exclude a mass. The patient was deemed not fit for this study
at this time due to the fact that she had been recently on
vasopressor agents, and the fact that this was considered to
be a questionable finding upon discussion with the
radiologist, and there was no other significant intra-
abdominal pathology at that time. There were noted to be
small pleural effusions bilaterally. Her microbiology at the
time of discharge revealed 2 negative blood cultures, most
recently from [**10-29**], 8 days before discharge, and 2
negative MRSA screens, and a negative swab for Vancomycin
resistant Enterococcus. The patient felt significantly better
and was working with physical therapy and was able to be
transferred from bed-to-chair during this time.
In terms of her amputation site, this was examined daily by
the vascular surgical staff and Dr. [**Last Name (STitle) **], and it was
noted to be very clean without any significant signs of
hematoma or infection. There was never any erythema at the
incision site, and there were staples in place which are to
stay in for a month. The patient's spirits had also improved.
She was taking a cardiac Heart Healthy Diet at this time and
was eager to be discharged, and on the morning of [**11-6**]
a bed had been found at a rehabilitation facility for her to
go to.
DISCHARGE INSTRUCTIONS: Patient will be discharged to a
worsening pains, fevers, chills, nausea, vomiting, shortness
of breath, chest pain, redness or drainage from or around the
wound in the patient's right stump. The patient is to take
medications as directed including Coumadin 5 mg once a daily
with daily INR checks until this level is stable, with goal
INR between 2.0 and 3.0.
FINAL DIAGNOSIS: Peripheral vascular disease, atrial
fibrillation, peripheral neuropathy, osteoporosis, chronic
obstructive pulmonary disease, aortic stenosis, spinal
stenosis.
RECOMMENDED FOLLOW-UP: Patient to follow-up with Dr.
[**Last Name (STitle) **] in [**10-24**] days and to call to have an appointment
scheduled at ([**Telephone/Fax (1) 18181**].
MAJOR SURGICAL OR INVASIVE PROCEDURES: Angiography of the
right lower extremity and aortogram, right below-the-knee
amputation and central venous line placement.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Amiodarone 200 mg p.o. once daily,
Toprol XL 25 mg p.o. once daily, gabapentin 600 mg p.o.
t.i.d., heparin 5000 units subcu q.i.d., latanoprost drops,
dorzolamide-Timolol drops, Hexavitamin 1 cap p.o. once daily,
regular insulin sliding scale--the scale will be printed out
and written on the discharge instructions, Tylenol p.r.n.,
fentanyl patch 25 mg/h q.72h., miconazole 1 application
topically q.i.d. as needed for raw skin, prednisone 10 mg
p.o. once daily, warfarin 5 mg p.o. once daily with daily INR
checks until stable INRs on warfarin--goal INR 2.0-3.0,
albuterol inhalations p.r.n.
DISPOSITION: Patient will be discharged to rehabilitation
facility and to follow-up with Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2144-11-5**] 20:27:35
T: [**2144-11-5**] 21:30:45
Job#: [**Job Number 18182**]
ICD9 Codes: 0389, 4280, 496, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4206
} | Medical Text: Admission Date: [**2188-7-25**] Discharge Date: [**2188-7-31**]
Date of Birth: [**2115-4-7**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Transferred from outside hospital with bilateral thalamic
strokes
Major Surgical or Invasive Procedure:
None while at [**Hospital1 18**], but was transferred 1 day post-operatively
following an L5/S1 anterior fusion and L2-pelvis posterior
fusion.
History of Present Illness:
73 yo left-handed woman with hx hypothyroidism, paroxysmal
SVT, s/p L5-S1 anterior fusion and L2 to pelvis posterior fusion
[**7-23**] at [**Hospital6 2910**], presents with
unresponsiveness since surgery. She was admitted for elective
surgery [**7-23**] and had a lengthy and complicated operation, losing
2300 cc of blood as well as brief episodes of hypotension during
the procedure. Post-operatively, she was noted to be
"unresponsive to noxious stimuli with pinpoint pupils" and was
given narcan twice without much effect. At one point she was
noted to "follow simple commands" however further details are
not
available. She was also noted to have occasional jerking
movements of her right hand. The patient had a CT head which
revealed bilateral thalamic strokes and was sent to [**Hospital1 18**] for
further evaluation and management.
Past Medical History:
Recent L5-S1 anterior fusion and L2-pelvis posterior fusion
[**Location (un) 931**] rod placement in lumbar spine
Hypothyroidism
Paroxysmal SVT
Social History:
Lives with her husband. [**Name (NI) **] etoh, tobacco, or drug use.
Family History:
Unavailable at this time.
Physical Exam:
VS; T 96.2 BP 122/53 P 87 RR 17 98% RA, FS 240
Gen; lying in bed
CV; RRR, no murmurs
Pulm; CTA anteriorly
Abd; soft, NT, ND
Extr; no edema. Surgical drain in place.
Neuro; Grimaces to painful stimlui, eyes are midline, pupils 1.5
mm --> 1mm, symmetric. + corneals bilaterally. Increased tone
in upper extremity. Withdraws to pain in RUE and both legs.
Spontaneous movement of right arm. Grimaces to pain in left arm
but no withdrawl. Reflexes 2+ and symmetric, upgoing toes
bilaterally
Pertinent Results:
[**2188-7-31**] 04:45AM BLOOD WBC-9.4 RBC-3.80* Hgb-11.0* Hct-35.5*
MCV-93 MCH-28.9 MCHC-31.0 RDW-14.4 Plt Ct-309
[**2188-7-31**] 04:45AM BLOOD Plt Ct-309
[**2188-7-31**] 04:45AM BLOOD PT-25.2* PTT-77.2* INR(PT)-2.4*
[**2188-7-31**] 04:45AM BLOOD Glucose-106* UreaN-22* Creat-0.7 Na-143
K-4.2 Cl-104 HCO3-27 AnGap-16
[**2188-7-31**] 04:45AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.3
[**2188-7-25**] 04:34AM BLOOD %HbA1c-5.9
[**2188-7-25**] 01:55AM BLOOD Triglyc-81 HDL-31 CHOL/HD-2.4 LDLcalc-28
[**2188-7-25**] 01:55AM BLOOD TSH-0.67
Radiology Report MRI SOFT TISSUE NECK, W/O & W/CONTRAST Study
Date of [**2188-7-30**] 12:43 AM
[**Last Name (LF) **],[**First Name3 (LF) 4267**] H. NMED FA11 [**2188-7-30**] 12:43 AM
MRI SOFT TISSUE NECK, W/O & W/ Clip # [**Clip Number (Radiology) 29333**]
Reason: Parotid mass noted on CT, please evaluate with MRI
Contrast: MAGNEVIST Amt: 14
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with parotid mass on CT
REASON FOR THIS EXAMINATION:
Parotid mass noted on CT, please evaluate with MRI
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: PXDb WED [**2188-7-30**] 3:04 PM
right masticator space enhcnaing tumor extending into the
parotid region, may
reflect a glomus tumor or a parotid tumor such as pleomorphic
adenoma with
medial extension. Embolic bilateral thalamic and right
cerebellar embolic
infarcts.
Final Report
INDICATION: Parotid mass seen on CT, for further evaluation.
COMPARISON: Outside hospital MR [**2188-7-24**], CTA head [**7-26**], [**2187**].
TECHNIQUE: Multiplanar T1- and T2-weighted sequences with and
without
administration of intravenous contrast.
FINDINGS: There is a large predominantly hyperenhancing mass
with central
areas of low signal intensity which appears to be centered
within the right
masticator space, extending laterally into the right parotid.
The
parapharyngeal fat plane is intact, however displaced medially
suggesting the
epicenter of the mass to be within the masticator space. There
is no
significant regional adenopathy. Adjacent right mandible and
mandibular
condyle is intact without evidence of osseous invasion. Overall,
these
features favor a benign etiology. The differential
considerations would
include glomus tumor along the jugular bulb or a nerve sheath
fibroma or a
plexiform neurofibroma or an intraparotid tumor such as a
pleomorphic adenoma.
There are areas of high signal intensity on T2-weighted
sequences in the right
cerebellum, consistent with known right cerebellar embolic
infarcts. Please
note the thalamic infarcts are not included in the field of view
of the
current study. There is significant motion on the coronal fat
sat post-
gadolinium images, rendering them uninterpretable.
IMPRESSION: Avidly enhancing right masticator space mass as
described above.
The differential considerations include glomus tumor, nerve
sheath
fibroma/neurofibroma, and intraparotid benign tumor such as
pleomorphic
adenoma.
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2188-7-26**] 11:53 AM
[**Last Name (LF) **],[**First Name3 (LF) 4267**] H. NMED SICU-B [**2188-7-26**] 11:53 AM
CTA HEAD W&W/O C & RECONS Clip # [**Clip Number (Radiology) 29334**]
Reason: Please evaluate for flow
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with bilateral thalamic and right
cerebellar infarct.
REASON FOR THIS EXAMINATION:
Please evaluate for flow
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: JXRl SAT [**2188-7-26**] 3:01 PM
- evolving bilateral thalamic infacts. pattern of infarct
suggest basilar tip
abnormality. however, vessels patent as visualized and no
filling defects
identified
- evolving right cerebellar infarct
- no intracranial hemorrhage
- large mass arising from right parotid, incompletely evaluated
but imaging
features suggest pleomorphic adenoma. if indicated, consider MRI
of the
parotid on a non-emergent basis for further evaluation
Final Report
EXAM: CTA of the head.
CLINICAL INFORMATION: Patient with thalamic and cerebellar
infarcts, for
further evaluation of vascular structures.
TECHNIQUE: Axial images of the head were obtained without
contrast. Following
this, using departmental protocol, CT angiography of the head
was acquired.
FINDINGS: Correlation was made with the previous outside MRI of
[**2188-7-24**].
Head CT demonstrates bilateral hypodensities in the thalami,
indicative of
acute infarct. A hypodensity is also seen in the right
cerebellar hemisphere
as well as a small hypodensity seen in the left cerebellar
hemisphere
indicative of infarcts.
CT angiography demonstrates normal flow within the anterior
circulation
without stenosis or occlusion. There is a fetal left posterior
cerebral
artery identified. The right posterior communicating artery is
also prominent
with a hypoplastic P1 segment on the right side. Evaluation of
posterior
circulation demonstrates a small right vertebral artery with a
hypoplastic
segment between the right posterior inferior cerebral artery and
the basilar
artery. The left distal vertebral artery appears normal in
appearance. The
basilar artery is small in size which could be consequent to the
fetal
posterior cerebral arteries. The distribution of infarcts
suggests lesion at
the basilar tip. However, no obvious filling defect is seen near
the basilar
tip. No other vascular abnormalities are seen.
There is a large mass identified in the region of right parotid
extending from
superficial to the deep lobe measuring approximately 4.5 cm. The
mass has
well-defined margins and demonstrates homogeneous enhancement.
This is
incompletely evaluated on this CTA examination.
IMPRESSION:
1. Head CT demonstrates bilateral thalamic and cerebellar
infarcts.
2. CT angiography demonstrates small vertebrobasilar system
which could be
secondary to fetal posterior cerebral arteries. The basilar tip
is not well
visualized with only P1 segment seen on the right side which
could be
secondary to variation. No definite filling defect is seen in
the basilar
tip. No stenosis is identified in the posterior circulation.
3. Large right parotid mass identified which could be due to
pleomorphic
adenoma, but further evaluation can be obtained with MRI of the
parotids if
clinically indicated.
Radiology Report CAROTID SERIES COMPLETE PORT Study Date of
[**2188-7-25**] 2:13 PM
[**Last Name (LF) **],[**First Name3 (LF) 4267**] H. NMED SICU-B [**2188-7-25**] 2:13 PM
CAROTID SERIES COMPLETE PORT Clip # [**Clip Number (Radiology) 29335**]
Reason: Evaluate for stenosis
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with back surgery c/b stoke.
REASON FOR THIS EXAMINATION:
Evaluate for stenosis
Final Report
INDICATION: 73-year-old female with back surgery complicated by
stroke.
Please evaluate carotids.
FINDINGS: RIGHT: The right carotid was not able to be imaged due
to the
presence of a venous catheter in place.
LEFT: B-mode images show mild heterogeneous plaque in the
carotid bulb. The
common carotid waveform is within normal limits and has a peak
velocity of 108
cm/sec. The ICA velocities are 108/25. The ECA velocity is 53.
The ICA/CCA
ratio is 1.0. By velocity criteria, this would correlate with a
1-39%
stenosis.
The left vertebral has antegrade, monophasic flow.
IMPRESSION: Unable to scan right carotid. Left ICA 1-39%
stenosis.
Brief Hospital Course:
73 yo left-handed woman with history of hypothyroidism,
paroxysmal SVT, s/o L5/S1 anterior fusion and L2-pelvis
posterior fusion at OSH [**7-23**], unresponsive since surgery, found
to have bilateral thalamic strokes, right cerebellar stroke, and
question of myoclonic activity.
1. Bilateral thalamic strokes. Prior to transfer, the patient
was found to have bilateral thalamic strokes on CT scan. She
was also found to have intermittant atrial fibrillation, as well
as an incidentally noted parotid gland tumor on MRI. She was
also noted to have a small vertebrobasilar circulation, with
fetal PCAs. It is likely that her atrial fibrillation and
underlying malignancy made her hypercoagulable, while her
vascular anatomy made her more prone to a posterior circulation
infarct. All of these factors, combined with the prolonged
surgical procedure likely resulted in her infarcts. For the
atrial fibrillation, she was rate controlled with Diltiazem, and
started on Coumadin. She is currently therapeutic with an INR
of 2.4. Her INR should continue to be monitored, with a goal
INR of [**1-7**].5. Her lipids were normal, and her A1C was 5.9%.
She was initially started on Dilantin before being transferred,
but showed no sign of seizure activity, and there is no
indication for her to be on an antiepileptic at this time. On
discharge her exam was notable for significant somnolance,
likely due to her impaired arousal system. When awake she is
able to answer questions appropriately, and follow most commands
- doing better with midline than appedicular. She is able to
identify objects and repeat sentences. Pupils are pinpoint, but
reactive, and she has limited vertical gaze. She is also able
to move all 4 extremities, with some purposeful movements,
however seems to have some R sided preference. Toes are upgoing
bilaterally. In the future, consideration may be given to
starting amantadine to help with arousal.
2. Tachycardia. The patient has a history of paroxismal SVT,
for which she has been on Diltiazem. While hospitalized she was
noted to also have atrial fibrillation with RVR. As it was
thought this may be contributing to her stroke risk, she was
started on Coumadin. Her INR should continue to be monitored,
with a goal of 2.0-2.5. She is currently rate controlled on
Diltiazem 120mg Q6hrs, and can consider switching to long acting
dosing once she is able to take pills PO.
3. Spinal surgery. Patient should continue to wear her spine
brace when out of bed until she has her follow-up appointment
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 29336**].
4. Right parotid mass - MRI showed an enhancing mass, concerning
for glomus tumor, nerve sheath fibroma/neurofibroma, or
intraparotid benign tumor such as pleomorphic
adenoma. Will need an ENT consult if clinically indicated as an
outpatient depending on family's wishes given her overall
clinical picture.
5. FEN. Patient is currently cleared by speech and swallow
evaluation for pureed solids and thin liquids as long as she is
awake and has 1:1 supervision. She is unable to meet her full
caloric needs with just PO intake at this time, so should also
continue tube feeds. However, if she becomes more alert, a
trial of PO intake with caloric counts should be attempted.
5. Code status: Patient is DNR/DNI, confirmed with husband.
Medications on Admission:
(at time of transfer)
synthroid 125 mcg daily
Cardiazem CD 240 mg daily
Fosamax 35 mg qSun
Percocet and dilaudid PRN for pain
Kefzol 1g q8
(patient was reported to take aspirin at home which was being
held for procedure)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain .
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
6. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Perioperative bilateral thalamic and cerebellar infarcts
Parotid gland tumor
Paroxismal atrial fibrillation
Discharge Condition:
Quite somnolant but arousable for brief periods of time, at
which point she is able to interact appropriately. Pupils
pinpoint but reactive, decreased vertical gaze. Able to move
all limbs against gravity, with some R>L preference. Toes
upgoing bilaterally.
Discharge Instructions:
You were admitted after being found to have a stroke following
surgery. You were also found to have atrial fibrillation, and
were started on Coumadin for anticoagulation to help prevent
further strokes. You should continue on Coumadin, with a goal
INR of 2.0-2.5. An MRI scan incidentally found a parotid tumor.
You should follow-up with an ENT for further evaluation of
this.
If you notice worsening symptoms, please return to the hospital
for further evaluation.
Followup Instructions:
You have the following follow-up appointment scheduled:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2188-9-17**] 1:30
You should also arrange for a follow-up appointment with the
spine surgeon, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 29336**] at [**Telephone/Fax (1) 29337**]
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4207
} | Medical Text: Admission Date: [**2164-4-16**] Discharge Date: [**2164-4-23**]
Date of Birth: [**2116-5-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
EGD with biopsies
History of Present Illness:
47 F c hx alcohol and cocaine abuse, recent admission ([**6-29**]) for
abdominal pain and GI bleed requiring exploratory laparotomy
showing diffuse hypoperfusion of bowel. Presented to ED c 4 d
hx of abdominal pain, chest pain, shortness of breath, vomiting,
decreased PO intake. Bulk of history obtained from patient's
boyfriend and mother, both who were not with patient through
majority of course of illness. Intermittent vomiting,
non-bloody. Significant alcohol intake over last 4 days;
unclear quantity. + Cocaine use over 4 days, unclear
[**Name2 (NI) 39469**]. No further details available re: nature of CP, SOB.
Boyfriend visited patient this morning and encouraged pt. to
call ambulance.
.
In ED, noted to be hypertensive (154/102), tachycardic (132) c
lactate of 4.5. Anion gap 26. L subclavian line placed for
sepsis protocol. Received vancomycin, levofloxacin,
metronidazole, PPI. Also treated for alcohol withdrawal with 1
mg ativan. Had two episodes hematemesis in ED and NG lavage
done, cleared after 250 cc. Also received 8 mg IV morphine for
abdominal pain. Surgery and GI evaluated pt in ED. CT done
showing no PE, marked esophageal and mild colonic wall
thickening, and findings c/w chronic pancreatitis.
Past Medical History:
EtOH abuse
Cocaine abuse
s/p ex-lap with cholecystectomy and G/J tube placement [**6-22**]
S/p skin graft to L foot for burn > 10 yrs ago
Social History:
Pt is presently living at [**Hospital 16662**] rehab facility. Pt reports
quitting EtOH 2 months ago. Pt had been drinking a pint of
vodka per day x 20 years. Pt denies other drug use although
documenation in the medical record notes hx of cocaine use. Pt
reports 8py hx of tobacco. Pt continues to smoke 6 cigarettes
per day. Pt is not employed and is on public assistance.
Family History:
non-contributory
Physical Exam:
VS - 126/89, 146, 96.6, 21, 100%
GEN - Middle aged woman difficult to arouse
HEENT - Dry MM, + skin tenting over forehead, JVP not elevated
LUNGS - CTA anteriorly, axillae
HEART - tachycardic, no murmurs, rubs; decrease in tachycardia
rate to 130s c carotid massage.
ABD - 10 cm linear scar midline abdomen, + tenderness to
palpation RLQ, LLQ. No rebound, no guarding. Hemorrhoids on
anus exam, no leaking blood from anus. Guiaic neg in ED.
EXT - dry, no edema, cool feet, warm ankles, 2+ DP/PT pulses
NEURO - responsive to voice, follows simple commands, difficult
to engage in conversation
Pertinent Results:
<b>labs</b> - see below; notable for K 2.6, Cl 114, CO2 10, AG
21. HCT 23.7, down from 33.7 on presentation to ED
<b>imaging</B> -
CT abd -
1. Marked esophageal and mild colonic wall thickening. This
appearance could be secondary to an infectious or inflammatory
process. The distribution is less suggestive of an ischemic
etiology.
2. No PE.
3. Findings consistent with chronic pancreatitis.
<b>micro</b> -
[**4-16**] bctx p * 2
<b>EKG</b> - sinus tachycardia c nl axis; ? negative deflection
in aVL - ? lead reversal. Tall p waves diffusely. ST
depressions inferior leads, lateral leads. T wane inversions
inferiorly new.
.
Brief Hospital Course:
# GIB - EGD showed severe esophagitis, gastritis, duodenitis.
Started on PPI [**Hospital1 **]. Also had positive H.pylori and started on 2
wk course of amoxicillin and clarithromycin.
.
# Ischemic Colitis: cocaine known to cause ischemic colitis and
ulcerations in the GI tract. Patient continued to have pain
abdomen with guarding. She had elevated Alk Phos which was
trending down. Her pain had significantly improved on the day of
amission and was able to tolerate her food very well.
.
# Alcohol Abuse/cocaine - She was monitored on CIWA scale for
alcohol withdrawal; her last dose of ativan was given on [**4-17**].
Social work was consulted regarding her polysubstance abuse, and
physical therapy was consulted given her chronic weakness
secondary to past surgery.
.
# Abdominal Pain - likely from ischemic colitis vs sever
gastritis/duodenitis vs pancreatitis flare. Improved during
course of hospitalization.
Medications on Admission:
MVI
Calcium
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
5. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
6. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Erosive Gastritis
Esophagitis
+ H. pylori
Polysubstance abuse
Discharge Condition:
Stable, tolerating PO
Discharge Instructions:
You were admitted with abdominal pain; an EGD demonstrated
erosive gastritis and esophagitis, and H. pylori testing was
positive. You should continue to take pantoprazole twice daily
and finish the entire course of antibiotics as prescribed.
.
If you develop worsening abdominal pain, fever, chills, nausea,
vomiting, diarrhea, or other conerning symptoms, please seek
medical attention immediately.
.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 23934**] within 2 weeks of discharge
from the hospital.[**Telephone/Fax (1) 39470**]
Completed by:[**2164-4-24**]
ICD9 Codes: 3051, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4208
} | Medical Text: Admission Date: [**2195-3-19**] Discharge Date: [**2195-3-23**]
Date of Birth: [**2131-8-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
[**3-20**] EGD & Colonoscopy
History of Present Illness:
63 y.o man with history of type II [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]'s disease and
history of GI bleeds presents with 2 week history of dark
stools. The patient reports that 2 weeks ago he had a nosebleed
that lasted longer than his usual ones. He then noticed that
his stools became progressively darker, becoming black as of
today. He also noticed that he had increasing frequency of
stools, from 2x a day to 4x a day. He began to feel more and
more fatigued and had shortness of breath on exertion. Several
days ago, he also noticed some blood tinged sputum. He also
reports that yesterday he had some chest discomfort that he
describes as a stinging sensation.
.
Per OMR and the patient he was diagnosed with type 2 [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 23872**] disease in [**2192**] after bleeding post-operatively. He
had no real complications aside from epistaxis until [**1-2**] when
he developed dyspnea, presented to the ED, and was found to have
UGIB with hct 15. He underwent EGD with clipping of the duodenal
blub and then required angiography with gastroduodenal artery
coiling, Humate 6, IVIG, and 16units pRBCs before his hct
stabilized at 22. After discharge he was seen in heme/onc clinic
and received IV iron for continued anemia. His hcts trended from
22-33 over the last two months.
.
In the ED, he was found to be hypotensive with pressures in the
80s. He was given 2L of NS and 2 units of blood, and GI was
consulted. His vitals prior to transfer were 73 131/78 20 98%
on RA. NG lavage negative for blood, although rectal exam was
positive for melena. On arrival to the ICU, the patient
reported that he felt much better. He was chest pain free and
denied any shortness of breath. He denies any recent NSAID use.
.
.
Review of systems:
(+) Per HPI; also positive for pica which has been chronic.
(-) Denies fever, chills, nausea, vomiting, current chest pain
or shortness of breath, abdominal pain, leg swelling.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Rt heart failure with diastolic dysfunction
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
MGUS
Acquired [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Disease
H/O RESPIRATORY FAILURE
H/O RT HEART FAILURE
Diastolic dysfunction.
H/O MORBID OBESITY
RENAL INSUFFICIENCY
FACTOR VIII DEFICIENCY
ERECTILE DIFFICULTY
MONOCLONAL GAMMOPATHY
HYPERTENSION
IRON DEFICIENCY ANEMIA
h/o ugi bleed from AV malformation seen on endoscopy 08.
PROBLEMS WITH BALANCE
SECONDARY HYPERPARATHYROIDISM
+Lupus anticoagulant
Social History:
Lives with son in [**Name2 (NI) **]. Retired. No ETOH, smoking [**6-30**] cigs
a day x 30 years from 20 to 50, hx of marijuana. Sister
currently in MICU at [**Hospital1 2177**].
Family History:
Sister with [**Name2 (NI) 14165**] cell trait, kidney transplant and sarcoid.
Father died of colon CA
Physical Exam:
97.6 145/90 83 20 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Mild
conjunctival pallor
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
at RUSB.
Abdomen: soft, non-tender, protuberant, 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:
EKG: NSR, no ST changes. Normal axis. Intervals OK. isolated
Q wave in III of no clinical significance. Unchanged from
prior.
.
Studies:.
EGD [**2195-3-19**]-
.
Polyps in the duodenal bulb
Normal mucosa in the whole examined duodenum
Mild thickening and erythema in the antrum
Small hiatal hernia
Erythema in the gastroesophageal junction compatible with mild
esophagitis
Otherwise normal EGD to second part of the duodenum
.
CLS [**2195-3-19**]-
.
Diverticulosis of the sigmoid colon and descending colon
Grade 2 internal hemorrhoids
Pigmented raised area noted at 40 cm in sigmoid colon. No clear
hx of tatoo from previous polypectomy site. Given bleeding
disorder and melena this site was not biopsied. No bleeding
noted from site.
Otherwise normal colonoscopy to terminal ileum
.
MRE:
IMPRESSION: The small bowel appears normal. No bowel
obstruction.
Admission:
[**2195-3-19**] 09:00AM BLOOD WBC-4.7 RBC-2.59*# Hgb-6.1*# Hct-19.6*#
MCV-76* MCH-23.4* MCHC-31.0 RDW-17.6* Plt Ct-196
[**2195-3-19**] 09:00AM BLOOD PT-13.3 PTT-39.2* INR(PT)-1.1
[**2195-3-21**] 08:40PM BLOOD Ret Aut-3.0
[**2195-3-19**] 09:00AM BLOOD Glucose-112* UreaN-34* Creat-1.6* Na-139
K-3.9 Cl-101 HCO3-34* AnGap-8
[**2195-3-20**] 03:02AM BLOOD Calcium-8.2* Phos-4.2 Mg-1.7 Iron-26*
[**2195-3-19**] 09:00AM BLOOD calTIBC-400 Ferritn-9.0* TRF-308
[**2195-3-21**] 08:40PM BLOOD Hapto-59
[**2195-3-19**] 09:00AM BLOOD VWF AG-26* VWF CoF-LESS THAN
[**2195-3-20**] 03:02AM BLOOD VWF AG-41* VWF CoF-33*
[**2195-3-21**] 04:41AM BLOOD VWF AG-68 VWF CoF-45*
[**2195-3-22**] 09:30AM BLOOD VWF AG-155 VWF CoF-136
[**2195-3-23**] 05:55AM BLOOD VWF AG-126 VWF CoF-105
[**2195-3-19**] 09:00AM BLOOD FacVIII-37*
[**2195-3-20**] 03:02AM BLOOD FacVIII-53
[**2195-3-21**] 04:41AM BLOOD FacVIII-81
[**2195-3-22**] 09:30AM BLOOD FacVIII-146
[**2195-3-23**] 05:55AM BLOOD FacVIII-123
Discharge:
[**2195-3-23**] 05:55AM BLOOD WBC-4.9 RBC-3.33* Hgb-8.8* Hct-26.8*
MCV-80* MCH-26.5* MCHC-33.0 RDW-17.3* Plt Ct-132*
[**2195-3-23**] 05:55AM BLOOD Glucose-115* UreaN-13 Creat-1.3* Na-136
K-3.9 Cl-100 HCO3-34* AnGap-6*
[**2195-3-21**] 08:40PM BLOOD LD(LDH)-158 TotBili-0.7 DirBili-0.2
IndBili-0.5
[**2195-3-23**] 05:55AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
Brief Hospital Course:
1. GI bleed: The patient does not have a clear inciting event
although clearly his vWD causes him to be at high risk for
bleeding. Upon admission to the ICU, hematocrits were closely
monitored every 6 hours with a transfusion goal of HCT >25. He
was placed on a protonix drip, GI was consulted who recommended
upper and lower endoscopy, so the patient and was prepped with
Moviprep. On [**3-20**], he underwent upper endoscopy which revealed
erythema in the gastroesophageal junction compatible with mild
esophagitis but otherwise normal EGD to second part of the
duodenum. Colonoscopy showed diverticulosis of the sigmoid colon
and descending colon, grade 2 internal hemorrhoids and a
pigmented raised area noted at 40 cm in sigmoid colon. No clear
hx of tattoo from previous polypectomy site. Given bleeding
disorder and melena this site was not biopsied. Otherwise normal
colonoscopy to terminal ileum. He underwent MRE that showed
normal small bowel. The patient received a total of 6U pRBC and
his Hct stablized at 26. He was hemodynamically stable and
transferred to the floor. On the floor the patient Hct remained
stable and stools were guaiac negative. The patient was followed
by GI with plans for outpatient capsule endoscopy and GI
follow-up
-- patient needs an outpatient capsule endoscopy
-- repeat CBC in Hem/[**Hospital **] clinic on [**3-26**]
*** patient needs evaluation of the pigmented raised area in the
sigmoid colon. No history of tattoo and possible melenoma.
2. [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) **] disease: Heme/Onc team was consulted as the
patient previously had received Humate-P and IVIG during his
last admission. He was treated with IVIG x2 days and had factor
VIII, vWF antigen and cofactor levels checked. He was closely
followed by Hem/Onc. His bleeding stopped and remained stable.
He will have repeat labs checked on [**2195-3-26**] and follow-up in
Hem/[**Hospital **] Clinic.
3. Nosebleeds: ENT evaluated and did not see evidence of active
bleeding. He was continued on nasal saline.
4. History of right heart failure with diastolic CHF: Patient
has been euvolemic thoughout his admission. His carvedilol,
lisinopril and lasix were initially held, but restarted on the
floor.
5. Hypertension - His anti-hypertensives were initially held in
the setting of his GI bleed, but restarted on the floor.
Medications on Admission:
Carvedilol 25mg [**Hospital1 **]
Furosemide 40mg daily
Lisinopril 10mg daily
Omeprazole 40mg daily
B complex vitamin daily
Calcium & Vit D
Discharge Medications:
1. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. B Complex Capsule Sig: One (1) Capsule PO once a day.
6. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
7. Outpatient Lab Work
Please have your CBC check on [**2195-3-26**] and have the results sent
to Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 22**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
GI bleed
Secondary:
Type 2 [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) **] disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted because of a bleed in your GI tract. You underwent a
EGD and colonoscopy that did not show any evidence of active
bleeding. You also had an MRI of you small bowel that was also
unremarkable. It is recommended that you have a capsule
endoscopy as an outpatient
The following changes were made to your medications:
1) You omeprazole was increased to 40mg twice a day.
You have several follow-up that are important to maintain.
1) You should have your lab drawn on Thursday, [**2195-3-26**], to check
your blood level. The results should be sent to Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 22**].
2) You should have an outpatient Capsule Endoscopy that should
be scheduled through the GI department within the next week. If
you do not hear from them within the next day or two please
call: [**Telephone/Fax (1) 463**]
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: [**Hospital1 **] [**2195-3-27**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
*It is recommended that you have a capsule endoscopy within the
next week.
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2195-3-31**] at 3:00 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: HEMATOLOGY/ONCOLOGY
When: [**Location (un) **] [**2195-4-10**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2195-3-24**]
ICD9 Codes: 5789, 2851, 4589, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4209
} | Medical Text: Admission Date: [**2179-9-27**] Discharge Date: [**2179-10-14**]
Date of Birth: [**2162-8-15**] Sex: F
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 17 year-old
female with no significant past medical history who was
brought in by med flight to the [**Hospital1 188**] on [**2179-9-27**]. The patient was the front seat
passenger in an automobile. She was unrestrained and was
ejected through the front windshield. There was positive
loss of consciousness. In the field the patient was
intubated. Systolic blood pressure was found to be in the
130s. There was significant damage to the car. The patient
had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 6 or 7 at the scene. In the
Emergency Department she was found to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma
scale of 3T. She was hemodynamically stable. She had a
notable right arm deformity. She was reportedly complaining
of abdominal pain at the scene. She had been at [**Hospital 8125**]
Hospital the same day for workup of possible pregnancy. This
was negative.
PAST MEDICAL HISTORY: Ovarian cyst.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient's family lives in [**State 108**].
PHYSICAL EXAMINATION: Initial vital signs showed heart rate
of 68, blood pressure 121/54, oxygen sat was 100% on room
air. The patient was intubated and sedated. Her pupils were
3 to 2 bilaterally and equal. Tympanic membranes were clear
bilaterally. Her trachea was midline. There were multiple
superficial facial abrasions. Lungs were clear to
auscultation bilaterally. The right chest had lateral
superficial abrasions. Heart was regular rate and rhythm.
Abdomen was soft, nontender, nondistended. Pelvis was
stable. The rectal examination was normal sphincter tone and
no guaiac positivity. Extremities revealed multiple
superficial ecchymosis and a gross deformity of the right
arm. There was a palpable pulse and brisk capillary refill.
The back was without step offs. There were multiple
superficial abrasions.
LABORATORY STUDIES: White blood cell count 20.9, hematocrit
29.9, platelets 318, sodium 143, potassium 3.3, chloride 111,
CO2 20, BUN 7, creatinine 0.9, glucose 129, amylase 59, PT
14.1, INR 1.4, PTT 33.6, fibrinogen 145, lactate 3.0.
Urinalysis showed large blood, 100 protein. Toxicology
screen showed an ethanol level of 11. Multiple radiologic
studies were undertaken while the patient was in the
Emergency Department. A C spine film revealed a C7
transverse process fracture. There was posterior
displacement and anterior fracture of C7. A chest x-ray
showed scoliosis, left apical caping suggestive of an aortic
injury and a right main stem bronchus intubation. Pelvic
film showed a right superior ramus fracture, right inferior
ramus fracture and bilateral sacral iliac fractures. The
patient was stable and transferred to the CT scanner. CT of
the chest, abdomen and pelvis showed a mediastinal hematoma
extending to the left apex and adjacent to the descending
intrathoracic aorta. There was no active extravasation, but
aortic dissection was not rule out. Number two was right
upper lobe liver laceration and contusion. Possible
aspiration pneumonia, multiple fractures involving C7, T1,
right scapular, right iliac bone, right sacrum and right
superior and inferior pubic symphyses, splenic laceration
with active contrast extravasation.
The patient was admitted promptly to the Surgical Intensive
Care Unit. Both cardiothoracic surgery and orthopedic
surgery were consulted urgently. On [**2179-9-28**] the patient had
an aortogram. This revealed a normal thoracic aorta with no
contour irregularities or contrast extravasation. An MR of
the cervical spine was obtained, which showed a burst
fracture involving the C7 vertebral body, but no intrinsic
signal abnormality within the cord itself. There was
disruption of the left facet joint at C6-7, C7 to T1 and
fractures at C7. There was also a fracture seen at T1.
Orthopedic Surgery saw the patient and determined that the
patient would benefit from operative management. She
underwent anterior cervical decompression and fusion from C6
to T1 on [**2179-10-4**]. The patient tolerated the procedure well
and was returned to the Intensive Care Unit.
The patient remained there for several days. She slowly
began to improve. Her course was complicated only by a
pneumonia, which was initially treated with Vancomycin and
then tailored to Oxacillin and Levofloxacin after Methacillin
sensitive staph aureus and hemophilus influenza grew out from
her cultures. She was maintained nutritionally with tube
feeds. The remainder of her fractures including her right
humerus fracture were managed nonoperatively. The patient's
intra-abdominal injuries were also managed conservatively
with observation and strict bed rest. The patient remained
stable and gradually had decreased discomfort in her abdomen.
An IVC filter was placed for PE prophylaxis.
Neurosurgery was then consulted to evaluate the patient. It
was recommended to get another CT scan of the head to rule
out subdural or subarachnoid bleed. The CT scan was
negative. Neurobehavioral Service was also consulted. It
was determined that the patient had findings consistent with
the diffuse external injury type of severe traumatic brain
injury. They anticipated that her amnesia and confusion
should improve over time particularly with active
rehabilitation. On [**2179-10-11**], the patient was transferred to
the hospital [**Hospital1 **]. She began feeding slowly. She had a TLSO
brace, which allows her to be removed from bed. The only
subsequently complication on the floor was a marked
thrombocytosis to platelets greater then one million. This
is now gradually resolving and thought to be an acute phase
reaction from trauma. Her pneumonia has resolved nicely and
her white blood cell count has drastically decreased to near
normal levels.
On [**2179-10-13**], interventional radiology removed the patient's
IVC filter without complication. On [**2179-10-14**] the patient is
doing much better. She is eating. She is performing her
physical therapy. She is more awake and alert. It is felt
that she will benefit from an aggressive rehabilitation stay.
Placement is pending currently.
CONDITION ON DISCHARGE: Improved.
DISCHARGE STATUS: To a rehab facility.
DISCHARGE DIAGNOSES:
1. Status post motor vehicle accident with ejection from the
vehicle.
2. Right humerus fracture.
3. Closed head injury with resultant diffuse external
injury.
4. Multiple spinal fractures including the levels of C4, C5,
C6, C7 and T1.
5. Status post anterior cervical decompression and fusion
from C6 to T1.
6. Right scapular fracture.
7. Right superior pubic ramus fracture.
8. Right inferior pubic ramus fracture.
9. Right iliac [**Doctor First Name 362**] fracture.
10. Left inferior pubic ramus fracture.
11. Grade 3 splenic laceration.
12. Pneumonia.
13. Thrombocytosis.
MEDICATIONS ON DISCHARGE: Lovenox 30 mg subQ b.i.d., Tylenol
650 q 4 hours prn, Percocet one to two q 4 hours prn, iron
sulfate 325 mg po q day, Levofloxacin 500 mg po q.d. to end
[**2179-10-15**]. Oxacillin 500 mg intravenous q 4 hours to end
[**2179-10-15**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 3600**]
MEDQUIST36
D: [**2179-10-14**] 09:02
T: [**2179-10-14**] 09:05
JOB#: [**Job Number 36486**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4210
} | Medical Text: Admission Date: [**2122-7-21**] Discharge Date: [**2122-7-31**]
Date of Birth: [**2063-10-26**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Dilaudid / Chlorhexidine
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Ventricular Tachycardia
Major Surgical or Invasive Procedure:
Electrophysiology Study for attempted Ventricular Tachycardia
Ablation
Cardiac Catheterization
History of Present Illness:
58 year old male with a PMH of a-fib, OSA, PVD secondary to a
gunshot wound to his right lower leg, and non-ischemic
cardiomyopathy with a reported EF of 15-20% in the past and a
recent EF of 40%. He had an AICD placed in [**5-30**], and he has had
4 episodes of syncope in the past 2 months. He has been shocked
8x in total, with one episode shocking him four times
consecutively. His history of cardiomyopathy (best attributed
to a possible viral illness, per patient report), dates back 8
years. He has also had long standing a-fib, and it is unclear
whether he had the cardiomyopathy or a-fib first as he has never
been symptomatic until [**Month (only) 205**].
.
He has had 3 hospitalizations for syncope since [**2122-5-21**]. The
first of which was [**5-24**] weekend, when his wife reports
witnessing him lose consciousness for a few seconds and falling
out of a chair. He was evaluated at [**Hospital 107**] Hospital, was
found to have VT, and had an AICD placed on [**2122-5-26**].
.
0n [**7-9**] he woke up from sleep, his AICD fired and 15 minutes
later it fired again. He was asymptomatic at the time, he was
then taken to [**Hospital3 8544**] and transferred to [**Hospital 107**]
hospital. He was given a loading dose of amiodarone, and
converted to lower dose because of dizziness. He was discharged
home and on [**7-17**], he was feeding his horses and felt dizzy and
lightheaded, fell to the ground had a jerking motion, his family
again witnessed the event. He didn't feel like he was shocked,
and had no palpitations at the time. He lost consciousness and
his wife was able to get him into the car and take him to the
hospital. He was initially treated for what was thought to be
ischemic chest pain. At [**Hospital3 **] they gave him dilaudid
for chest discomfort which caused him to flush and have
diaphoresis. He was transferred to [**Location (un) 796**] and they gave him
nitroglycerin, which caused his blood pressure to drop. This
entire course he was kept on amiodarone of 400mg [**Hospital1 **]. He had
several 6-7 beat runs of NSVT while there and on Monday [**7-20**] he
was intially increased to 400mg TID of amio, then due to
persistent episodes of NSVT he was put on IV amio at 1mg/min and
transitioned today to 0.5mg/min.
.
His outpatient cardiologist was concerned for AICD lead
migration and on [**7-21**] he was taken to the cath lab for lead
replacement. Subsequently he developed 20 beats of VT, at which
time the aforementioned amio drip was started at 1mg/minute.
Since that time his EKG and tele has shown paced beats and
ectopy.
.
Of note at the OSH his creatinine was 1.1, CE negative x 3,
electrolytes WNL, Vanc ppx for lead placement, Coreg was
decreased to 25 [**Hospital1 **], Coumadin was held, mag oxide added to keep
a-fib better controlled. He was continued on digoxin and
lisinopril. BPs ranged 86-126/46-60.
.
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. 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 syncope, orthopnea
(chronic), and lower extremity edema right greater than left, as
well as absence of chest pain, dyspnea on exertion, paroxysmal
nocturnal dyspnea, palpitations.
.
On the floor, initial vitals were T: 96.5, BP: 98/72, HR: 93,
RR: 23, SaO2 95% on RA, resting comfortably in bed, asymptomatic
with his wife and son at the bedside.
.
Past Medical History:
1. CARDIAC RISK FACTORS: None
2. CARDIAC HISTORY:
Ventricular tachycardia
Chronic a-fib
nonischemic cardiomyopathy with (?)EF of 20-25%
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: AICD placed in [**2122-5-26**]
3. OTHER PAST MEDICAL HISTORY:
. OSA on nasal CPAP
. PVD secondary to gunshot wound at 17
. Colecystectomy
Social History:
Former boxer, asymptomatic with activity. Currently a farmer.
-Tobacco history: denies
-ETOH: rare alcohol use
-Illicit drugs: denies
Family History:
2 sisters died from acute myocardial infarction. One sister was
33 at the time of her death, and his other sister was 50 when
she died of myocardial infarction. He states they don't know
what caused the heart attacks.
Physical Exam:
VS: T: 96.5, BP: 98/72, HR: 93, RR: 23, SaO2 95% on RA
GENERAL: Well appearing man in NAD. Oriented x3. Mood, affect
appropriate. Appears his stated age.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No pallor or
cyanosis of the oral mucosa.
NECK: Supple with JVP of ~7cm.
CARDIAC: Irregular rate with frequent extra beats, normal S1,
S2. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Sparse end inspiratory
wheezes, but in all lung fields. Mild scattered expiratory
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Scar on the
umbilicus from prior cholecystectomy.
EXTREMITIES: No c/c/e. Well healed scar, and considerable
indentation close to the medial tibial plateau with scar vs skin
graft well healed x many years on the right lower extremity
SKIN: No stasis dermatitis, ulcers, or scars.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
.
Exam on Discharge:
VS: Tmax: 98.9 T current: 98.1 BP: 100-125/50-71 HR: 69-85 RR:
18 SaO2 98% on RA
24 hours: I=1040 O= 1440
8 hours: I=180 O=750
GENERAL: Well appearing man in NAD.
HEENT: NCAT. Sclera anicteric.
NECK: Supple, no JVD.
CARDIAC: irregular rate, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. Wheezes
posteriorly. No cough.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Right groin sites with minimal ecchymosis
and no hematoma.
SKIN: Rash improving, few patchy areas around pacer site, none
on neck now. Has peeling skin on left hand only, pt states this
is chronic.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2122-7-21**] 08:42PM BLOOD WBC-8.3 RBC-3.95* Hgb-12.1* Hct-34.4*
MCV-87 MCH-30.7 MCHC-35.3* RDW-13.7 Plt Ct-218
[**2122-7-22**] 04:36AM BLOOD WBC-8.4 RBC-4.13* Hgb-12.7* Hct-36.2*
MCV-88 MCH-30.7 MCHC-35.1* RDW-13.8 Plt Ct-219
[**2122-7-23**] 06:13AM BLOOD WBC-8.9 RBC-4.19* Hgb-12.6* Hct-37.2*
MCV-89 MCH-30.2 MCHC-34.0 RDW-13.8 Plt Ct-226
[**2122-7-24**] 02:28AM BLOOD WBC-10.0 RBC-4.20* Hgb-12.8* Hct-36.4*
MCV-87 MCH-30.4 MCHC-35.1* RDW-13.6 Plt Ct-234
[**2122-7-21**] 08:42PM BLOOD Neuts-78.7* Lymphs-14.1* Monos-4.7
Eos-2.2 Baso-0.3
[**2122-7-21**] 08:42PM BLOOD PT-17.2* PTT-25.1 INR(PT)-1.5*
[**2122-7-21**] 08:42PM BLOOD Plt Ct-218
[**2122-7-22**] 04:36AM BLOOD PT-17.6* PTT-40.7* INR(PT)-1.6*
[**2122-7-22**] 04:36AM BLOOD Plt Ct-219
[**2122-7-23**] 06:13AM BLOOD PT-15.8* PTT-53.5* INR(PT)-1.4*
[**2122-7-24**] 02:28AM BLOOD PT-14.7* PTT-23.9 INR(PT)-1.3*
[**2122-7-24**] 02:28AM BLOOD Plt Ct-234
[**2122-7-24**] 08:36AM BLOOD PTT-58.3*
[**2122-7-21**] 08:42PM BLOOD Glucose-114* UreaN-18 Creat-1.3* Na-137
K-4.2 Cl-103 HCO3-26 AnGap-12
[**2122-7-22**] 04:36AM BLOOD Glucose-115* UreaN-18 Creat-1.3* Na-139
K-4.2 Cl-103 HCO3-27 AnGap-13
[**2122-7-23**] 06:13AM BLOOD Glucose-109* UreaN-22* Creat-1.5* Na-136
K-4.3 Cl-101 HCO3-27 AnGap-12
[**2122-7-24**] 02:28AM BLOOD Glucose-100 UreaN-26* Creat-1.5* Na-137
K-4.1 Cl-100 HCO3-27 AnGap-14
[**2122-7-24**] 08:36AM BLOOD Na-136 K-4.4 Cl-100
[**2122-7-22**] 04:36AM BLOOD ALT-51* AST-29 AlkPhos-98
[**2122-7-23**] 06:13AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.7*
[**2122-7-24**] 02:28AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.9*
[**2122-7-24**] 08:36AM BLOOD Mg-2.5
[**2122-7-21**] 08:42PM BLOOD Calcium-9.0 Phos-3.3 Mg-2.4
[**2122-7-22**] 04:36AM BLOOD Triglyc-115 HDL-40 CHOL/HD-2.8 LDLcalc-48
[**2122-7-22**] 04:36AM BLOOD TSH-4.3*
[**2122-7-22**] 04:36AM BLOOD Digoxin-0.9
.
ECHO:
The left atrium is moderately dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is
10-20mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function appears severely depressed (LVEF= 20-25 %) but is
difficult to assess due to poor image quality and frequent
ventricular ectopy. Relative preservation of basal inferolateral
wall function. There is considerable beat-to-beat variability of
the left ventricular ejection fraction due to an irregular
rhythm/premature beats. The right ventricular cavity is
moderately dilated with depressed free wall contractility. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a prominent fat pad.
.
IMPRESSION: Suboptimal image quality. Dilated left ventricle
with severe systolic dysfunction. Right ventricular dilation and
dysfunction.
.
Cardiac Cath Study Date of [**2122-7-28**]
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated no
angiongraphically apparent disease. The LMCA, LAD, LCx and RCA
had no
evidence of angiographically apparent disease.
2. Resting hemodyanamics revealed slightly elevated right sided
filling
pressures with RVEDP of 15mmHg. Cardiac output was preserved at
7
l/min.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal ventricular function.
.
TTE (Complete) Done [**2122-7-29**]
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is moderate global left ventricular
hypokinesis (LVEF = 30-35%). The estimated cardiac index is
normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular cavity is mildly dilated with borderline
normal free wall function. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
There is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2122-7-22**],
biventricular systolic cavity sizes are smaller and systolic
function is slightly improved.
.
Brief Hospital Course:
58 year old with a PMH significant for non-ischemic
cardiomyopathy, chronic a-fib, and ventricullar tachycardia s/p
AICD placement on [**2122-5-26**], that was transferred from [**Hospital 107**]
Hospital in RI for treatment of ventricular tachycardia with
ablation.
.
# Ventricular tachycardia/dialated cardiomyopathy: Mr. [**Known lastname **] has
ventricular tachycardia in the setting of non-ischemic
cardiomyopathy. These episodes of ventricular tachycardia
started in [**2122-5-21**], he is s/p AICD placement and has had
several instances recently of firing of his AICD. Etiology of
his v-tach is likely cardiomyopathy resulting in ectopy. An
initial echo was done the morning after admission and showed
dilated left ventricle with severe systolic dysfunction, also
right ventricular dilation and dysfunction. Hemodynamically
stable and asymptomatic. He was conitnued on an amiodarone drip
of 0.5mg/min until he was taken for EP procedure on [**2122-7-23**].
During the study, they were beginning to warm a site for
ablation, and he went into fast VT, so the study was aborted.
He converted back to his normal rhythm. His amiodarone was
converted to 200mg PO TID and he still had VT with walking
minimal distances, therefore loading dose was increased to 400mg
[**Hospital1 **], with plan to transition to 200mg PO BID in one week
(starting [**2122-8-1**]). Now currently undergoing workup for heart
transplant. CT chest completed which showed multifocal small
ground-glass nodules predominantly involving the upper lobes,
requiring a follow up repeat CT in [**2-24**] weeks as an outpatient.
CT abd/pelvis showed hypoattenuating left upper pole renal
lesion, most likely benign, but a renal US could be considered
as an outpatient. Hepatitis A,B,C, CMV and HIV serologies were
negative.
While on the floor [**2122-7-27**] and [**2122-7-28**] he had increased runs of
VTach resulting in AICD firing. The device fired once on [**2122-7-27**]
at 9:30 in the morning when he was walking with the EP team to
reproduce symptoms. On the 7th, he was washing his hair sitting
at the sink and he became symptomatic with lightheadedness and
flushing. He had 2 runs of VTach that both resulted in ICD
firings at 8:09 and 8:10 in the morning. He was taken to cath
immediately following, and then he was taken to the EP lab for
readjustment of his leads. The lead wires were adjusted to
remove slack from the wires. He tolerated the procedure well
and has been without any runs of VTach since.
He received a TTE on [**2122-7-29**] when compared with the prior study
(images reviewed) of [**2122-7-22**], biventricular systolic cavity
sizes are smaller and systolic function is slightly improved to
30-35%. A right/left heart cardiac catheterization that showed:
right dominant system that demonstrated no angiongraphically
apparent disease. The LMCA, LAD, LCx and RCA had no evidence of
angiographically apparent disease. Resting hemodyanamics
revealed slightly elevated right sided filling pressures with
RVEDP of 15mmHg. Cardiac output was preserved at 7 l/min. His
volume status was medically managed and he was transitioned back
to his home PO Lasix of 20mg daily.
.
# Contact dermatitis/cellulitis: He developed a likely contact
dermatitis after lead replacement at OSH. The contact
dermatitis may have been from the chlorhexadine prep during the
procedure as the patient reported that this happened in the past
during a prior cath. The contact dermatitis likely became
super-infected and he developed erispelas which was treated
successfully with doxycyline for 7 days last dose [**2122-7-28**].
.
# Atrial fibrillation: His atrial fibrillation was rate
controlled and medically managed. His coumadin was held
secondary to need for cardiac catheterization and he was placed
on a heparin drip throughout his admission.
.
# Sleep apnea: His sleep apnea was medically managed with his
CPAP mask at night without complications.
.
The patient was full code for this admission. Pt was discharged
home with further outpt follow-up planned.
Medications on Admission:
On Transfer from OSH:
. Coumadin last dose 8/28 for a-fib
. Digoxin 0.25mg PO Q24
. Lisinopril 40mg PO Q24
. Coreg 25mg PO Q12
. Mag Oxide 400mg PO Q24
. Lovastatin 20mg PO Q24
. Aldactone 12.5mg PO Q24
. Amiodarone 0.5mg/min IV
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular Tachycardia
Non-ischemic Cardiomyopathy
Acute Renal Failure
Discharge Condition:
Alert and Oriented x3
Independent Ambulation
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were initially admitted to the hospital for loss of
consciousness, and were found to have an abnormal heart rhythm
called ventricular tachycardia. You were transferred to [**Hospital1 18**]
for further management of your ventricular tachycardia and
evaluation for potential ablation. Unfortunately, the site of
the abnormal heart rhythm could not be localized for ablation on
this attempt. Your pacemaker/defibrillator settings were
adjusted to optimize your own normal heart rhythm and
conduction. You felt significantly improved following the
adjustment, and it was decided that your irregular heart rhythm
would be controlled with medications. We required you to stay in
the hospital for a few days to best optimize your medications
for rhythm control.
During this hospitalization, we also began the evaluation for a
heart transplant in case this is something that might benefit
you in the future.
Other issues on this hospitalization included a rash involving
your chest, shoulders and neck. It was believed to be related
to contact allergy to "chlorhexidine", a cleaning [**Doctor Last Name 360**] we
commonly use before procedures. We also believe this skin rash
became secondarily infected, for which we treated you with
antibiotics.
The following changes were made to your home medications:
- Amiodarone was continued at 400mg TWICE daily for 3 more days,
then decrease to 400 mg once daily on [**2122-9-2**]. Please continue
that dose until you see Dr. [**Last Name (STitle) **].
- Start Metoprolol Succinate to control your ventricular
tachycardia
- STOP taking Carvedilol, Magnesium and Digoxin
- DECREASE the dose of Warfarin to 4mg daily. Please check your
INR on Monday [**8-3**] with results to Dr. [**Last Name (STitle) **].
- Start taking clindamycin, an antibiotic, to prevent infection
at the ICD site
- Start taking Tylenol as needed for pain at the ICD site
- Start taking Lorazepam if you need for anxiety or sleep.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Check your INR at Dr.[**Name (NI) 87185**] office on Monday [**8-3**]. You should
have the INR followed closely now that you are on amiodarone.
Please be sure to have your blood drawn at your doctor's office
in [**11-22**] months to check your thyroid and liver function tests
because amiodarone can sometimes affect these with time. You
will also need to have pulmonary function tests done to make
sure the amiodarone is not affecting your lungs.
Your initial CT scan of your chest here showed that you have
some non-specific nodules that may be due to an infection,
inflammatory disease, or even cancer. Please talk to your
primary care doctor and cardiologist regarding ordering a follow
up CT of your chest in [**2-24**] weeks to evaluate whether there is
any change.
Followup Instructions:
Please be sure to keep all of your followup appointments, as
listed below:
Department: CARDIAC SERVICES
When: MONDAY [**2123-1-25**] at 1:30 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) **]
When: Monday [**2122-8-17**] at 2 PM
Location: PRIMARY CARE CENTER OF [**Location **]
Address: [**Street Address(2) 87186**], [**Location **],[**Numeric Identifier 87187**]
Phone: [**Telephone/Fax (1) 87188**]
Department: Interventional Cardiology
Name: Dr. [**First Name (STitle) **] Hordes
When: Friday [**2122-8-7**] at 3 PM. Please call the office
on [**2122-8-7**] after 1 PM to verify this appointment.
Location: [**Location (un) **] CARDIOLOGY
Address: [**Street Address(2) 51165**] [**Apartment Address(1) 51166**], [**Location (un) **],[**Numeric Identifier 51167**]
Phone: [**Telephone/Fax (1) 51168**]
Department: CARDIAC SERVICES
When: MONDAY [**2122-8-24**] at 12:30 PM
With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], 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: CARDIAC SERVICES
When: MONDAY [**2122-8-24**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2122-7-31**]
ICD9 Codes: 4271, 5849, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4211
} | Medical Text: Admission Date: [**2178-1-10**] Discharge Date: [**2178-2-5**]
Date of Birth: [**2106-8-2**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Heparin Agents / Morphine / Tylenol
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Hypotension at HD
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 F with DM, cirrhosis [**3-7**] NASH and acetaminophen toxicity, h/o
gastric angioectasia (GAVE/watermelon stomach) with GIB, ESRD on
HD MWF, diastolic CHF, HIT, seizure dx on [**Month/Day (2) 13401**], admitted on
[**1-11**] to the ICU for low hematocrit and hypotension. She went to
HD on [**1-11**] where she was found to be hypotensive in the 70's and
80's systolic. Of note, ED documentation indicates that she may
have received the wrong antihypertensive prior to dialysis.
Patient does not recall what medications she may have received,
and only vaguely recalls the events surrounding her dialysis.
She had a recent hospitalization from [**Date range (1) 40795**] for fall
complicated by tib/fib fracture, altered mental status (with
contributions from UTI, hepatic encephalopathy, and hypercapnea
from narcotic use), ESBL enterobacter UTI, and heme positive
stools.
In the ED, her BP was 86/p, HR 70, RR 16, Sat 100%RA. She was
given 1L fluid, one unit of packed red cells, and platelets. She
was guaiac positive. Blood cultures were drawn and stool was
sent for C-diff. Inferior ST changes were concerning for ongoing
ischemia, and she was transferred to the MICU.
In ICU, patient was given 2 unit PRBC's and 1 unit of platelets.
Her BP improved thereafter and Hct stabilized. She was then
transferred to the floor for management.
Past Medical History:
Recent history includes multiple admissions in [**5-7**], and
[**9-10**] for confusion in the setting of lactulose noncompliance,
and in [**12-11**] for hypotension. In [**5-11**], she was diagnosed with
GIB from gastric angioectasias/watermelon stomach. She was also
found to have a portal vein thrombosis on ultrasound but was not
anticoagulated for h/o GAVE, GIB, HIT.
OTHER PAST MEDICAL HISTORY:
- Portal vein thrombosis [**5-11**] but not anticoagulated for h/o
GAVE, GIB, HIT
- Type 2 diabetes.
- End-stage renal disease, on hemodialysis M/W/F
- Cirrhosis [**3-7**] NASH and acetaminophen toxicity.
- Gastric angioectasia with h/o GI bleeding in 4/[**2177**].
- Diastolic CHF. EF>55% by echocardiogram in 7/[**2176**]. She has a
prlonged mitral deceleration time and moderate MR.
- ?right sided pleural effusion: diagnosed on U/S [**11/2176**], CXR
showed a small effusion - stayed stable in subsequent imaging.
- Heparin-induced thrombocytopenia, Ab+ in 1/[**2176**].
- History of seizure disorder, on [**Year (4 digits) 13401**].
- History of infection in the left knee.
- History of MRSA and Clostridium difficile.
- History of gram-positive rod bacteremia in 4/[**2177**].
- Status post ORIF of the left distal femur fracture 12/[**2175**].
Social History:
She was recently discharged [**2178-1-8**] to [**Location (un) **] Manor in
[**Location (un) **]. Her daughter is involved in her care. The patient
currently denies alcohol use, tobacco use, and illicit
drugs.
Family History:
Noncontributory.
Physical Exam:
On transfer to the floor...
VITALS: Tm 97, Tc 95.9, Hr 73, BP 120/51, RR 14, 97%RA
GENERAL: Comfortable, in no acute distress.
[**Location (un) 4459**]: Sclerae icteric, OP clear, MMM, EOMI
HEART: [**4-9**] holosystolic murmur, radiating to the axilla, audible
across precordium.
LUNGS: Mild crackles at left based, decreased on right, clear
anteriorly
ABDOMEN: Extremely Obese, soft, + bowel sounds. Cannot assess
hepatosplenomegaly given body habitus. 2+ dependent edema.
EXTREMITIES: 2+ edema bilaterally, 2+ DP pulses, LUE AV fistula
with palpable thrill
NEURO: A&O x 3, +mild asterixis, tremor.
Pertinent Results:
[**2178-1-10**] 05:00PM WBC-2.2* RBC-2.00* HGB-6.9* HCT-21.3*
MCV-107* MCH-34.5* MCHC-32.4 RDW-21.5*
[**2178-1-10**] 05:00PM NEUTS-61.6 LYMPHS-29.7 MONOS-5.6 EOS-2.9
BASOS-0.1
[**2178-1-10**] 05:00PM GLUCOSE-125* UREA N-17 CREAT-2.2*# SODIUM-144
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-30 ANION GAP-11
[**2178-1-9**] 04:45PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.7
[**2178-1-10**] 05:12PM LACTATE-3.0*
[**2178-1-10**] 05:00PM CK-MB-NotDone cTropnT-<0.01
BLOOD CULTURES: [**1-13**] enterococcus and coag neg staph; [**1-15**] w/
GNR
Urine cx 12/ll: mixed bacterial flora
[**Last Name (un) **] U/S [**1-14**]: no e/o ascites but pleural effusion noted
CXR [**1-15**]: stable right-sided pleural effusion
Brief Hospital Course:
71 yo h/o gastric angioectasia (GAVE/watermelon stomach) with
chronic GIB, type 2 diabetes, ESRD on HD (MWF), diastolic CHF,
HIT, seizure dx on [**Month/Year (2) 13401**], admitted with hypotension and anemia
in setting of chronic GIB and polymicrobial (proteus,
enterococcus, coag neg staph) cultures from PICC line and AV
fistula.
#) BACTEREMIA:
Patient w/baseline low blood pressures in 80s/90s likely [**3-7**]
ESLD and generalized low systemic vascular resistence. Cortisol
stim from [**1-20**]: 10.1->15.6. Patient also with PICC cultures
growing pansensitive ENTEROCOCCUS FAECALIS and coag negative
staph [**1-12**], CORYNEBACTERIUM SPECIES [**1-13**], PROTEUS MIRABILIS
[**1-14**], and GNRs [**1-14**], [**1-16**], and VANC resistant ENTEROCOCCUS
FAECIUM. Surveillance cultures since [**1-17**] has NGTD until
[**Female First Name (un) **] on [**1-25**]. CT scan without clear abdominal source. Other
source could be GI fistula (no fluid collection per US). TTE
negative for vegetations and no TEE obtained as pt was not a
surgical candidate given comorbidities. Antibiotics were
planned for full four week course. ID followed her during her
stay, and in the days preceeding her death, she was on a four
drug pathogen-specific regimen. Despite these treatments, Ms.
[**Known lastname 32662**] continued to have progressively poor hemodynamic stabily,
until, despite pressors, her blood pressure declined causing
cardiopulmonary arrest.
#) Hypotension: Likely [**3-7**] to sepsis and low SVR due to ESLD.
Required pressor support throughout her stay. Many family
discussion were held, and, given her poor prognosis, it was
decided that pressor support would not be escalated. Thus,
despite these treatments, Ms. [**Known lastname 32662**] continued to have
progressively poor hemodynamic stabily, until, despite pressors,
her blood pressure declined causing cardiopulmonary arrest.
#) Cirrhosis secondary to NASH/acetaminophen. Hepatologist Dr.
[**Last Name (STitle) **]. Liver disease was end-stage upon admission. Total Bili
and INR were monitor and continued to increase during her stay.
Associated illnesses included coagulopathy, thrombocytopenia,
hypotension and chronic GI bleed. Per Liver consult obtained
while inpatient, she was not a transplant candidate. She was
continued on rifaximin, ursodiol, and lactulose. Nadolol was
held given hypotension.
.
#) Anemia/GI bleed. Has known chronic GI bleed from GAVE as well
as insufficient erythropoeitin in setting of ESRD. Transfused
for Hct less than 21.
#) Thrombocytopenia. Chronic, most likely from splenomegaly and
ESLD with poor thrombopoetin levels. Also has h/o HIT so heparin
products were avoided. Transfused for platelets of < 10K for
spontaneous bleed.
#) ESRD on HD. Upon admission was requiring dialysis three times
weekly, but becamed too hypotensive to tolerate HD. Per Renal,
CVVH would be the next step, but this is not indicated given
patient's continued hypotension and poor prognosis.
#) Type 2 Diabetes: Well controlled while inpatient with insulin
sliding scale and QID glucose monitoring.
#) Diastolic CHF. Extravascular hypervolemia but continued to
need pressor support to maintain adequate blood pressure. Thus,
diuretics were held while inpatient.
#) Seizure disorder. No observed seizures while in patient.
Continued on [**Last Name (STitle) 13401**] at home dose.
#) s/p L tib-fib fracture: First noted [**2177-12-17**] upon follow-up
appointment with orthopedics s/p ORIF. Admitted with external
brace. Orthopedics followied while inpatient and determined no
additional interventions were required.
Despite these treatments, Ms. [**Known lastname 32662**] continued to have
progressively poor hemodynamic stabily, until, despite pressors,
her blood pressure declined causing cardiopulmonary arrest.
Medications on Admission:
Pantoprazole 40mg Q12H
Sevelamer 800mg TID with meals
Urosdiol 300mg [**Hospital1 **]
Rifaximin 400mg TID
Levetiracetam 500mg daily
Lactulose 30mL PO QID
Propranolol 10mg [**Hospital1 **]
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Sepsis
Secondary: ESLD, ESRD, Diastolic CHF, chronic anemia
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 4240, 5856, 5715, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4212
} | Medical Text: Admission Date: [**2112-9-3**] Discharge Date: [**2112-9-12**]
Service: MEDICINE
Allergies:
Halothane
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hip fx
Major Surgical or Invasive Procedure:
-R ORIF
-L cordis placed and d/c'd prior to transfer
History of Present Illness:
Pt is a [**Age over 90 **] year old man with a history of CAD, HTN, A Fib, CVA
who presents status post fall. Pt was ambulating with walker in
nursing home and had an unwitnessed fall. Pt is a poor
historian and can't relate details of fall. Pt apparently
tripped and fell backwards landing on his right side. There was
no loss of consciousness, no chest pain. Pt presented with pain
in right arm and right hip pain.
.
In the [**Name (NI) **], pt's vitals were 97.1, 134/52, 66, 20, 93% on RA. Pt
was given Morphine 4 mg IV, Dilaudid 0.5 mg IV for pain relief.
Pt voided and a foley was placed. Pt was started on 2L O2
w/nasal canula. Pt placed in right arm sling. No acute
intracranial hemorrhage is identified on CT. No acute cervical
pathology including no fracture on CT c-spine. Humerus xrays
showed impacted comminuted fracture of the surgical neck of the
right humerus with overriding of the fracture fragments. Pelvis
xrays showed a cervical fracture of the right femur.
Past Medical History:
1. CAD s/p 3 vessel CABG in [**2096**]
- Last stress was [**6-/2102**] which showed moderate reversible
perfusion defects in the inferior, inferolateral, and posterior
walls
- Last echo was [**7-3**] LVEF of 35%, [**2-2**]+ AR, 3+ MR, and [**2-2**]+ TR
2. HTN
3. Hypercholesterolemia
4. Hypothyroidism
5. Macular degeneration
6. Small brainstem/cerebellar CVA- [**7-3**]
7. s/p hip replacement
8. CRI (creat 2.0-2.6)
9. A fib --> on coumadin
Social History:
Currently living at [**Location (un) 5481**] [**Hospital3 **]. Denies EtOH,
tobacco, or drug use.
Family History:
NC
Physical Exam:
Vitals: 95.1, 92, 119/42, 22, 93%
Gen: NAD, alert
HEENT: perrla, eomi, ncat, c-collar in place, op clear
Resp: ctab, no crepitus
Card: RRR, +S3 vs mechanical click
ABD: soft, nt, nd
EXT: + pain with flexion/rotation of right hip, limited rom
right hip, increased pain at right shoulder, 2+ pulses,
Skin: warm, dry
Neuro: CN 2-12 intact
Pertinent Results:
Admission Labs:
[**2112-9-3**] 11:50AM BLOOD WBC-18.0*# RBC-3.91* Hgb-10.8* Hct-31.8*
MCV-81* MCH-27.6 MCHC-34.0 RDW-16.7* Plt Ct-421
[**2112-9-3**] 11:50AM BLOOD PT-17.1* PTT-32.8 INR(PT)-1.6*
[**2112-9-3**] 11:50AM BLOOD Glucose-148* UreaN-67* Creat-2.0* Na-137
K-4.2 Cl-97 HCO3-28 AnGap-16
Discharge Labs:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2112-9-12**] 04:17AM 11.1* 3.29* 9.7* 29.1* 88 29.6 33.5 17.5*
433
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2112-9-12**] 04:17AM 156* 45* 1.2 143 3.9 113* 23 11
.
.
SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT [**2112-9-3**] 3:13 PM
Impacted, comminuted fracture of the surgical neck of the
proximal humerus, with overriding and angulation of the distal
fracture fragment. The fracture component involves the base of
the greater tuberosity, but may not be complete.
.
ELBOW (AP, LAT & OBLIQUE) RIGHT [**2112-9-3**] 11:58 AM
Impacted comminuted fracture of the surgical neck of the right
humerus with overriding of the fracture fragments.
.
CHEST (SINGLE VIEW) [**2112-9-3**] 11:58 AM
1. Cardiomegaly.
2. Large left thyroid mass extending into the mediastinum better
seen on recent CT.
3. No pneumonia or CHF.
.
PELVIS (AP ONLY),KNEE (2 VIEWS) RIGHT [**2112-9-3**] 11:59 PM
1. Cervical fracture of the right femur.
2. Linear lucency along the prosthetic bone interface of the
left hip prosthesis femoral component, not fully evaluated on
this radiographs. A dedicated study is recommended to rule out
loosening.
3. Small right knee joint effusion.
.
CT HEAD W/O CONTRAST [**2112-9-3**] 12:05 PM
1. No acute intracranial hemorrhage is identified.
2. The left frontal meningioma is unchanged in size, however,
demonstrates interval increase in density, most likely related
to interval calcification.
3. Encephalomalacia of the right occipital lobe consistent with
the patient's history of infarction in this area.
.
CT C-SPINE W/O CONTRAST [**2112-9-3**] 12:06 PM
1. No acute cervical pathology including no fracture.
2. Unchanged appearance of anterolisthesis of C4 over C5,
probably degenerative.
3. Multilevel degenerative changes of the cervical spine as
mentioned in the body of the report.
4. Large thyroid goiter with extension to superior mediatinum.
CT chest can help for further assessment.
.
[**2112-9-5**]: Hip films:
FINDINGS: There is a left bipolar prosthesis seen without
evidence of hardware-related complication. A transcervical
fracture of the right femoral neck is seen with varus angulation
at the fracture line. The degree of angulation is unchanged
compared to the previous study. No additional fracture or
dislocation is seen. The sacrum is obscured by overlying bowel
gas. Soft tissues are otherwise unremarkable.
IMPRESSION:
Right femoral neck fracture, unchanged in alignment compared to
the previous study.
.
Chest CT [**2112-9-8**]:
CT ABDOMEN: Visualized lung bases are notable for marked global
cardiomegaly. There is mild-to-moderate dependent bibasilar
atelectasis, greater on the left. There is no pleural or
pericardial effusion. Note is also made of sternotomy wires and
evidence of previous cardiac surgery.
Absence of intravenous contrast limits evaluation of the
abdominal parenchymal organs and vasculature. Liver contour is
smooth, and there is no biliary ductal dilatation or ascites.
There is a large, multilobulated, fluid-filled mass, with
well-defined borders, seen in the right upper quadrant. It may
arise from the caudate lobe of the liver, but this is difficult
to determine without intravenous contrast. It could also arise
from adjacent stromal tissues or mesentery. It contains multiple
small internal calcifications, and measures approximately 15 cm
in craniocaudal dimension, and 11 x 8.5 cm in greatest axial
dimension, not significantly changed when compared to prior
ultrasound. There is one other small 9 mm hypodensity in segment
V, incompletely characterized without contrast.
Multiple small calcified gallstones are seen within the
gallbladder lumen, but the gallbladder is not distended and
there is no wall thickening or pericholecystic fluid. Pancreas,
spleen, adrenal glands, stomach, and intra- abdominal loops of
bowel demonstrate normal non-contrast appearance. Kidneys are
mildly atrophic bilaterally, but otherwise unremarkable. There
is no free air, free intraperitoneal fluid, or abnormal
intra-abdominal lymphadenopathy.
CT PELVIS: Pelvic loops of large and small bowel are
unremarkable. Deep structures in the lower pelvis are obscured
by streak artifact from bilateral hip prostheses, but there is
no definite free pelvic fluid or abnormal pelvic or inguinal
lymphadenopathy. Foley catheter balloon is seen within a
decompressed bladder. There is a large left inguinal hernia,
which contains fluid and air-filled loops of non-distended small
bowel. There is no sign to suggest obstruction or strangulation.
A small punctate calcification is also seen within the left
hernia sac. There is no sign of retro- or extra- peritoneal
hematoma. Note is made of a left femoral approach central venous
catheter in place.
OSSEOUS STRUCTURES: Bilateral hip arthroplasties are seen, and
subcutaneous gas seen in the soft tissues of the right thigh is
consistent with recent surgery.
There is no suspicious osteolytic or sclerotic lesion seen.
There is diffuse osteopenia. There is compression deformity of
the L3 vertebral body, which is new at least since L-spine MRI
of [**2106-6-24**]. There is greater than 50% loss of vertebral body
height, particularly centrally within the vertebral body. There
is slight retropulsion of some bony fragments into the spinal
canal.
IMPRESSION:
1. No evidence of retroperitoneal hemorrhage. No sign of
bleeding within the abdomen or pelvis.
2. Moderate-to-large left inguinal hernia, containing fluid and
air-filled loops of small bowel, without evidence of obstruction
or incarceration.
3. 15-cm lobulated mass in the right upper quadrant. This is
incompletely evaluated without intravenous contrast, but is not
significantly changed in size since prior ultrasound of
[**2108-1-30**]. It may represent a mesenchymal or stromal tumor, but
it could also possibly arise from the caudate lobe of the liver,
and may represent extrahepatic spread of giant hemangioma.
4. Cholelithiasis, without evidence of cholecystitis.
5. L3 compression fracture, new since last L-spine exam of
[**2106-6-24**]. Slight retropulsion of some bony fragments into the
spinal canal. CT is unable to provide intrathecal detail
comparable to MRI. If there is clinical concern for cauda
impingement, or other neurologic symptoms, MRI of the lumbar
spine is recommended.
CT head [**2112-9-9**]:
FINDINGS: Comparison made to prior study dated [**2112-9-3**].
Again seen is a 1.8 cm x 1.5 cm left parafalcine mass anteriorly
which is likely the result of a meningioma. Compared to the
prior study, there is no significant interval change. Again see
is a right occiptal encephalomalacia consistent with patient
history of prior infarct in this location. There is prominence
of the ventricular system and cerebral sulci which is
age-related brain atrophy.
There is no evidence of an acute intracranial bleed. No CT
evidence of an acute territorial infarct is noted. The basal
cisterns are patent. The visualized paranasal sinuses and
mastoid air cells are clear.
IMPRESSION: Compared to the prior study dated [**2112-9-3**], there is
no significant interval change. Stable left anterior parafalcine
meningioma. No evidence of an acute intracranial hemorrhage. Old
right occipital area of encephalomacia consistent with the
patient history of prior infarct.
CXR [**2112-8-31**]:
IMPRESSION: AP chest compared to [**9-6**] through 10:
Nasogastric tube ends in the upper stomach and should be
advanced 2-4 cm to move all the side ports beyond the
gastroesophageal junction. Moderate cardiomegaly and severely
enlarged central pulmonary arteries are longstanding. Borderline
interstitial edema is new since [**9-6**]. Significant rightward
displacement of the trachea is due to a large left goiter. Tip
of the left PIC catheter projects over the mid-to-low SVC. No
pneumothorax or appreciable pleural effusion.
Brief Hospital Course:
A/ Pt is a [**Age over 90 **] M with h/o Parkinson's disease, dementia, AF,
presenting w/R hip fx, R humerus fx after unwitnessed fall
.
Plan:
#. R hip fracture: Patient initially went to the OR and had an
ORIF. The procedure was well tolerated. Ortho was following
the patient and he is cleared for weight bearing as tolerated.
On [**9-7**], went to OR for ORIF/hemiarthroplasty of R hip. His
course was c/b GIB and hypotension which resolved. He is to
follow up with Dr. [**Last Name (STitle) **] in 1 week due to slow ooze but wound
looks well. Ortho aware pt is leaving to rehab on [**9-12**]. Pt was
kept on lovenox 40mg daily for ppx.
#. Hypotension: Patient was found to have hypotension to the 60s
on the floor. This was likely secondary to dehydration and poor
PO intake as well as GI bleed. Once patient was volume
resusitated he was no longer hypotensive. His BP meds
(carvediolol, furosemide) were held in this setting but should
be restarted as an outpatient as he tolerates. His carvedilol
was restarted at a lower dose 6.25 mg [**Hospital1 **] on [**9-12**], it needs to
be titrated as his BP tolerates to his home dose 12.5mg [**Hospital1 **].
#. GI bleeding: On POD#1, was found to be somnolent with new L
eye ptosis by [**Hospital1 **] intern. Over next 30 minutes, had a
melanotic, OB + stool and coffee ground emesis. Was transiently
bradycardic to 30s with BP 60s/palp; surgery was consulted for
IV access and placed L groin Cordis. Pt was noted to have new
lower abdominal/pelvic distension at time line was placed. BP
stabilized with 2 liters NS, and patient transferred to MICU.
While in the MICU, the patient had stable hematocrits and did
not require additional transfusions. Given that he had no signs
of active bleeding as well as stable hematocrit and
hemodynamics, the decision by GI was made to defer endoscopy for
now. If the family desires, the patient may need an outpatient
endoscopy/colonoscopy. Of note there is a mass on CT that was
not evaluated further. Given his AF and GIB he was not
anticoagulated but b/c he was hemodynamically stable, ASA 81mg
was started on [**9-12**]. His last transfusion was on [**9-9**] and HCT
was very stable, guaiac negative on [**9-11**].
#. R humerus fracture: does not require operative management.
Recommend sling for 6 weeks per Ortho and pain management.
#. Dementia: Patient was continued on Namenda, aricept. Other
sedating medications were limited.
#. Systolic Dyfunction: EF 40-45% on TTE [**2111**]. Continue lasix
100 mg daily and aldactone 25 mg daily
#. Atrial fibrillation: Was initially continued on Coreg, ASA.
The coreg was held as above but was restarted on [**9-12**] at a lower
dose. For now the patient is not on coumadin. However, it
should be restarted on [**2-2**] weeks if there are no more signs of
bleeding. Aspirin 81mg was started on [**9-12**].
.
#. Chronic Renal Failure: Creatinine is 1.2, which is below
baseline.
.
#. Nutrition: Given patient's poor mental status an NGT was
placed for TF/nutrition. On [**9-12**] S&S evaluation cleared the pt
for thin liquids and regular solids. NGT was d/c'd prior to
transfer. RECOMMENDATIONS: 1. Suggest a PO diet of thin liquids
and regular consistency solids. 2. Pills whole with purees. 3.
Assist with feeding during meals as needed.
.
#. Code: DNR/DNI
Contact: [**Name (NI) 53767**], [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 96535**] (HCP)
Medications on Admission:
Carvedilol 12.5 mg PO BID
Donepezil 10 mg PO DAILY
Midodrine 2.5 mg PO BID
Furosemide 100 mg PO DAILY
Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Atorvastatin 10 mg PO DAILY
Lisinopril 5 mg PO DAILY
Levothyroxine Sodium 50 mcg PO DAILY
Vitamin D 400 UNIT PO DAILY
Calcium Carbonate 500 mg PO DAILY
Docusate Sodium 100 mg PO BID
Aspirin 81 mg PO DAILY
FoLIC Acid 1 mg PO DAILY
Multivitamins 1 CAP PO DAILY
Namenda *NF* 10 mg Oral [**Hospital1 **]
Spironolactone 25 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Ferrous Sulfate 325 mg PO DAILY
Coumadin
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Tramadol 50 mg Tablet Sig: 0.25 Tablet PO Q6H (every 6 hours)
as needed.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
11. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
Q24H (every 24 hours).
13. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours).
14. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Pantoprazole 40 mg IV Q12H
18. 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.
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary
-R hip fracture
-R humerus fracture
-GIB
Secondary
-Dementia/Parkinson's Disease
-Systolic Dysfunction
-AFib
Discharge Condition:
Stable, tolerating POs, mentating well
Discharge Instructions:
Please take all your medications as directed.
.
Please return to the emergency department if your Right Hip
wound is bleeding, has pus or discharge coming from it or the
area around the wound is red, more painful or worrisome, having
fevers or difficulty breathing.
Followup Instructions:
You must follow up with Dr. [**Last Name (STitle) **] from Orthopeadic Surgery in
1 week, please call his office at [**Telephone/Fax (1) 1228**] for an
appointment.
Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2112-12-5**] 2:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2112-9-12**]
ICD9 Codes: 5789, 5859, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4213
} | Medical Text: Admission Date: [**2114-2-23**] Discharge Date: [**2114-3-13**]
Date of Birth: [**2082-3-28**] Sex: F
Service: MICU
CHIEF COMPLAINT: Transfer for hypercapneic respiratory
failure.
HISTORY OF PRESENT ILLNESS: The patient is a morbidly obese
31 year old female with a history of asthma (recent admission
to outside hospital, no history of intubations), who was in
her usual state of health until approximately two weeks prior
to admission when she began experiencing increasing shortness
of breath at home, not improving with her outpatient asthma
medications. She began using her father's home oxygen.
She was admitted to [**Hospital3 1443**] Hospital on [**2114-2-8**].
Arterial blood gases on admission revealed pH 7.19, pCO2 of
108 and pO2 of 119. Her bicarbonate level at that time was
37. She was treated with BIPAP, [**Last Name (un) **]-Dur, Solu-Medrol which
was switched to Prednisone. Chest x-ray reportedly was
unremarkable at that time. She improved with treatment and
was transferred to [**Hospital1 34648**].
Admitted to [**Hospital1 34648**] on [**2114-2-14**], with arterial blood gases of
pH of 7.41, pCO2 of 86 and pO2 of 84 on 40% FIO2 face mask.
She was aggressively diuresed and plan was for rehabilitation
with subsequent follow-up at [**Hospital 34649**] Clinic. She began to do
poorly, however, with increasing shortness of breath and
occasional nonproductive cough. Arterial blood gases showed
pH of 7.31, pCO2 of 131 and pO2 of 63 on 90%. She was placed
on BIPAP and unable to be weaned off.
Over that time, she denied fever, chills, chest pain,
light-headedness, confusion, calf pain. She was treated with
Enoxaparin prophylactically. She did describe some nasal
stuffiness. She was started on Augmentin for suspected
sinusitis and Levaquin was added on [**2114-2-23**], for possible
pneumonia when her chest x-ray showed white out of the right
lung. She was transferred to [**Hospital1 188**] at that time for likely tracheostomy.
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. Asthma.
3. Anxiety/depression.
4. Question history of thyroid nodule.
5. Echocardiogram in 05/00, shows left atrial enlargement
with an ejection fraction of 60%.
MEDICATIONS ON TRANSFER:
1. Levaquin 500 milligrams intravenously q.d.
2. Augmentin 875 milligrams p.o. q.d.
3. Flonase b.i.d.
4. Afrin b.i.d.
5. Multivitamin.
6. Sertraline 50 milligrams p.o. q.h.s.
7. Combivent inhaler q.i.d.
8. Theophylline 300 milligrams p.o. q.d.
9. Guaifenesin 10 milligrams p.r.n.
10. Enoxaparin 40 milligrams subcutaneously q12hours.
11. Singulair.
12. K-Dur.
ALLERGIES: Vicodin and Percocet.
SOCIAL HISTORY: She lives with her parents. No history of
tobacco or alcohol use.
PHYSICAL EXAMINATION: On admission, in general, morbidly
obese female with marked respiratory distress speaking in
complete sentences and mentally alert. Head, eyes, ears,
nose and throat anicteric sclera. The pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. No sinus tenderness. Mucous membranes
are moist with no oral lesions. The heart is regular rate
and rhythm, normal S1 and S2, with a II/VI systolic ejection
murmur at the left upper sternal border radiating to the
carotids. Lungs - bilateral crackles two thirds of the way
up on the right, half way up on the left. The abdomen is
morbidly obese, soft, nontender, positive bowel sounds.
Extremities are warm, 2+ distal pulses bilaterally, no
cyanosis, clubbing or edema.
LABORATORY DATA: Arterial blood gases revealed a pH of 7.33,
pCO2 116, pO2 70 on 90% FIO2. Chest x-ray showed white out
of the right hemithorax and one half of the way up on the
left. White count 5.8, hematocrit 33.9, platelets 259,000,
Sodium 139, potassium 4.1, chloride 84, bicarbonate 53, blood
urea nitrogen 10, creatinine 0.4, glucose 93. Prothrombin
time 13.4, partial thromboplastin time 26.5, INR 1.2.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit and initially she was alternated between
100% nonrebreather and BIPAP at 18/8. She was continued on
Albuterol and Atrovent nebulizers, Flovent meter dose inhaler
and Levofloxacin for a seven day course of empiric treatment
for pneumonia. Over the next two days, her breathing did not
improve significantly despite the above measures and in the
a.m. of [**2114-2-26**], her pCO2 had climbed to 132, and she was
less mentally responsive. She was then intubated and over
the next few hours, she was unable to wean down from 100%
FIO2 and was changed to pressure control ventilation for
better oxygenation. She was subsequently weaned down to 50%
FIO2.
Bronchoscopy on [**2114-2-26**], revealed edematous airways that
were collapsible on expiration, however, there was no visible
plugging or secretions. She was evaluated for tracheostomy
at the bedside by Doctor [**Last Name (Titles) **], but was felt to be a poor
candidate for the bedside procedure secondary to her obesity
and high PEEP. [**First Name8 (NamePattern2) **] [**Last Name (un) 20042**] was contact[**Name (NI) **] and she was
scheduled for tracheostomy to be performed in the operating
room. In the meantime, she made gradual improvement in her
respiratory function with lower driving pressure requirements
on pressure control ventilation. She was changed back to
assist control on the morning of [**2114-2-28**].
The patient was unable to be transported to the operating
room due to her size. The tracheostomy was changed to a
bedside procedure performed by CT Surgery which was done on
[**2114-3-6**]. Complication was only moderate amount of blood
loss. She tolerated the procedure well. She was taken off
all sedatives and began to wake up at that time. She was
then turned to pressure support ventilation and continued at
a PEEP of 20. The PEEP was unable to be weaned down
secondary to her overall size and relative supine position.
The second issue is her infectious disease issue. She had
intermittent temperature spikes to 101. She completed an
initial course of Levofloxacin for presumed pneumonia which
had been started on admission to the [**Hospital1 190**]. Blood cultures drawn on [**2114-3-2**], began to
grow gram positive cocci that was later identified as
staphylococcus epidermidis. She had subsequent positive
blood cultures with the same organism from her central line.
Her left IJ line was switched to a right IJ which also began
to grow gram positive cocci.
Eventually all central lines were removed and peripheral
access was obtained. She was continued on Vancomycin. Given
the multiple positive blood cultures and high grade
bacteremia, a Transesophageal Echocardiogram was performed
that showed no evidence of valvular vegetation and a normal
ejection fraction. It was planned that she would complete a
four week course of Vancomycin for her high grade bacteremia
and possible endovascular source.
She continued to spike fever despite treatment with
Vancomycin and a subsequent respiratory culture began to grow
pseudomonas. She was started on Levofloxacin and Ceftazidime
for treatment to complete a ten day course of these. Her
white count has trended down and she has been afebrile since
started on these antibiotics and is stable from an infectious
disease standpoint.
Fluids, Electrolytes and Nutrition - She was started on tube
feeds via nasogastric tube. The plan is for her to take p.o.
intake at a later time. Her goal for her tube feeds is 80 cc
per hour with replete with fiber. She has required
occasional fluid boluses for decreased urine output at times.
Prophylaxis - She has been treated with subcutaneous Heparin
t.i.d. as well as p.o. Zantac.
Access - The patient is to be evaluated for a PICC line prior
to transfer to [**Hospital1 34648**].
DISPOSITION: The patient will be transferred to [**Hospital1 34648**] when
a bed is available. She is a full code. Her family is very
supportive and have been present regularly throughout her
hospitalization.
DISCHARGE DIAGNOSES:
1. Morbid obesity with obesity hypoventilation syndrome.
2. Asthma.
3. Anxiety/depression.
MEDICATIONS:
1. Ceftazidime one gram intravenously q8hours to complete
ten day course.
2. Vancomycin one gram intravenously q12hours to complete
four week course.
3. Levofloxacin 500 milligrams p.o. q.d. to complete ten day
course.
4. Iron Sulfate 325 milligrams p.o. t.i.d.
5. Heparin 8000 units subcutaneous t.i.d.
6. Flonase nasal spray two puffs nasally b.i.d.
7. Multivitamin 5 cc p.o. q.d.
8. Colace Elixir 100 milligrams per nasogastric tube t.i.d.
9. Zoloft 100 milligrams p.o. q.d.
10. Zantac 150 milligrams per nasogastric tube b.i.d.
11. Nystatin swish and swallow q6hours.
12. Miconazole powder applied t.i.d. and p.r.n.
13. Flovent 110 mcg MDI four puffs b.i.d.
14. Duragesic patch 25 mcg transdermally q72hours.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7512**]
Dictated By:[**Last Name (NamePattern1) 9422**]
MEDQUIST36
D: [**2114-3-12**] 17:29
T: [**2114-3-12**] 17:45
JOB#: [**Job Number **]
ICD9 Codes: 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4214
} | Medical Text: Admission Date: [**2127-10-10**] Discharge Date: [**2127-10-18**]
Date of Birth: [**2058-12-19**] Sex: M
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
leg weakness, chest pain
Major Surgical or Invasive Procedure:
Persantine MIBI.
Central line placement.
History of Present Illness:
Pt is a 68 yo M with very complicated hx including diastolic
CHF, probable CAD, s/p pacer for CHB, PE ([**2125**]), htn,
dyslipidemia, tracheal stenosis s/p multiple T-tubes, dilations,
stents, COPD, OSA, h/o pneumothorax, AAA s/p repair and s/p
graft infection, axillary DVT, h/o seizure disorder, adrenal
insufficiency on prednisone, h/o pseudomonas sepsis, h/o ARDS,
h/o MRSA bronchitis, h/o c.diff, GIB, gout, balanitis, reflex
sympathetic dystrophy, and depression who presents today with hx
of multiple falls over the past few weeks and en route for an
outpatient head CT was noted to have decreased BP in the 90s and
slurred speech. He was also noted to have one minute of chest
pain en route to the ED.
.
He states that since his hospitalization in [**Month (only) **] for toe
surgeries, he has noticed that he has not been able to walk and
has been dependent on a walker and wheelchair. Before this
hospitalization, he was able to walk 30 steps. He also has had
multiple leg surgeries and states he has had a right foot drop
for a while. However, 3 weeks ago, he noticed that he has been
falling ore. His first fall 3 weeks ago, he states that his
hands were shaking uncontrollably but not similar to his
previous seizures. He denies any bowel or bladder incontinence
with this. He was lightheaded at the time. He states he was
referred to a neurologist who increased his neurontin dose at
that time. He then had his second fall on [**10-2**] where he noticed
his legs were shaking uncontrollably. He also complained of
lightheadedness at that time and had subsequent blurry/double
vision. At [**Hospital1 18**], he had a normal head CT, negative UA/lytes and
was discharged home. He subsequently saw an ophthalmologist 2
days ago who stated his "eyes were fine". He was enroute to have
a repeat head CT today and in the ambulance was noted to have a
slight decrease in BP to the 90's and ?slurred speech (which he
states is not slurred, just his mouth is very dry). He also had
1 minute of chest pain which he describes as SSCP [**2-10**], no
associated N/V, +lightheadedness, no fevers, no radiation of
chest pain. +chronic SOB. Thus, he was brought into the ED. He
states that he has chronic SOB and lately, if he bends over to
feed his cat, his SOB worsens. He also states he sleeps upright
in his wheelchair at night because he doesn't like his hospital
bed at home.
.
In the AM of [**2127-10-14**], the patient was noted to have a SBP around
80, and was given a 500cc fluid bolus. Later that AM, the
patient was again found to have SBP in the 80s, asymptomatic,
and was given another 250cc fluid bolus. The patient then became
unresponsive, slumped over, and mumbling. His O2 saturation
dropped and his SBP went from 80s to 50-60 range. A code blue
was called. The patient was placed on NRB with good O2 response.
He was then started on levophed 0.04 with good response and SBP
into the 100-110s. He was given a head CT and torso CT
(negative) and admitted to the CCU. He was started on stress
dose hydrocortisone, and maintained adequate BP from 110-140
systolic. He was then transferred back to the primary medical
team for further care.
Past Medical History:
PMHx:
1. Presumed Coronary artery disease with last evaluation [**2-3**]
(negative P-MIBI)
2. CHF with preserved EF of about 57%
3. CHB s/p [**Month/Year (2) 4448**] implantation in [**2122-3-3**] with CPI
Discovery SR.
2. Hypertension.
3. Seizure disorder after head trauma.
4. COPD and a history of prior ARDS.
5. Abdominal aortic aneurysm, status post repair andcomplicated
by graft infection.
6. History of pseudomonas sepsis.
7. History of DVTs and right lower lobe pulmonary embolism in
[**2125-1-31**].
8. Depression.
9. Reflex sympathetic dystrophy of the right lower extremity.
10. History of GI bleeding.
11. History of C. difficile colitis.
12. Obstructive sleep apnea.
13. Gout.
Social History:
SOCIAL HISTORY: Lives with wife and four children. Went to
Korean War and received blood transfusions. Denies alcohol. Has
a history of three-and-a-half-pack-per-year smoking;stopped in
[**2121**]. Denies intravenous drug use. Was an arbitration lawyer.
[**Name (NI) **] is Catholic.
Family History:
non contributory
Physical Exam:
Gen- lying in bed flat in NAD, speaking full sentences, no
slurred speech, AAOx3
HEENT- EOMI, +horizontal nystagmus, PERRL
NECK- supple, no JVD appreciated but thick neck
CV- RR, nl S1/S2, no M/G/R
CHEST- CTAB
ABD- obese, soft, NT/ND, +BS
EXT- + bilat. plastic posterior splints with attached neoprene
orthopedic shoes; 2(+) pedal edema BLE; no cyanosis, clubbing,
joint inflammation
NEURO- CN2-12 intact, bilateral UE strength 5/5, RLE strength
[**5-6**], LLE strength 5/5, R. foot drop noted with multiple ankle
surgical scars, +1 patellar reflexes bilaterally. AAOx3.
Pertinent Results:
[**2127-10-10**] 03:00PM GLUCOSE-121* UREA N-32* CREAT-1.1 SODIUM-141
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-23 ANION GAP-17
[**2127-10-10**] 03:00PM CK(CPK)-89
[**2127-10-10**] 03:00PM CK-MB-NotDone cTropnT-0.02*
[**2127-10-10**] 03:00PM PHENYTOIN-34.2*
[**2127-10-10**] 03:00PM WBC-7.8 RBC-4.38* HGB-13.9* HCT-41.2 MCV-94
MCH-31.8 MCHC-33.8 RDW-13.8
[**2127-10-10**] 03:00PM NEUTS-75.9* LYMPHS-15.7* MONOS-4.2 EOS-3.7
BASOS-0.6
[**2127-10-10**] 03:00PM PLT COUNT-197
[**2127-10-10**] 03:00PM PT-12.5 PTT-23.4 INR(PT)-1.0
[**2127-10-9**] 12:48PM GLUCOSE-154*
[**2127-10-9**] 12:48PM CREAT-1.1 POTASSIUM-4.1
[**2127-10-9**] 12:48PM PHENYTOIN-29.5*
[**2127-10-9**] 12:48PM WBC-9.8 RBC-4.16* HGB-13.0* HCT-39.5* MCV-95
MCH-31.2 MCHC-32.9 RDW-13.5
[**2127-10-9**] 12:48PM PLT COUNT-211
.
MIBI: Normal Persantine MIBI study with a left ventricular
ejection
fraction calculated to be 52%.
.
CT head: No evidence of acute mass effect, hemorrhage or
territorial infarction. Question raised about possible
abnormality in the right basal ganglia. See above discussion.
.
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: A large bleb in
the right lung is unchanged. There is minor bibasilar
atelectasis with tiny bilateral pleural effusions. No
lymphadenopathy is identified in the mediastinum, hila or
axillae. The aorta is not dilated, although it contains mural
calcifications. There is a right-sided dual lead [**Month/Day/Year 4448**]. A
calcified granuloma is seen in the left lung base.
.
CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is poor
vascular enhancement by IV contrast, which may be due to the
patient's cardiac status. On this limited scan, the liver,
gallbladder, spleen, stomach, adrenals, pancreas and right
kidney are unremarkable. Multiple round low-density lesions are
seen in left kidney. No lymphadenopathy is identified. There is
no free fluid in the abdomen. The aorta is normal in caliber and
contains mural calcifications, however, there is no unusual
retroperitoneal density to suggest a hematoma.
.
CT OF THE PELVIS WITHOUT AND WITH IV CONTRAST: There are
calcifications within the iliac vessels, without evidence of an
extravasation. Bowel loops, distal ureters, and Foley containing
bladder are unremarkable.
Brief Hospital Course:
#. Chest Pain: The patient was admitted to internal medicine.
An EKG was performed which revealed no changes from previous.
Cardiac troponins were drawn and were shown to be flat. Because
the patient has a history of CAD s/p PCI in [**2-/2127**], a Persantine
MIBI scan was performed to assess for restenosis. This scan
revealed normal cardiac perfusion with an estimated 52% EF. The
patient experienced a resurgence of his chest pain during the
period of hypotension that occurred during his hospitalization.
Repeat EKG again showed no change, and repeated serial troponins
were negative.
.
#. Hypotension: as noted in the HPI, the patient experienced
brief hypotension in the ambulance PTA. The patient had stable
BP for the majority of his stay. However, in the AM on [**10-13**] the
patient experienced an episode of unresponsiveness with BP
falling into the 60s systolic. The BP responded to Levophed at
0.04 with SBP rising to 100-110. The patient was transferred to
the CCU, and was placed on Hydrocortisone 50mg IV Q6h, with
rising BP to the 110-140 SBP range off Levophed. He was then
transferred back to the floor. Hydrocortisone was converted to
Prednisone 60mg PO QD on discharge. He should continue 60mg PO
QD for 3 days, then 40mg PO QD for 3 days, then 20mg PO QD
indefinitely. He experienced no further episodes of
hypotension. The etiology of this episode is unclear. However,
the patient has had several episodes similar to this in the
past. It has been at least partially attributed to his
narcotics regimen, however, Narcan was administered during his
hypotension with no resolution of his signs. The attending
physician was able to get the patient do decrease his Oxycontin
dose somewhat on discharge. The patient had been taking large
doses of Tizanidine prior to arrival for unclear reasons.
Because of the alpha-blockade with this medication, it was held
after his episode of hypotension.
.
#. Leg weakness: The patient's primary complaint on admission
was his leg weakness, which has been going on since his foot
surgery in [**2127-7-2**]. Neurology was consulted, and concluded
that the weakness was likely multifactorial, at least partially
due to a steroid myopathy. Deconditioning likely also plays a
central role, particularly given that the problems all started
after the patient had been bedbound for several days. He will
likely benefit from an acute rehabilitation stay. In the
future, it would likely be beneficial if the patient could
titrate back his steroid requirements, but in the context of his
lung disease this may not be possible.
.
#. LLL lung nodule: A nodule has been noted in a previous CT
scan of the chest which was going to be followed up as an
outpatient for CT-guided biopsy. However, this was scheduled
twice and the patient never had it done. The procedure has been
rescheduled for [**2127-10-22**], and the patient was instructed not to
take his Plavix or Aspirin 325 for 5 days prior to the
procedure. He was instead placed on ASA 81mg during the interim
to prevent in-stent restenosis. This was discussed with the
patient's primary cardiologist, Dr. [**Last Name (STitle) **].
.
#. Diplopia: The patient complained of diplopia throughout his
stay. He reported that it all started after a fall several
months ago. He has seen an outpatient ophthalmologist, who
concluded that everything was normal. He has had 2 outpatient
CT head with no abnormalities seen. This should be followed up
as an outpatient. If intractable, the patient may need an eye
patch, per neurology recommendations.
.
#. CHF/CAD: The patient was continued on his B-blocker, statin,
ACE-I, ASA, Plavix until his episode of hypotension, when they
were discontinued. If the patient continues to maintain good
BPs as his steroids are tapered down, then Lisinopril 10mg PO
QD, Metoprolol 50mg PO BID, and Lasix 40mg PO BID can be added
back as tolerated. The patient had a 2L O2 requirement
throughout his stay. He received a large amount of fluids with
his period of hypotension, but actually tolerated it
surprisingly well. His CXR was consistent with mild volume
overload, but he had no exacerbation of his CHF during his stay.
If his BP can tolerate, he really would benefit from getting
back onto his anti-hypertensive and diuretic.
.
#. Seizure disorder s/p TBI: The patient was noted to have a
grossly elevated dilantin level in the 40s on admission. This
may in fact have been a factor in his recent falls. Dilantin
was held and the level was followed down. Per the PCP, [**Name10 (NameIs) **]
patient typically requires around 600mg-800mg divided TID to
maintain phenytoin levels between [**11-20**]. Dilantin was restarted
at 200mg PO TID, and should be titrated as needed to maintain
therapeutic dose range.
.
#. Gout: allopurinol was continued throughout the
hospitalization with no changes made on discharge.
Medications on Admission:
ALLOPURINOL 100MG--One by mouth every day
CALCIUM CARBONATE 650MG--One by mouth twice a day
DIFLUCAN 100MG--One by mouth every day
DILANTIN 100 mg--3 capsule(s) by mouth three times a day
FERROUS SULFATE 325MG--One tablet by mouth twice a day
HUMABID 600 MG--2 tablets by mouth twice a day
IMIPRAMINE HCL 25MG--3 tabs by mouth at bedtime
LASIX 40 mg--1 tablet(s) by mouth twice a day
LIPITOR 20MG--Take one by mouth every day
LISINOPRIL 10MG--Take one by mouth every day
METOPROLOL TARTRATE 50MG--One tablet(s) by mouth twice a day
MUPIROCIN 2 %--apply to affected skin three times a day
NEURONTIN 400MG--2 tabs by mouth three times a day
NEXIUM 20 mg--1 capsule(s) by mouth once a day
NITROGLYCERIN 0.6 mg--1 tablet(s) sublingually every 5 minutes
times 3, then call 911
OXYCONTIN 80 mg--1 tablet(s) by mouth three times a day as
needed
PERCOCET 5-325MG--One by mouth every 4 hours as needed
PLAVIX 75MG--One tablet(s) by mouth once a day
POTASSIUM CHLORIDE 20MEQ/15ML--One tbsp. three times a day
PREDNISONE 20 mg--1 tablet(s) by mouth once a day
SERZONE 150MG--One by mouth [**Hospital1 **], as directed
ZANAFLEX 4MG--2 by mouth three times a day
ZINCATE 220MG--One by mouth every day
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Imipramine HCl 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet 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. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO q12h ().
13. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
16. Methyl Salicylate-Menthol 15-15 % Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed for local muscle pain.
17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching, burning.
18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
19. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
20. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO TID (3 times a day).
21. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
22. OxyContin 20 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO every eight (8) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Dx:
Chest pain
Hypotension
Leg weakness
Discharge Condition:
Stable, tolerating PO and ambulating with assistance.
Discharge Instructions:
If you experience fevers, chills, nausea, vomiting, chest pain,
shortness of breath, or any other concerning symptoms, contact
your physician or return to the emergency room.
.
You have an appointment for a CT-guided lung biopsy on [**2127-10-22**]
at 9:30 AM on the [**Location (un) 470**] of the [**Hospital Unit Name 1825**] on the [**Hospital Ward Name **] of [**Hospital1 18**].
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 5717**] in the next 2-4 weeks. Call
[**Telephone/Fax (1) 250**] for an appointment.
.
Your scheduled appointments are as follows:
.
Provider: [**Name10 (NameIs) **] Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX) RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-10-22**] 10:30
.
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2127-10-28**] 2:00
.
Provider: [**Name10 (NameIs) **] Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2127-10-28**] 3:00
Completed by:[**2127-10-17**]
ICD9 Codes: 4589, 4280, 496, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4215
} | Medical Text: Admission Date: [**2174-11-13**] Discharge Date: [**2174-11-27**]
Date of Birth: [**2123-8-16**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
respiratory failure/tylenol OD
Major Surgical or Invasive Procedure:
Endotracheal intubation
arterial line
History of Present Illness:
This is a 51 y/o female with PMH significant for HTN, NIDDM,
hypothyroidism, who presented to an OSH early this morning with
URI sx and cough x 2 weeks. Per the patient's husband, and later
verified by the patient, she had been having URI sx and a
non-productive cough for 2 weeks and occasionally low-grade
temperature. She saw [**Name8 (MD) **] NP recently, who recommended OTC meds
and also prescribed a "cough medicine", the name of which is not
known. Her symptoms did not improve however and her cough
progressed with symptoms of respiratory distress as well,
prompting her to present at an OSH early this AM around 3 am. At
the OSH, she was noted to be tachypneic in moderate distress,
with VS of T 97.7, HR 77, BP 120's systolic, RR 26, SaO2 91%/RA.
Her labs there was significant for WBC 17, Hct 31, tylenol level
of 70 (at 4:40 am), Na 115 and ABG of 7.4/28/48 on ?room air.
She received 400 mg moxifloxacin there, 125 mg IV solumedrol x
1, unknown dose of lasix, and a loading dose of IV NAC (10.5
gm).
.
Upon further history, the husband states that the patient has
been taking NyQuil frequently due to her symptoms, however he is
not sure how much she was taking as he is at work most of the
day when she is at home. He notes that he thinks she finished an
entire bottle of NyQuil on Friday (300 mL) and another half a
bottle on Saturday (150 mL). It is unknown what formulation of
NyQuil this was. He also does not know whether she was taking
other cough/URI medications containing tylenol. Patient has a
history of depression, however the husband denies any prior SI
and does not believe the patient was trying to hurt herself with
the NyQuil.
.
The patient was transferred to the [**Hospital1 18**] ED at 7 am due to lack
of ICU beds at the OSH. Initial VS were T afebrile, BP 120's, HR
80's, 95%/4 L. The patient was in moderate resp distress with
somnolent MS, so was electively intubated and set at AC 450x16,
PEEP 5, FiO2 100%. An ABG was unable to be obtained prior to
intubation. Tylenol level in the ED at 7:30 am was 45 (3 hours
later from the initial level). She received vancomycin and
doxycycline in the ED for CAP/ca-MRSA coverage. The patient was
sent to the MICU for further management. Upon arrival, her ABG
was 7.23/65/400's on the initial vent settings, so her RR was
increased and TV was decreased. IV NAC was also started.
.
ROS unable to be obtained at this time.
Past Medical History:
PMH (per husband) -
DM II
Hypothyroidism
HTN
Asthma
Depression
h/o Diverticulitis
Social History:
SH - Lives with her husband and son in [**Name (NI) **]. Does not work.
Smokes 1 ppd x >20 years. Drinks approx 6 beers/week. Admits
cocaine use, which was positive on tox screen at time of
admission.
Family History:
FH - NC
Physical Exam:
VS: Tc 96.6, BP 111/59, HR 70, RR 24, SaO2 95% on AC
350x30/0.6/5
General: intubated, sedated female
HEENT: Pupils pinpoint and minimally reactive. Anicteric
sclerae. ETT in place.
Neck: supple, no JVD
Chest: diffuse rhonchi throughout, no wheezes
CV: RRR distant, no m/g/r
Abd: soft, NT/ND, NABS, no HSM
Ext: 1+ pitting pedal edema
Neuro: sedated, does not withdraw to pain
Pertinent Results:
[**11-13**] EKG - NSR at 70 bpm, normal intervals and axis. No
ischemic changes noted. Compared to OSH EKG [**2174-11-13**]. No prior
available for comparison.
.
[**2174-11-13**] BLOOD WBC-15.7* RBC-4.45 Hgb-11.0* Hct-34.5* MCV-78*
MCH-24.7* MCHC-31.7 RDW-20.4* Plt Ct-245
Neuts-93.4* Bands-0 Lymphs-3.4* Monos-2.5 Eos-0.6 Baso-0
PT-21.3* PTT-33.0 INR(PT)-2.0*
Glucose-108* UreaN-9 Creat-0.4 Na-118* K-4.2 Cl-83* HCO3-23
AnGap-16
ALT-25 AST-74* AlkPhos-150* Amylase-16 TotBili-2.1*
DirBili-1.1* Lipase-18
Calcium-7.6* Phos-4.9* Mg-1.5*
Albumin-2.2*
Ammonia-41
TSH-0.44
HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE IgM HAV-NEGATIVE
HCV Ab-POSITIVE
AMA-NEGATIVE Smooth-NEGATIVE
[**Doctor First Name **]-NEGATIVE
AFP-1.7
IgG-2070* IgA-272 IgM-392*
BLOOD ASA-NEG Ethanol-NEG Acetmnp-45.6* Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
.
[**2174-11-13**] BLOOD pO2-413* pCO2-65* pH-7.23* calTCO2-29 Base XS--1
[**2174-11-13**] URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-POS
amphetm-NEG mthdone-NEG
.
[**2174-11-23**] BLOOD WBC-8.3 RBC-3.71* Hgb-9.2* Hct-29.9* MCV-81*
MCH-24.7* MCHC-30.7* RDW-22.2* Plt Ct-136*
PT-16.9* PTT-34.4 INR(PT)-1.5*
Glucose-160* UreaN-11 Creat-0.5 Na-135 K-3.8 Cl-99 HCO3-34*
AnGap-6*
ALT-61* AST-154* AlkPhos-204* TotBili-1.6*
Calcium-7.9* Phos-3.3 Mg-1.8
.
[**2174-11-13**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-NEG
RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0-2
Urine Osmolal-395
.
HCV VIRAL LOAD (Final [**2174-11-21**]):
1,490,000 IU/mL.
.
HCV GENOTYPE (Final [**2174-11-23**]):
Hepatitis C genotype, 1.
.
[**2174-11-13**] CXR:
FINDINGS: A single AP upright view of the chest is lordotic.
The lateral
aspect of the right costophrenic angle is excluded from the
film. The cardiac silhouette appears normal in size. There is
significant prominence of the interstitial markings bilaterally.
There are ill-defined fluffy airspace opacities throughout both
lung fields. Fullness at the hila bilaterally could represent an
element of pulmonary edema. There is significant scoliosis of
the thoracic spine.
IMPRESSION: Findings consistent with a diffuse bilateral,
multifocal airspace process, such as ARDS or multifocal
pneumonia. Component of interstitial edema is likely.
.
[**2174-11-13**] RUQ U/S:
RIGHT UPPER QUADRANT ULTRASOUND: The liver is heterogeneous in
echotexture and shrunken with a nodular contour, consistent with
cirrhosis. A subcentimeter simple cyst is noted within the
hepatic dome. Additionally, within the right lobe, there is a
subtle, ill-defined hypoechoic lesion measuring 1.7 x 2.8 x 2.6
cm. Remaining liver appears unremarkable. The gallbladder
displays evidence of cholelithiasis, along with mild-to-moderate
wall thickening and wall edema. A moderate amount of ascites is
noted surrounding the liver and within the lower quadrants
bilaterally.
DOPPLER ULTRASOUND: Portal vein is patent with normal
hepatopetal flow.
Hepatic venous and arterial systems display appropriate
waveforms with a
slightly increased resistive indices noted within the main
hepatic artery,
likely related to underlying parenchymal disease. Common bile
duct is normal measuring approximately 0.35 and 0.5 cm. No
intrahepatic ductal dilatation is identified.
IMPRESSION:
1. Shrunken and nodular liver, consistent with cirrhosis.
Cholelithiasis with wall thickening and wall edema, most likely
secondary to third spacing from underlying liver disease.
2. Unremarkable hepatic vascular doppler ultrasound.
3. Moderate amount of intra-abdominal ascites.
4. Possible abnormal hypoechoic lesion within the right lobe.
This could be further assessed with dedicated MRI or
contrast-enhanced multiphasic CT.
.
[**2174-11-14**] TTE:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
.
IMPRESSION: Normal global and regional biventricular systolic
function. No pathologic valvular abnormality seen.
.
[**2174-11-21**] CXR:
CHEST PA AND LATERAL: There continues to be improvement of
multifocal air
space consolidation with residual areas of opacification.
Diffuse bilateral
reticular opacities are coarser with slightly improved aeration
in the right lung base. This could represent the beginnings of
a fibrotic repair with post-inflammatory bronchiectasis. No
pleural effusion. Cardiomediastinal silhouette is unchanged.
IMPRESSION: Diffuse bilateral reticular opacities with slight
improved
aeration of the right lung base, which could represent
post-inflammatory
bronchiectasis and beginnings of a fibrotic repair.
Brief Hospital Course:
# Respiratory failue - Bilateral airspace disease on CXR, most
likely secondary to community acquired PNA, +/- [**Doctor Last Name **], given
PaO2/FiO2 ratio. She was intubated and started on ABX
(vancomycin and levofloxacin). Urine legionella was negative.
After 4 days, vancomycin was discontinued as cultures remained
negative. She was diuresed and treated for reactive airways
with nebulizers and solumedrol. She was extubated on day 5, and
did well. She completed a 7 day course of levofloxacin. Oxygen
was gradually titrated down over the course of several days.
Lasix (initially lasix gtt in ICU, then 40mg IV bid, then 80 PO
BID at time of discharge) for component of pulmonary edema, with
good effect and brisk diuresis. Subsequent CXR demonstrated
improved aeration with coarsening of interstitial markings,
perhaps indicating an element of fibrotic repair. By the time of
discharge she was weaned off oxygen and able to ambulate without
shortness of breath, though still satting only in the low 90's.
She was discharged with the intent of continuing diuresis and
with close follow-up in place.
.
# Tylenol toxicity - Initially treated with NAC protocol. After
her history became more clear, it was felt that this was an
accidental overdose. Psychiatry was consulted, who agreed there
was no evidence of intention to harm. She should be instructed
to limit her acetaminophen use in the future to 2gm/day.
.
# HCV cirrhosis - Imaging demonstrated a cirrhotic-appearing
liver on RUQ ultrasound. Subsequent workup demonstrated that
Mrs. [**Known lastname 5987**] was HCV positive, with HCV VL of 1.5 million,
genotype 1. She was previously unaware of her HCV status or
diagnosis of cirrhosis. She was HAV Ab negative, HBV sAB and cAB
positive. She did have evidence of hepatic dysfunction, with INR
between 1.5-2.0 (although component of acetaminophen toxicity
makes it difficult to assess her baseline), albumin 2.2, and
hyponatremia as below. AFP was 1.7. She was set up with an
appointment with a hepatologist near her home, Dr. [**Last Name (STitle) **], on
[**12-1**] for follow-up. An EGD was not done in-house to assess
for varices. She did have moderate ascites, and was discharged
on maintenance Lasix, though it is unclear whether she will need
to remain on this long-term. Of note, RUQ U/S also demonstrated
a 1.7 x 2.8 x 2.6 cm hypoechoic lesion in the right lobe of the
liver, which will need to be followed up as an outpatient by CT
or MRI.
.
# Hyponatremia - Markedly hyponatremic on admission to 118.
Thought to be a mixed picture at first, and in retrospect likely
complicated by concommittant cirrhosis. Urine Na was 10,
elevated urine osms of 400, FeNa 0.1%. After a brief trial of
normal saline, which did not raise her sodium, it was thought
that she was hypervolemic, and diureseis was initiated via Lasix
drip, with good effect. After cessation of Lasix drip, her
sodium again began to drop to 130, and again responded to
maintainance Lasix IV and then PO.
.
# DM - Metformin was held while in-house. She was initially
covered with glargine and humalog sliding scale, but did require
an insulin gtt while she was on solumedrol. After solumedrol
was stopped, she was converted back to standing and sliding
scale insulin.
.
# Hypothyroidism - The patient was continued on home dose of
levothyroxine, 50mcg daily.
.
# HTN - Her home atenolol was held initially but restarted after
her extubation and she became hypertensive.
.
# Depression/Delerium - Effexor were held during her ICU stay
due to mild to moderate delerium, and was restarted at the time
of discharge. The patient's mental status cleared significantly
over the course of her hospital stay.
.
# F/E/N - Diabetic diet. Electrolytes were repleted as needed.
.
# Pneumoboots were used for DVT prophylaxis .
.
# Communication - With husband, [**Name (NI) **] [**Name (NI) 5987**] (c)
[**Telephone/Fax (1) 76459**]; (h) [**Telephone/Fax (1) 76460**]
.
# The patient was a full code.
Medications on Admission:
(doses confirmed with the husband)
Levothyroxine 50 mcg daily
Singulair 10 mg po daily
Atenolol 25 mg daily
Lorazepam 2 mg PO QID prn (taking at least 3x/day)
Metformin 500 mg [**Hospital1 **]
Effexor XR 225 mg daily
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID prn as
needed for anxiety or back spasm.
Disp:*21 Tablet(s)* Refills:*0*
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*2 Disk with Device(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation Every 4 hours as needed for shortness of breath,
coughing or wheezing.
Disp:*1 * Refills:*2*
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Effexor XR 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
-respiratory failure
-acetaminophen toxicity
-hepatitis C
-cirrhosis
-hyponatremia
-delerium
-hypothyroidism
-DM
-HTN
-depression/anxiety
Discharge Condition:
Good. Mental status improved, LFTs stable, respiratory status at
baseline.
Discharge Instructions:
-It is important that you continue to take your medications as
directed.
- Your Effexor was stopped during your hospitalization and
restarted at discharge at a lower dose. You should discuss with
your new PCP whether this dose needs to be titrated.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 39375**], internal medicine,
[**12-12**] at 2pm. WE WOULD LIKE YOU TO SEE A DOCTOR WITHIN A
FEW DAYS AFTER DISCHARGE. IF YOU ARE NOT GOING TO SEE DR. [**Last Name (STitle) **]
ON [**2173-12-2**], PLEASE CALL DR. [**Last Name (STitle) **] AT [**0-0-**] FOR AN EARLIER
APPOINTMENT.
.
You have an appointment with Dr. [**Last Name (STitle) **] in liver clinic on [**12-1**] at 4pm. Please call [**Telephone/Fax (1) 76461**] for directions.
.
Dr. [**Last Name (STitle) 497**] of the liver department at [**Hospital1 18**] will have his office
call to schedule a follow up appointment with him in the next
[**1-1**] wks.
ICD9 Codes: 5070, 2930, 2761, 5715, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4216
} | Medical Text: Admission Date: [**2126-6-17**] Discharge Date: [**2126-6-27**]
Service:
HISTORY OF PRESENT ILLNESS: This 80-year-old gentleman was
admitted from [**Hospital3 **] with chest pain for which he
was treated with Nitroglycerin and transferred to [**Hospital1 346**]. Cardiac catheterization was
performed which showed three vessel disease. Intra-aortic
balloon pump was placed and patient was referred to
cardiothoracic surgery service.
PAST MEDICAL HISTORY: Includes skin cancer, glaucoma,
hypertension, polymyalgia rheumatica, cervical disc disease.
PAST SURGICAL HISTORY: Negative.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission, Timoptic, Lopressor 50 mg po bid
and enteric coated Aspirin 375 mg po q d, Prednisone 3 mg po
bid.
PHYSICAL EXAMINATION: On admission, blood pressure 180/100,
heart rate 68. His neck had no carotid bruits. His chest
was clear. Heart was regular rate and rhythm with no murmur.
Abdominal exam was benign. His extremities had normal
pulses, no varicosities were noted.
LABORATORY DATA: His labs on admission were white count of
8.4, hematocrit 45.2, platelet count 152,000, potassium 4.2,
BUN 25, creatinine 1.1, blood sugar 172 and INR of 0.98.
HOSPITAL COURSE: Patient was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]
of cardiothoracic surgery service. Cardiac catheterization
on [**6-17**] revealed a severe left main disease with a 90% lesion,
90% proximal LAD, 90% left circumflex, 70% RCA. Ejection
fraction was approximately 40%. Intra-aortic balloon pump
was placed in anticipation of surgery. On [**6-18**] the patient
underwent coronary artery bypass grafting times two with a
LIMA to the LAD and a vein graft to the obtuse marginal of
the circumflex. The patient was transferred to
cardiothoracic ICU with his balloon in place in stable
condition. The patient also had some bright red blood per
the orogastric tube in the operating room and a consult was
requested by Dr. [**Last Name (STitle) 70**] for the patient to be seen by
medicine. The recommendations were to treat the patient with
some Protonix and follow his hematocrit and treat as needed
and then possibly do an EGD when the patient was more
currently stable after his bypass surgery with obvious
coagulopathies to be corrected.
On postoperative day #1 the patient continued on his
perioperative Vancomycin. The patient was extubated, was
hemodynamically stable with blood pressure 123/44, satting
98%. The T max was 100.8. Cardiac index was 3.0. His
hematocrit was 36 with BUN of 14, creatinine 1.1. He was
alert. He had a slight respiratory wheeze. His heart was
regular rate and rhythm. His abdominal exam was benign. He
had 1+ pedal edema bilaterally. His dressings were dry and
intact. He was on 0.25 of Milrinone and 1.0 of [**Female First Name (un) **] with
plans to wean his drips after discontinuing his intra-aortic
balloon pump.
On postoperative day #2 his balloon had been discontinued, he
remained on an Amiodarone drip in sinus rhythm at 0.5 with
plans to switch his Amiodarone over to po. His Foley was
discontinued. His exam was relatively benign, was
maintaining a good blood pressure and satting well with
cardiac index of 2.3 and a creatinine of 1.5 with hematocrit
of 30. He was started on all of his oral medications and
continued on his perioperative Vancomycin.
On postoperative day #3 his chest tubes were discontinued, he
began Lasix diuresis, he was on nasal cannula, satting well
with good blood pressure, T max of 100.4. His exam was
benign. He remained on Amiodarone and Lopressor to keep him
in sinus rhythm and sliding scale insulin for his blood
sugars. His Prednisone was restarted on postoperative day #2
and he was alert and awake. He was seen by physical therapy
and GI service. His hematocrit was stable and they continued
to follow him.
On postoperative day #4 he had another bout of atrial
fibrillation which was stopped with 10 mg of IV Lopressor. H
His heart was regular rate and rhythm otherwise. Once he was
in sinus his lungs were clear bilaterally. His abdominal
exam was benign. He continued to have bilateral lower
extremity edema. His Foley was removed. His Metoprolol was
increased to 50 mg tid to help combat his rapid atrial
fibrillation.
He was seen again by respiratory therapy on postoperative day
#5. He had some bouts of atrial fibrillation and complained
of some right hand weakness. His blood pressure was 95/32
with T max of 97.7, heart was regular rate and rhythm. Head
CT was ordered to rule OT a CVA for his new hand weakness
symptoms. The patient continued to have a little bit of
improvement in his hands during the day.
On postoperative day #6 he continued with intermittent atrial
fibrillation. His CT scan was preliminarily negative for
evidence of a CVA. His incisions remained clean, dry and
intact. His blood pressure was 162/74 and heart rate of 72.
He continued to have a slight improvement in his right hand
weakness. Pending results to neurology consult, the patient
could be restarted on Heparin and Coumadin if needed.
General impression was that he had an isolated radial nerve
injury termed a Saturday night palsy. Management
recommendations were conservative with therapy as needed or
splint to prevent contractures and further evaluation as the
patient improved from his bypass surgery. On postoperative
day #6 in the evening, the patient again went into atrial
fibrillation with a heart rate of 123, maintaining a good
blood pressure, more IV Lopressor was given which broke the
patient and put him back in sinus rhythm. He was also given
repletion magnesium and decision was made not to restart
Amiodarone at that time.
On postoperative day #7 the patient was in sinus rhythm with
intermittent atrial fibrillation in the morning. Lungs were
clear. Abdominal exam was benign. The patient had been
started on Heparin at about approximately 1,000 units per
hour and continued with physical therapy for ambulation and
his radial nerve palsy. He continued to be followed by
neurology, was seen by occupational therapy services and
respiratory care for pulmonary toilet.
On postoperative day #8 he had no acute events and no atrial
fibrillation for the 24 hours prior. His exam was benign
with the exception of his right hand strength continuing to
improve. His extremities still had 1+ edema. He continued
to receive chest PT and occupational therapy and continued on
Heparin and continued to improve.
On [**6-27**], postoperative day #9 the patient had an unremarkable
exam with trace edema in bilateral lower extremities. His
incisions were clean, dry and intact. He continued to
improve and was given instructions for follow-up with Dr.
[**Last Name (STitle) 39288**], his primary care physician [**Last Name (NamePattern4) **] [**2-18**] weeks and
instructions to contact Dr.[**Name2 (NI) 27686**] office for a
follow-up appointment in 6 weeks. He was discharged to rehab
facility on the following medications.
DISCHARGE MEDICATIONS: Lansoprazole oral solution 30 mg po q
d, Amiodarone 400 mg po q d, Prednisone 3 mg po bid,
Haloperidol 1 mg po tid, enteric coated Aspirin 325 mg po q
d, Metoprolol 75 mg po tid, Lasix 20 mg po q d times four
days, KCL 20 mEq po q d times four days, Timoptic 0.5% one
drop OU q h.s., Docusate 100 mg po bid prn, Tylenol 325 mg to
650 mg po prn q 4-6 hours, Coumadin for dosing to an INR of
2.0, Albuterol nebs q 6 hours.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass grafting times two.
2. Atrial fibrillation.
3. Skin cancer.
4. Glaucoma.
5. Hypertension.
6. PMR treated with Prednisone.
7. Right radial nerve palsy.
Again, the patient was discharged to rehabilitation facility
on [**6-27**] in stable condition.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2126-9-11**] 11:30
T: [**2126-9-16**] 18:50
JOB#: [**Job Number 99209**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4217
} | Medical Text: Admission Date: [**2101-6-10**] Discharge Date: [**2101-6-16**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Admitted after fall in bathroom with rib fractures and
hemothorax.
Major Surgical or Invasive Procedure:
[**6-10**]: Blood transfusions, vitamin K and FFP, chest tube
insertion, epidural catheter placement.
History of Present Illness:
86 year old male was evaluated at an outside hospital after a
fall in the bathroom at his rehab facility and was discharged
back to rehab that same day. Hematocrit check at rehab was 18,
so pt returned to outside hospital, got 1 unit packed RBCs,
vitamin k, and ffp and was transferred to [**Hospital1 18**].
Past Medical History:
?CHF, Atrial fibrillation with pacemaker, DM, HTN, chronic
UTI/chronic renal failure
Social History:
Was recuperating at [**Hospital 5503**] Health Care Center at time of
admission. Son [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 79118**]) lives in area.
Family History:
Non-contributory
Physical Exam:
Afebrile, vital signs stable.
Gen: No distress, alert and oriented x3
CV: RRR
Resp: Bibasilar crackles
Abd: Soft/non-tender/non-distended. +bowel sounds
Ext: Warm and well perfused.
Pertinent Results:
[**2101-6-10**] 07:15PM URINE RBC-21-50* WBC->1000 BACTERIA-MANY
YEAST-NONE EPI-0
[**2101-6-10**] 07:15PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2101-6-10**] 07:15PM PT-23.0* PTT-33.1 INR(PT)-2.2*
[**2101-6-10**] 07:15PM WBC-18.5* RBC-2.74* HGB-6.9* HCT-21.6*
MCV-79* MCH-25.2* MCHC-31.9 RDW-17.5*
[**2101-6-15**] 06:10AM HCT 34.0*
[**2101-6-12**] 03:20AM Gluc 108* BUN 61* Creatinine 1.5* Sodium
134 Potassium 5.2* Chloride 106 HCO3 20* Anion Gap 13
[**6-10**] EKG: Sinus tachycardia. Left bundle-branch block.
[**6-10**] CXR: Extensive right-sided rib fractures multiple in more
than one
place highly suggestive of a flail chest. There is also a
posteriorly layering pneumothorax.
[**6-15**] CXR: Interval removal of right-sided chest tube with
development of small apical pneumothorax. No significant
residual effusion. The heart remains mildly enlarged without
evidence for overhydration. There is also a hazy area of opacity
in the left upper lobe, which could be resolving contusion
injury; however, this should be followed to resolution. No
change to previously seen rib fractures.
[**6-16**] CXR: Stable small apical pneumothorax. F/u right lower lobe
opacity (likely pulmonary contusion) with future films.
Brief Hospital Course:
He was admitted to the Trauma service with right sided rib [**5-4**]
fractures, a hematocrit of 21.6 and INR 2.2. A chest tube was
placed and returned 800cc of blood from the thorax. He was
initially admitted to the trauma ICU for monitoring. His
hematocrit improved after transfer of 4 units RBCs, vit k, and
ffp. On [**6-11**], urinalysis revealed a UTI, for which he was
treated with 3 days of ciprofloxacin.
His hematocrit subsequently remained stable and gradually
increased to 34.0 on [**6-15**].
Because of his rib fractures the Acute Pain service was
consulted for epidural analgesia. The epidural catheter was
placed and remained for several days. He was later transitioned
to oral narcotics and the epidural was removed. His pain
adequately controlled on Tylenol, Tramadol, and Oxycodone prn.
He is on a bowel regimen.
Pt was previously anticoagulated for atrial fibrillation.
Because of his recent fall and hemothorax and increased risk of
similar subsequent events given pt's age and relative
instability, would recommend not restarting Coumadin for
anticoagulation in spite of pt'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] score of 4.
Physical therapy was consulted and have recommended rehab after
acute hospital stay.
Medications on Admission:
Coumadin, Digoxin 0.125 mg QD, Accupril 40 mg QD, Humalog 15 u
TID, Lantus 20 U QHS, Glucophage 1000 mg [**Hospital1 **], Colace 100 [**Hospital1 **],
Atenolol 25 mg QD, Lasix 40 QD
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day). Tablet(s)
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
11. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Insulin NPH & Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Health Care Center
Discharge Diagnosis:
Right rib [**5-4**] fractures and hemothorax secondary to fall from
standing.
Discharge Condition:
Stable, meeting discharge criteria, afebrile, vital signs
stable, eating regular diet, pain controlled on oral meds,
indwelling foley.
Discharge Instructions:
It is important that you continue to cough, deep breathe and use
the incentive spirometer every hour that you are awake to
prevent pneumonia that is often a complication associated with
rib fractures.
Followup Instructions:
Call Dr.[**Name (NI) 18535**] office to schedule a follow up appointment in
2 weeks at ([**Telephone/Fax (1) 36338**].
Follow up with a urologist to evaluate your urinary retention
and history of urinary tract infections after discharge from
rehab.
Follow up with your PCP after discharge from rehab.
ICD9 Codes: 5849, 2859, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4218
} | Medical Text: Admission Date: [**2100-9-29**] Discharge Date: [**2100-10-7**]
Date of Birth: [**2022-11-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
metastatic breast cancer, fever, lethargy, hypotension/early
sepsis
Major Surgical or Invasive Procedure:
internal jugular CVL
History of Present Illness:
77 y/o female with metastatic breast cancer to brain, POD #5 s/p
right sided craniotomy on Friday by NSGY for tumor debulking,
discharged to rehab yesterday, who is sent in to [**Hospital1 18**] ED for
fever, lethargy, and left sided weakness.
.
Patient's breast cancer was diagnosed in 12/[**2097**]. She is s/p
chemotherapy and Herceptin, with course complicated by seizure
(now on dilantin). Patient had a PET scan in [**8-20**] that was
normal except a low attenuation lesion in R parietal lobe.
Outpatient brain MRI on
[**2100-9-17**] showed 1.2 cm right parietal mass with extensive edema
c/w sole metastasis. Her recent admission from [**Date range (1) 87323**] is
notable for being continued on decadron and phenytoin. She was
seen by the neuro-oncology service, neurosurgery service, and
the radiation oncology service. The patient opted for
neurosurgical treatment of her solitary brain metastasis.
.
Over past two days, patient's son reports that [**Name (NI) 37190**] had
increased lethargy. She was "losing strength on her left side."
She reports no cough or viral URI sx. She reports diarrhea x 1
week (no recent Abx). She does report increased urinary
frequency without dysuria. She denies HA or neck stiffness. Her
temperature was 100.1 this AM.
.
In the ED, initial vs were: 99.2, 84, 104/62, 18, 95%. Exam
notable for dry MM, L facial droop, LUE 2-3/5, LLE 0/5, R-full
strength, A&Ox3 (similar to discharge exam). Labs notable for
WBC 22.8, positive U/A, and lactate 1.5. CT head performed which
was in general similar to [**9-27**] images - slight decrease in
pneumocephalus, no new hemorrhage, post-surgical changes in the
right parietal lobe with decreased hyperdense component (blood
products), edema overall stable. NSGY was consulted in the ED,
and felt that there was no acute neurosurgical concerns. CVL was
placed in the ED for SBP in the 80s which rose to SBP in 90s
with IVF. Patient was given vancomycin, cefepime, dexamethasone,
and tylenol in the ED. Blood and urine cultures were sent.
.
On transfer, vs: HR 69, BP 101/36, RR 20, 98% on 2L NC. Access:
2 PIV (18 and 20 guage).
.
On the floor,
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- Breast cancer, stage IIIb (T3N3M0), diagnosed in [**11/2098**],
right breast mass with positive supraclavicular and axillary
nodes, ER neg, PR neg, HER-2/Neu positive, s/p chemotherapy with
6 cycles of Taxotere, carboplatin, and Herceptin followed by
Herceptin completed 3 weeks ago by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 88501**]).
Social History:
Currently at [**Hospital 38**] Rehab, but normally lives
w/husband, has three additional children. Non-smoker, denies
ETOH.
Family History:
No familial hx of cancer
Physical Exam:
ADMISSION EXAM:
General: sleepy, tired, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP 6 cm, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, grade II
holosystolic murmur at LSB
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:
[**2100-9-29**] 11:40PM GLUCOSE-106* UREA N-18 CREAT-0.7 SODIUM-144
POTASSIUM-4.1 CHLORIDE-113* TOTAL CO2-20* ANION GAP-15
[**2100-9-29**] 11:40PM ALT(SGPT)-9 AST(SGOT)-7 LD(LDH)-170 ALK
PHOS-86 TOT BILI-0.3
[**2100-9-29**] 11:40PM ALBUMIN-2.7* CALCIUM-7.1* PHOSPHATE-3.6
MAGNESIUM-1.4*
[**2100-9-29**] 11:40PM WBC-22.1* RBC-3.70* HGB-11.8*# HCT-35.3*
MCV-96 MCH-32.0 MCHC-33.5 RDW-13.4
[**2100-9-29**] 11:40PM NEUTS-87* BANDS-7* LYMPHS-2* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2100-9-29**] 11:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2100-9-29**] 11:40PM PLT SMR-NORMAL PLT COUNT-190
[**2100-9-29**] 11:40PM PT-14.2* PTT-36.5* INR(PT)-1.2*
[**2100-9-29**] 03:40PM GLUCOSE-104* UREA N-23* CREAT-1.0 SODIUM-133
POTASSIUM-4.8 CHLORIDE-97 TOTAL CO2-23 ANION GAP-18
[**2100-9-29**] 03:40PM estGFR-Using this
[**2100-9-29**] 03:40PM WBC-22.8*# RBC-4.82 HGB-15.2 HCT-44.6 MCV-93
MCH-31.6 MCHC-34.1 RDW-13.8
[**2100-9-29**] 03:40PM NEUTS-93* BANDS-1 LYMPHS-1* MONOS-4 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2100-9-29**] 03:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2100-9-29**] 03:40PM PLT SMR-NORMAL PLT COUNT-215
[**2100-9-29**] 03:40PM PT-14.0* PTT-35.0 INR(PT)-1.2*
[**2100-9-29**] 03:40PM URINE COLOR-[**Location (un) **] APPEAR-Cloudy SP [**Last Name (un) 155**]-1.026
[**2100-9-29**] 03:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2100-9-29**] 03:40PM URINE RBC->50 WBC->50 BACTERIA-MOD YEAST-NONE
EPI-0
[**2100-9-29**] 03:35PM LACTATE-1.5
[**2100-10-7**] 10:57AM BLOOD WBC-6.9 RBC-3.57* Hgb-11.3* Hct-33.8*
MCV-95 MCH-31.8 MCHC-33.5 RDW-13.9 Plt Ct-371
[**2100-10-7**] 10:57AM BLOOD Glucose-110* UreaN-13 Creat-0.7 Na-140
K-4.4 Cl-106 HCO3-24 AnGap-14
[**2100-10-6**] 05:18AM BLOOD ALT-62* AST-43* AlkPhos-114* TotBili-0.2
[**2100-10-7**] 10:57AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.5*
[**2100-10-3**] 05:26AM BLOOD calTIBC-121* VitB12-207* Folate-6.0
Ferritn-251* TRF-93*
[**2100-10-2**] 04:00AM BLOOD Hapto-224*
Brief Hospital Course:
77 yo woman with metastatic breast CA to brain, s/p right-sided
craniotomy [**2100-9-24**] for tumor debulking, who is admitted for
fever, lethargy, and left-sided weakness. Hypotension required
pressors and IV fluids. Initially she received vancomycin and
cefepime in the ED. Urine culture returned positive for
pansensitive proteus. Stool also returned positive for Cdiff.
Patient was placed on po vancomycin, IV metronidazole, and
ciprofloxacin and her symptoms resolved. CT head showed no
acute changes.
PLAN:
1. Urosepsis: Blood cultures negative. Continue cipro for
Proteus mirabilis x14d, last day [**2100-10-13**].
2. C. dif colitis: She has responded well to combined therapy. I
will changed metronidazole to PO and continue both metronidazole
and PO vanco x14d, last day [**2100-10-14**].
3. Hypotension: Resolved. Outpatient atenolol restarted.
4. Brain Met post debulking: Continue dexamethasone taper.
Patient and family in coordination with radiation oncology have
decided to pursue whole brain radiation therapy AFTER rehab is
complete.
5. B12 deficiency: Started B12 1000mcg IM x7d loading regimen,
followed by B12 1000mcg IM qmo.
6. Hypomagnesemia: Will give Mg oxide today and follow.
7. Dispo: Anticipating discharge to rehab today.
Code status: DNR/DNI.
Medications on Admission:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
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).
7. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
8. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO q6hrs () for 3
days.
10. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q6hrs ()
for 3 days.
11. dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO q6hrs () for 3
days.
12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-12**]
Tablets PO Q4H (every 4 hours) as needed for pain.
14. heparin, porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush.
15. heparin lock flush (porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 1mL
Injection TID (3 times a day).
8. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 7 days: Last day [**2100-10-14**].
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days: Last day [**2100-10-13**].
10. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) 1mL Injection As directed: Daily x3 days, then monthly.
11. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 7 days.
13. dexamethasone 0.5 mg Tablet Sig: One (1) Tablet PO As
directed for 6 days: 0.5mg PO BID x3 days, then 0.5mg PO daily
x3 days, then stop.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
1. Urosepsis.
2. C. diff colitis.
3. Hypotension.
4. Metastatic breast cancer to the brain.
5. Vitamin B12 deficiency.
6. Hypomagnesemia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were diagnosed with urosepsis (a severe infection of the
urinary tract) and C. diff colitis (a severe infection of the
large colon). You required initial care in the Intensive Care
Unit for very low blood pressure, but then you responded to
antibiotics and fluids. You also need radiation therapy to the
brain for the metastatic breast cancer. This will be done after
rehabilitation. You were also found to have vitamin B12
deficiency and were started on B12 injections.
Followup Instructions:
You will need to follow-up with Radiation Oncology (Dr. [**First Name (STitle) **]
[**Name (STitle) 3929**]) for whole brain radiation therapy after rehab is
complete.
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4219
} | Medical Text: Admission Date: [**2166-3-24**] Discharge Date: [**2166-4-17**]
Date of Birth: [**2106-9-14**] Sex: F
Service: MEDICINE
Allergies:
Biaxin / Erythromycin Base / Amiodarone
Attending:[**First Name3 (LF) 9569**]
Chief Complaint:
Milrinone Holiday
Major Surgical or Invasive Procedure:
Swan Ganz Catheter
History of Present Illness:
Mrs. [**Known lastname **] is a 59 year old female with h/o ischemic CMP, s/p
CABG with residual EF 15%, & hypothyroid disease c/b amiodarone
induced thyrotoxicosis presents with SOB & cough wks x 3 weeks
and fevers to 101F x 4 days. Pt states that she has been
feeling unwell since her discharge from [**Hospital1 18**] 2 weeks PTA. She
reports decreased energy, SOB, non-productive cough, sore
throat, and sweats x 2-3 weeks. She has also had incr facial,
abdominal, and LE edema despite decr po intake x 5 days. She
has recently been feeling dizzy but has not had syncope or chest
pain. Has PND & 3 pillow orthopnea. She did had a flu shot
this season.
ROS: No HA, no photophobia, no urinary sxs, occ diarrhea & occ
epigastric pain.
Past Medical History:
Ischemic CMP, CHF, EF 15%, dry wt 158-162#, CAD s/p MI '[**39**], s/p
CABG '[**42**] SVT to LAD, severe MR, severe TR, pulm HTN, s/p bivent
pacer/ICD, PAF, hypothyroidism [**1-29**] amiodarone toxicity
Social History:
Smoked for 7 years, currently, not smoking. No alcohol use. The
patient lives alone and is retired.
Family History:
Mother - non-alcoholic liver cirrhosis. Father - DM.
Father deceased of MI at 50.
Sister with SLE.
Physical Exam:
VS: 98.2, 97/70 (86-101/47-70), 80, 18, 96%RA
I/O: poorly recorded, wt 83.8kg (<-84.2kg)
Gen: NAD, mildly ill appearing, sitting in a chair, slightly
tachypnic
HEENT: anicteric, very dry MM
Card: irreg irreg, nl S1 S2, II/VI EM
Resp: few mild wheezes, mild bibasilar crackles
Abd: nl BS, soft, mild RUQ tenderness, no [**Doctor Last Name 515**], no rebound
Exts: mild non-pitting edema, WWP
Neuro: A&O3, MAE
Pertinent Results:
[**2166-3-24**] 10:12PM PT-68.2* PTT-65.3* INR(PT)-29.3
[**2166-3-24**] 08:00PM GLUCOSE-107* UREA N-31* CREAT-1.1 SODIUM-137
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-20* ANION GAP-21*
[**2166-3-24**] 08:00PM ALT(SGPT)-83* AST(SGOT)-159* LD(LDH)-428* ALK
PHOS-150* AMYLASE-64 TOT BILI-1.9*
[**2166-3-24**] 08:00PM LIPASE-26
[**2166-3-24**] 08:00PM ALBUMIN-4.0 CALCIUM-8.4 PHOSPHATE-2.7
MAGNESIUM-1.8
[**2166-3-24**] 08:00PM TSH-17*
[**2166-3-24**] 08:00PM DIGOXIN-1.9
[**2166-3-24**] 08:00PM WBC-7.0 RBC-3.80* HGB-12.4 HCT-40.3# MCV-106*
MCH-32.6* MCHC-30.7* RDW-15.3
[**2166-3-24**] 08:00PM PLT COUNT-210
[**2166-3-24**] 08:00PM PT-75.9* PTT-67.1* INR(PT)-36.3
INR from 36 on admission to 2.7 on HD #2 after vitamin K 10meq
po
.
STUDIES:
Liver U/S [**2166-3-25**]
1. Normal color flow and waveforms within the hepatic arteries,
hepatic veins, and portal veins.
2. Unremarkable abdominal ultrasound.
.
CXR [**2166-3-24**]: Stable appearance of the chest compared with
[**2166-2-16**] with no radiographic evidence of acute cardiopulmonary
process.
.
Rest thallium [**2166-2-17**]: Large, fixed perfusion defect involving
the expected LAD territory, not significantly changed since the
prior study. Markedly dilated left ventricular cavity, stable
since the prior exam.
.
Echo [**7-30**]: EF < 20%, dilated LV, 4+ MR.
Cath [**9-29**]: no sign CAD, EF 15%, 3+MR, mod pulm hypotension,
65/30.
CXR [**2166-3-24**]: Stable c/w [**2166-2-16**], no acute cardiopulmonary
process.
.
MICRO:
[**2166-3-25**] Influenza A/B by DFA negative
[**2166-3-25**] URINE CULTURE negative
[**2166-3-24**] BLOOD CULTURE negative
[**2166-3-24**] BLOOD CULTURE negative
DISCHARGE LABS:
[**2166-4-16**] 06:45AM BLOOD WBC-10.3 RBC-3.19* Hgb-10.1* Hct-31.7*
MCV-99* MCH-31.6 MCHC-31.9 RDW-15.1 Plt Ct-522*
[**2166-4-17**] 06:00AM BLOOD PT-16.0* PTT-34.8 INR(PT)-1.6
[**2166-4-16**] 06:45AM BLOOD Glucose-91 UreaN-4* Creat-0.7 Na-138
K-3.9 Cl-109* HCO3-22 AnGap-11
[**2166-4-15**] 07:08AM BLOOD ALT-33 AST-19 AlkPhos-111 TotBili-0.9
[**2166-4-15**] 07:08AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2166-4-15**] 07:08AM BLOOD HIV Ab-NEGATIVE
[**2166-4-15**] 07:08AM BLOOD HCV Ab-NEGATIVE
[**2166-4-15**] 07:08AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-PND
[**2166-4-15**] 07:08AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-PND
Brief Hospital Course:
59 year old female with dilated CM (EF 15%) s/p BiV ICD, s/p
CABG '[**42**] SVG-LAD, Severe MR & TR, PAF, presenting with SOB &
fevers.
1. CV:
A) Pump: The patient presented with a history of CHF/CMP and hx,
sx and exam consistent with failure (SOB, orthopnea, JVD, mild
crackles, non-pitting edema). On admission, she was started on
milrinone and her lasix was increased as her BP tolerated. She
did not diurese well on this regimen and was transferred to the
CCU on [**2166-3-27**] where a a Swan Ganz catheter was placed for
tailored CHF therapy.
In the CCU, she was continued on milrinone gtt and a nipride gtt
was titirated up to achieve a CI of >2.2 and a decreased SVR and
PAP. On this therapy she achieved good diuresis with average 24
hours fluid balance negative 1-2L. After the initial success
with diuresis, the patient was started on valsartan and imdur in
an attempt to wean off drips and convert to oral medication.
With steadily increasing doses of valsartan and imdur, she did
wean off the nipride and the milrinone but developed an episode
of sustained hypotension and decreased urine output when the
milrinone was stopped. From this it was presumed that the
patient required the additional inotropic support of the
milrinone, and after re-starting milrinone her CO and CI
increased sufficiently to maintain MAP >60. On HD#10 ([**2166-4-2**]),
the patient was on a stable dose of aldactone 25mg once daily
(decreased from 50mg po daily as an outpatient), bisoprolol 5mg
once daily, milrinone 0.385mcg/kg/min gtt and was loaded on
digoxin. Her isordil, nipride, valsartan, and lasix were
discontinued. Once on a stable heart failure regimen, the
patient was transferred out of the CCU and sent to the step down
unit. There her ins and outs were not well recorded and
secondary to a foley that was re-inserted on the floor, she
developed a UTI/pyelonephritis confirmed by CT scan which
required re-admission to the CCU for further management. On her
second admission to the CCU, her heart failure regimen was again
altered due to her inability to tolerate milrinone secondary to
development of persistent HA. She was empirically taken off
milrinone with subsequent decompensation and was then started on
low dose dopamine instead. She tolerated the dopamine well with
good urine output and maintenance of pressures. She was able to
regain forward flow and returned to compensated heart failure.
At this point her regimen consisted of Dopamine 2.5mcg/kg/min,
bisoprolol 5mg once daily, and digoxin 0.125mg once daily. She
was taken off the aldactone for persistent hyponatremia.
Initially the plan was to discharge her on home dopamine, but
without right heart catheterization, approval was not granted
for home dopamine infusion. The patient refused another right
heart cath. Upon the patient's insistence, dopamine was
discontinued. She maintained her blood pressures and remained
in compensated CHF during the following day.
She also decided to pursue cardiac transplantation prior to
discharge. The PFT's, carotid studies and panel of serologies
were sent prior to discharge.
B) Coronaries: The patient has had CABG in past but appears most
of her initial CAD was secondary to complications of the cath
from atypical chest pain. The patient is on baby aspirin, and
b-b (bisoprolol), and diuretics. Statins were held temporarily
given her elevated LFTs on admission (which was most likely due
to RHF). This will need to be revisited by her PCP [**Name Initial (PRE) 176**] 6
weeks of discharge for possible re-initiation of statin therapy.
C). Rhythm: The patient was admitted in afib which was thought
to contribute to her decompensated heart failure (with loss of
her atrial kick). She spontaneously converted to NSR after some
diuresis but then continued to go in and out of atrial
fibrillation. The BiV pacer was interrogated on [**2166-3-26**] and was
found to be RV pacing. The capture rate was increased to a HR
of 80 at which point the pacer was pacing both ventricles with
good synchrony. The patient could not be started on ibutilide
or dofetilide due to concerns of torsades while the patient was
on milrinone. The milrinone or dopamine was required to
maintain pressure, and good forward flow as manifested by the
low CO/CI and hypotension when either was stopped, therefore
cardioversion was not considered an option. The patient was
also loaded on amiodarone and continued on her digoxin. If the
patient can remain in sinus rhythm for a few months, then it may
be possible to stop the milrinone or dopamine and start
dofetilide. For anticoagulation she was placed on a heparin gtt
and coumadin PO. The coumadin was loaded slowly as the
amiodarone could elevate the INR. At time of discharge, the
patient was on amiodarone and digoxin for her atrial
fibrillation with evidence of some organized atrial activity.
2. Headache (HA): The patient first reported a HA on return to
the CCU for her second admission. At first the HA was very
concerning for a viral or partially treated bacterial
meningitis. Neurology was consulted and recommended a LP,
however the patient contniued to refuse the procedure. As the
patient had a similar experience with HA on previous admission
where milrinone was used, the possibility of a milrinone induced
vasodilatory migraine type HA was raised. The patient was
empirically taken off the milrinone with some improvement in her
HA. At the same time however, the patient was also given
reduced doses of amiodarone and digoxin as well (dig was held
due to supratherapeutic levels). Also at this time, her
infection (see below) was under better control and the patient
began to respond to abx. Therefore the HA may have been
secondary to any of the above etiologies. Regardless, the
patient was continued on morphine IV for pain control and the
digoxin was held, amiodarone dose was decreased and the pt was
given a milrinone holiday for several days as above with
improvement.
She continued to have morning headaches on and off of dopamine
but this was well-relieved with tylenol.
3. ID:
A). The patient was re-admitted to the CCU with evidence of
urosepsis (fever, elevated WBC, clinical findings and CT scan
consistent with pyelonephritis and blood and urine cultures
positive for E.coli). She was initially started on imipenem,
vanc, and flagyl for empiric coverage of GU, GI and pulm
bacteria. The blood and urine cultures both returned positive
for E.coli with sensitivies to ceftriaxone, ceftaz, gent and
tobramycin and she was swiched over to Ceftriaxone IV 1mg on
[**2166-4-7**]. C. diff returned negative x3 and the flagyl was also
d/c'd. With the ceftriaxone alone, the patient became afebrile
for >48 hours and her WBC count and bands [**Month (only) **].
She was continued on levaquin for a 2wk course and remained
afebrile.
B). The patient had a small 1cm mass that is hard, mobile with
erythema and tenderness at the former RIJ site. US demonstrated
a samll 5x8mm fluid collection which was treated with warm
compresses with some improvement.
C) the patient believed he had a history of hepatitis, although
a full panel of serologies for her pre-transplantation workup
were negative.
4. Elevated LFTs: The patient initially had mild RUQ pain which
resolved during her hospitalization. She had a history of
cholecystectomy, and her LFTs were slightly elevated but stable
during the admission. Causes for liver dysfunction were
explored, and the patient was found to have a negative tylenol
screen, negative hepatitis panel, and a liver ultra sound on
[**2166-3-25**] which was unremarkable and showed normal flow in the
hepatic vasculature. The elevation in LFTs was presumed to be
from hepatic congestion.
5. Chest pain: From description by patient, the chest pain
seemed to be pleuritic in nature. There was no friction rub on
physical exam. The patient was treated with pain medications but
NSAIDs were held in the setting of aggressive diuresis and
concern over renal toxicity. The chest pain did not change over
the course of her hospital stay, and the patient states that she
chronically has this pain.
6. Thyroid: The patient was continued on her home dose of
synthroid. In hospital her TSH was 17 but her free T4 was 1.2.
The problem of starting amiodarone in this patient who has a
istory tyrotoxicosis secondary to amiodarone was discussed with
her endocrinologist, Dr. [**Last Name (STitle) **]. He felt comfortable starting
amiodarone and will follow her closely as a outpatient.
7. Psychiatric: The patient's amitriptyline wean by 25% per week
(decreased from 100->75mg q day on [**2166-3-26**]) with the plan of
starting a antiarrhythmic once she is completely off of the TCA.
She was started on sertraline 50mg PO once daily which was
increased to 100mg once daily on [**2166-4-11**]. She was continued on
her home doses of clonipin and ativan.
8. Renal:
A). Hyponatremia: The patient had significantly worsening
hyponatremia on return to the CCU(132->128->124->121). Given
the [**Month (only) **]. u/o, and [**Month (only) **]. FeNa and FeUrea, as well as the clinical
circumstance of urosepsis, this was thought to be consistent
with hypovolemic hyponatremia. The patient improved with NS as
well as with improved forward flow from milrinone and/ dopamine
as well as dicontinuation of aldactone.
B). Gap metabolic acidosis: The patient developed a gap with
[**Month (only) **]. in HCO3 earlier. This may be secondary to poor flow with
temporary stoppage of milrinone. After re-starting milrinone,
the gap closed to 12 and was no longer an issue.
9. Pulm: The patient had an Abd CT on [**2166-4-6**] that demonstrated
"innumerable non-calcified nodules on RLL". Chest CT confirmed
these findings and the ddx includes septic emboli, mycotic
infection, metastatic CA. During this course of acute
urosepsis, the patient is Not a candidate for bronchoscopy and
we will treat conservatively with repeat chest CT in future. If
patient becomes more symptomatic, we will consider additional
invasive procedure.
---f/u mycotic cultures and Aspergillus Ag
---Age appropriate CA screening when CCU stay is over -
Colonscopy, mammogram, pap.
10. FEN: Low sodium diet, replete potassium and magnessium
.
11. Ppx: Pt was started on a heparin gtt, however has had
elevated coags including PTT and INR. Suspect this may be
secondary to RHF with possible potentiation of coumadin received
on the floor with amiodarone and dig. We will stop all
anticoagulants as she is supratherapeutic. Anticipate
improvement in anticoagulation with improved PO intake and
improved CHF.
12. Access: The patient currently has peripheral IV x1 and PICC
line. PICC line of left arm appears to be somewhat swollen but
without erythema, induration or tenderness. US demonstrates no
thrombus within LUE veins. She was discharged with the PICC in
place.
13. Code Status: The patient was made DNR/DNI on this
admission. The status was discussed with her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 449**] P.
[**Doctor Last Name 2031**]. Prior to discharge, the patient decided to pursue
cardiac transplantation at [**Hospital1 336**] and her code status was changed
to full code.
Medications on Admission:
Aldactone 50mg QD, Ativan 1mg TID, Avaprol 75mg QD, Digoxin
125mcg QOD alternating with 250mcg. Imdur 120mg QD (30mg QD in
recent note from Cardiologist), Klonopin 0.5mg TID, Lasix 20 QD,
Synthriod 137mcg qd (in recent note from cardiologist), Lipitor
10mg QD, Pepcid 40mg QD, Zebeta 5mg QD, Percocet 5/325 TID, and
Coumadin 3mg QD ([**3-11**] INR 2.9).
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. Levothyroxine Sodium 137 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Famotidine 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed: per protocol.
Disp:*1 month supply* Refills:*0*
8. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Sodium Chloride 0.9 % Syringe Sig: Three (3) ML Injection
DAILY (Daily) as needed: per protocol.
Disp:*1 month supply* Refills:*0*
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
12. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Warfarin Sodium 1 mg Tablet Sig: Two (2) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Congestive heart failure
Discharge Condition:
fair
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc
.
Please take you medications as prescribed.
Call your doctor or go to the ER if you are having chest pain,
shortness of breath, chest heaviness, light headedness, leg
swelling, weight gain, or any other worrisome symptoms
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2031**] in 1 week. Please call to
schedule an appointment: [**Telephone/Fax (1) 11216**]
1) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2166-5-8**] 2:00
2) Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2166-6-12**] 1:00
3) You will also follow up with the [**Hospital1 336**] transplant service.
4) You will followup with the Heart Failure service for INR
checks
ICD9 Codes: 2765, 2761, 4240, 5849, 412, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4220
} | Medical Text: Service: Date: [**2191-8-29**]
Date of Birth: [**2120-9-30**] Sex: M
Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 9739**]
HISTORY OF THE PRESENT ILLNESS: This is a 70-year-old male
who presented with epigastric pain for several hours. The
pain migrated to the right upper quadrant. There no was
nausea, vomiting, or prior episodes.
PAST MEDICAL HISTORY:
1. History revealed brain metastasis secondary to renal
carcinoma.
2. Renal carcinoma, status post left nephrectomy [**2188-10-14**].
3. Status post MI, [**2181**].
MEDICATIONS:
1. Dilantin 200 mg p.o.b.i.d.
2. Lipitor 10 mg q.d.
3. Folic acid.
SOCIAL HISTORY: The patient is a former smoker. No alcohol.
PHYSICAL EXAMINATION: Examination revealed the temperature
of 97.3, heart rate 87, blood pressure 135/69, and
respiratory rate 20. The patient was alert, oriented times
three. CHEST: Chest was clear to auscultation. CARDIAC:
Regular rate and rhythm. ABDOMEN: Protuberant, right upper
quadrant tenderness, voluntary guarding, tap tenderness.
RECTAL: Guaiac negative.
LABORATORY DATA: Labs revealed the white count of 7.7;
hematocrit 37; platelets 224; sodium 139; potassium 4.8;
chloride 104; bicarbonate 28; BUN 19; creatinine .9; glucose
101; CK 27. Abdominal ultrasound revealed distended
gallbladder with stones. A son[**Name (NI) 493**] [**Name (NI) **] sign was
present. No wall thickening. Common bile duct was 7-mm. No
pericholecystic fluid.
HOSPITAL COURSE: The patient was admitted and started on
antibiotics and made NPO. On [**8-24**], the patient went
to the operating room to have a laparoscopic cholecystectomy
performed. The procedure was converted to an open
cholecystectomy. Postoperatively, he was started on
Lopressor 5 mg IV q.6h.; Levofloxacin; Flagyl for three
doses; and subcutaneous Heparin.
On [**8-25**], during the evening, Mr. [**Known lastname 9740**] was found
nonarousable. He became agitated and responded to Narcan.
Due to this episode, the patient was transferred to the
Intensive Care Unit for monitoring. He was rule out for MI
by cardiac enzymes. Chest x-ray revealed small bilateral
pleural effusion. An EKG revealed no acute ST and W changes.
On [**2191-8-26**], due to some shortness of breath, a VQ
scan was obtained, which revealed low probability. Lower
bilateral Doppler ultrasound was also obtained, which showed
no evidence of deep venous thrombosis.
Mr. [**Known lastname 9740**] became alert and oriented later on
[**8-26**], [**2190**]. The O2 saturation was 94% on 10 liter
face mask.
On [**8-27**], he was transferred to the floor. Repeat
white count was 9.3. A regular diet was started, which was
tolerated well. The oxygen saturation was 93% on four
liters.
On [**8-29**], [**2190**], Mr. [**Known lastname 9740**] was ready for discharge.
It was found that he was still dependent on O2 to maintain
his saturations above 90 on room air. Also, his ambulation
was slightly unsteady. It was thus felt that he should go to
a rehabilitation facility.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Rehabilitation Facility.
DISCHARGE STATUS: Mr. [**Known lastname 9740**] will followup with Dr. [**Last Name (STitle) 1305**]
in 10 to 14 days. He will go to a rehabilitation facility
with oxygen. Also, the Department of Physical Therapy will
work with him to improve his ambulation.
DISCHARGE MEDICATIONS:
1. Atenolol 50 mg p.o.q.d.
2. Percocet 1-2 tablets p.o.q.4-6h.p.r.n. pain.
3. Dilantin 200 mg p.o.b.i.d.
4. Lipitor 10 mg p.o.q.d.
5. Folic acid.
6. Combivent two puffs q.i.d.
7. Oxygen.
DISCHARGE DIAGNOSIS:
Cholecystitis.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] L. 02-164
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2191-8-29**] 12:38
T: [**2191-8-29**] 12:45
JOB#: [**Job Number 9741**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4221
} | Medical Text: Admission Date: [**2106-3-17**] Discharge Date: [**2106-3-20**]
Date of Birth: [**2027-9-8**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
consulted for SDH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt s/p fall at home on [**2106-3-15**]. It is unknown if there was
any loss of conscience with the fall. It is documented as pt
"slipped". Pt seemed fine to family during the week until this
morning at which time she was noted to be confused, incoherent
at
times and aphasic. The pt also began to complain of a headache
that began this morning.
Pt was evaluated by her PCP [**Last Name (NamePattern4) **] [**3-16**] for diffuse bruising on
her lt face,hand and bil. knee bruises. Pt is also on coumadin
therapy therefore an outpt head CT was scheduled for this a.m.
as
well. When the pts daughter arrived to bring pt for CT scan, she
found the pt to be confused with a right sided facial droop and
difficulty speaking. Pt was then brought to [**Hospital6 **]
for further evaluation via ALS. CT imaging revealed a large Left
sided Subdural hematoma with midline shift. Pt transferred to
[**Hospital1 18**] for Neurosurgical evaluation and treatment.
Past Medical History:
CVA [**2100**], HTN, DVT [**2099**], AAA [**2099**] s/p repair, Ruptured appy
[**2089**], hyperlididemia
Social History:
Widowed lives alone. No home services. +Tobacco use
<1ppd.
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM UPON ADMISSION:
T: febrile BP: 230/77 HR:80 R 14 O2Sats 100
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:2.5mm to 2.0mm sluggish reaction. bilat. No
nystagmus. Does not focus on examiner or tract to voice.
Neck: Supple. No JVD
Lungs: ETT patent. CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Thin, soft with +Bowel sounds
Extrem: Warm and well-perfused. No tremors.
Neuro:
Mental status: Quiet. No sedative medications, +corneal, +gag
Left periorbital eccymosis present. Cervical neck collar in
use.
Orientation: Nonverbal. Does not interact or follow simple or
complex commands.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5mm to
2.0 mm bilaterally.
III, IV, VI: without nystagmus.
V, VII: Face symmetric with ETT in place.
VIII: Does not respond to loud voice.
IX, X: UTA
[**Doctor First Name 81**]: UTA
XII: UTA
Motor: Does not follow command or respond to this examiner other
than appropriate withdrawl to deep, painful stimuli from the
Upper extremities. With toenail bed pressure the left leg does
minimally move on the bed. Toes are mute on left. Great toe
upgoing on the rt.
Pertinent Results:
CT head [**3-18**] am:
FINDINGS: A left frontal/parietal subdural hematoma with maximum
diameter of 19 mm. There is minimal midline shift without
subfalcine herniation, no
evidence of intraparenchymal hemorrhage. There is no acute
infarct or
hydrocephalus. The included paranasal sinuses and mastoid air
cells are clear. There are no fractures.
IMPRESSION: left sided SDH with minimal midline shift.
CT Head [**3-18**] pm:
NON-CONTRAST HEAD CT: There has been no significant change since
[**07**] hours
prior. Again seen is a moderate-sized left subdural hematoma
with
hyperattenuating blood products. The hematoma measures 19 mm in
greatest
diameter and causes unchanged mass effect on the subjacent sulci
as well as 7 mm of rightward midline shift. There is no evidence
of subfalcine or uncal herniation. No intraparenchymal
hemorrhage. The occipital and temporal horns of the left lateral
ventricle are effaced. The extensive periventricular
hypoattenuation consistent with chronic microvascular ischemic
disease is again noted. Age-related involutional changes are
also unchanged.
IMPRESSION: Unchanged moderate-sized left subdural hematoma with
unchanged
mass effect.
Brief Hospital Course:
The patient was admitted to the ICU after having been intubated
prior to transfer from the OSH. She did not have any surgical
interventions. The first day her clinical exam was poor and the
family decided to make her CMO. Palliative care was called for
help managing the comfort of this patient. She passed away
comfortably on [**2106-3-20**] at 1250.
Medications on Admission:
Coumadin, Atenolol, Folic Acid, Simvastatin, Citracal, Centrum,
Calcium citrate
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
SDH
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4222
} | Medical Text: Admission Date: [**2198-12-5**] Discharge Date: [**2199-1-13**]
Date of Birth: [**2198-12-5**] Sex: F
Service: NEONATOLOGY
HISTORY: A 2.03 kilogram female infant born by spontaneous
vaginal delivery to a 29 year-old gravida II, para I mother.
Prenatal screens: A positive, antibody negative, Rubella
immune, RPR nonreactive, GBS unknown. Afebrile, with
ruptures membranes just prior to delivery. Mother presented
to local medical doctor in advanced stage of labor. 32 6/7
weeks gestation, based on 18 week ultrasound. Noted to be
footling breech upon rupture of membranes, cesarean section
under general anesthesia. Infant emerge stunned, dried,
bulbed mouth and nose, delivered several positive pressure
ventilation breaths, infant cried, continued with blow-by
oxygen for several minutes, then pink on room air. [**Hospital **]
transferred to Neonatal Intensive Care Unit for further
management of respiratory distress and prematurity.
PHYSICAL EXAMINATION: On admission birth weight [**2226**] grams
(greater than 75th percentile), length 43 cm (50th
percentile), head circumference 32.5 cm (90th percentile),
molding.
Nondysmorphic pink, initially hypotonic, improving tone,
saturations greater than 95 on room air, bilateral breath
sounds clear and equal, regular rate and rhythm, normal S1,
S2, no murmur. Abdomen soft, nontender, no
hepatosplenomegaly, three vessel cord, straight spine, no
dimple, stable hips, anterior fontanelle open and soft,
molded head, moving all extremities, bruising noted on chest,
normal female external genitalia, anus patent.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Infant has remained on room air throughout this
entire hospitalization. Respiratory rate 40 to 60, infant has
not been treated with methylxanthine and has not had a
history of apnea or bradycardia of prematurity.
Cardiovascular: Soft intermittent PPS murmur noted, infant
has remained hemodynamically stable with hospitalization.
Heart rate 150 to 160.
Fluid, electrolytes and nutrition: Infant was started on
intravenous fluids D10W at 80 cc/kilo/day and enteral feedings
were started on day of life one. Total fluids were advanced
to 150 cc/kilo/day on day of life six and infant was on full
antral feedings by day of life four. Infant tolerated
feeding advancement without difficulty. On day of life ten
infant noted to have increased abdominal distention, guaiac
positive stools and made n.p.o. for rule out necrotizing
enterocolitis. Infant was n.p.o. for a total of 14 days for
medical necrotizing enterocolitis and was receiving total
parenteral nutrition with interlipids through a PICC line
during that time. Feedings were resumed after 14 days course
of n.p.o. and restarted on day of life 25, were slowly
advanced to full enteral feedings by day of life 29. Calories
were advanced to an excellent caloric intake of Premature
Enfamil 26 calories per ounce at 150 cc/kilo/day by day of
life 35. The infant is currently receiving Enfamil 24
calories per ounce p.o. ad lib taking approximately 150
cc/kilo/day. Most recent electrolytes on [**2199-1-10**]
were sodium 136, chloride 107, potassium 4.9, pCO2 25,
albumin 3.7, calcium 9.7, phosphorus 6.3. Discharge weight
is 2720 grams, head circumference 34.5 cm, length is 48 cm.
Gastrointestinal: Status post medical necrotizing
enterocolitis. Infant n.p.o. for a total of 14 days from day
of life 10 to day of life 25. Infant noted to have vomiting
on day of life 34. A KUB was done at that time which was
within normal limits, no pneumatosis, no evidence of
obstruction. On day of life #38 infant noted to have
intermittent guaiac positive stool. Abdomen nondistended.
Tolerating feedings well at that time. A KUB was done at
that time which was also within normal limits, no
pneumatosis, no evidence of obstruction. Infant did not
receive phototherapy this hospitalization. Maximum bilirubin
on day of life #3 was 8.2/0.4. The most recent bilirubin
done on [**2199-1-10**] showed a total bilirubin 2.1 and a
direct of 0.4.
Hematology: Infant did not require blood transfusion this
hospitalization. Most recent hematocrit on [**2199-1-10**]
was 28.6 with a reticulocyte count of 3.9.
Infectious disease: Infant initially received a 48 hour
course of Ampicillin and Gentamicin for rule out sepsis.
Blood culture at that time was negative. The infant received
a total of 14 days of Vancomycin and Gentamicin for medical
necrotizing enterocolitis.
Neurology: A head ultrasound was done on [**1-9**] (day of
life 30) which showed no intraventricular hemorrhage.
Sensory: hearing screen was performed with automated
auditory brain stem responses. Infant passed in both ears.
Ophthalmology: Infant does not meet criteria for eye
examination.
Psychosocial: [**Hospital1 69**] social
worker involved with family. The contact social worker can
be reached at [**Telephone/Fax (1) 8717**]. Family speaks Cantonese.
CONDITION AT DISCHARGE: Excellent.
DISCHARGE DISPOSITION: Home with parents. Name of primary
pediatrician: [**Hospital3 **] Pediatrics, phone number
[**Telephone/Fax (1) 37524**].
CARE AND RECOMMENDATIONS: Feedings at discharge: Enfamil 24
calories per ounce p.o. ad lib. Medications: Fer-In-[**Male First Name (un) **] 2
mg/kilo/day p.o. Car seat positioning - infant passed car
position screening on [**2199-1-13**].
Immunizations received: Infant received hepatitis B vaccine
on [**2199-1-9**], received Synagis on [**2199-1-12**].
Immunizations recommended: Synagis RC 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 RC season, with a smoker in the household, or
with preschool kids; or 3) chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
each six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
Follow up appointments schedules: 1) [**Hospital3 **] Pediatrics,
phone #[**Telephone/Fax (1) 8236**]. Appointment [**2199-1-15**] at 9 A.M.
2) [**Location (un) 86**] [**Hospital6 407**], phone number
[**Telephone/Fax (1) 37525**].
DISCHARGE DIAGNOSES:
1. Prematurity, former 32 [**5-17**] week gestation, now 38 [**2-14**]
weeks corrected.
2. Rule out sepsis.
3. Status post medical necrotizing enterocolitis.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2199-1-13**] 07:32
T: [**2199-1-13**] 06:59
JOB#: [**Job Number 22526**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4223
} | Medical Text: Admission Date: [**2103-9-19**] Discharge Date: [**2103-9-27**]
Date of Birth: [**2045-12-29**] Sex: F
Service: CSU
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 57-year-old woman who
was referred into the Medical Center as a patient of Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] of Cardiology and Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] of
Cardiac Surgery. She reported that she had a heart murmur
since childhood and her primary care physician had recently
referred her for a routine echocardiogram. This showed mild
MR with normal LV chamber size and function and a thickening
in the descending portion of the aortic arch. She was then
referred for further testing. On [**2103-7-20**], she had an
MRI at [**Hospital1 18**] which showed a large irregular mass at the
proximal descending aorta with an abnormal pretracheal lymph
node. The differential diagnosis includes neoplasm versus
thrombus. She has since been seen by Dr. [**Last Name (Prefixes) **] and
Oncology at [**Hospital1 **] and is referred now for cardiac
catheterization. This was the note recorded prior to her
cardiac catheterization done on [**2103-8-15**], one month
prior to her admission. The patient denied any symptoms at
the time. Her only complaint was of episodic indigestion.
She was normally quite active, participating in aerobics and
swimming without any difficulties. She denied any
claudication, edema, orthopnea, PND, lightheadedness, and
admitted to rare palpitations.
PAST MEDICAL HISTORY:
1. Aortic mass.
2. Heart murmur.
3. Hypertension.
4. Hypercholesterolemia.
5. Positive family history with her father having an MI at 62
and mother with coronary disease in her late 60s. Her
mother also had an abdominal aortic aneurysm. The
patient's older brother had an MI at 45 and another MI and
CABG at 54 and another brother had a CVA at age 48, all
contributing to a very positive family history.
6. Grave's disease.
7. An episode of bilateral pneumococcal pneumonia in [**2086**].
PAST SURGICAL HISTORY:
1. Tonsillectomy and adenoidectomy.
2. Appendectomy.
3. Ectopic pregnancy surgery in [**2068**].
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS AT THE TIME OF CARDIAC CATHETERIZATION:
1. Tapazole 10 mg p.o. daily.
2. Atenolol 50 mg p.o. daily.
3. Hydrochlorothiazide 25 mg p.o. daily.
4. Aspirin 81 mg p.o. daily.
SOCIAL HISTORY: The patient admitted to smoking 1 1/2 packs
per day for 40 years. She cut back in [**Month (only) **] to three-
quarters of a pack in that year and quit approximately two
weeks prior to her cardiac catheterization. The patient is
divorced and lives alone. The patient has two children. She
works as a project manager for a demolition company. She
denied any history of emotional, physical, or sexual abuse or
threats of abuse.
HOSPITAL COURSE: She came in for cardiac catheterization on
[**2103-8-15**]. A preoperative echocardiogram done in
[**2103-5-24**] showed a mild MR, trace TR, trace TI, ejection
fraction 60 percent, and a thickening in the descending
portion of the aortic arch.
DICTATION ENDED
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2103-11-6**] 10:42:17
T: [**2103-11-6**] 11:27:43
Job#: [**Job Number 57736**]
ICD9 Codes: 5119, 496, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4224
} | Medical Text: Admission Date: [**2138-2-6**] Discharge Date: [**2138-2-18**]
Date of Birth: [**2061-10-8**] Sex: F
Service: SURGERY
Allergies:
Codeine / Ibuprofen
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Biliary hilar stricture c/w concern for cholangiocarcinoma
Major Surgical or Invasive Procedure:
[**2138-2-13**]: ERCP
[**2138-2-17**]: Bilateral Wallstent placement
History of Present Illness:
76 y.o. F with multiple CV problems transferred from [**Name (NI) **]
for concern of cholangiocarcinoma. Over 2 weeks, patient had
increased pruritus. U/S of liver showed ductal dilatation with
bilirubin elevation. GI at [**Hospital1 **] performed ERCT [**2138-2-5**] with
sphincterotomy with stent (8.5Fr 12 cm). ERCP findings
concerning for cholangiocarcinoma with hilar stricture c/w
cholangiocarcinoma on right side
Past Medical History:
CAD s/p pacemaker, s/p cath [**2133**]: 70% stenosis, HTN, DM, h/o
DVT/PE, pancreatitis
PSH: s/p TKA [**2135**], SBR ? diverticulitis
Social History:
widowed with children
denied etoh/smoking/illicit drugs
independent at senior living
Brief Hospital Course:
On [**2138-2-7**], a cholangiogram was performed to evaluate the bile
duct anatomy. This demonstrated severely dilated left-sided
hepatic ducts with high-
grade stricture approximately 2 cm in lenght extending from the
confluence of the common hepatic and left hepatic ducts to just
central to the
confluence of the segment II and segment III left hepatic ducts.
Mildly
dilated right anterior ducts were noted with a stricture in the
central right
anterior ducts as well as a markedly dilated gallbladder were
also noted. The
patient's post ERCP plastic stent was noted within the common
duct with
extension superiorly into the superior common hepatic duct. The
right posterior ducts were not visualized likely due to high
grade stricture or obstruction of central right posterior ducts.
An 8 French internal/external biliary drain was placed via the
left biliary system after cholangioplasty of strictured region
to 5 mm. On [**2-9**] she spiked a temperature to 102.5 with chills.
Blood and urine cultures were done. All were negative. On [**2-10**],
bile was sent for culture growing Klebsiella pneumoniae. Unasyn
had been started prior to the Cholangiogram and this was
continued for 5 days until bile cultures revealed that
Klebsiella sensitivity to Unasyn was indeterminate. It was
otherwise pansensitive. Unasyn was switched to Cipro on [**2-12**]
after 5 days of Unasyn. Fever resolved. Overall, LFTs trended
down.
On [**2-9**], a triple phase CT was done showing a large
Klatskin-type hilar mass with imaging characteristics compatible
with a cholangiocarcinoma. There was intrahepatic bile duct
dilatation in all segments except for segment III, where there
was an internal-external biliary drain and a biliary stent. The
left portal vein was completely encased by tumor and minimal
enhancing portal vein is seen. There were numerous enlarged
porta hepatis lymph nodes. A small anterior pelvic wall hernia
and small pleural effusions were noted.
A cardiac workup was started with TTE noting LVEF of 45-50%,
mild to moderate MR, mild pulmonary systolic HTN. Of note, on
[**2-12**], she had an episode of L chest pain when transferring from
chair to bed. O 2 2 liters and NTG 0.4 sl was given with relief.
EKG was unchanged, cardiac enzymes were negative. She had no
further episodes of chest pain. It was noted that her hct was 26
and she was given 2 units of PRBC. Hct increased to 33.
On [**2-13**], an ERCP was performed to remove the previously placed
stent at OSH. She did have a questionable run of V tach after
the procedure. She then underwent placement of left and right
wall stents with placement of PTCs thru the wall stents.
Findings were notable for a Klatskin type biliary stricture at
confluence of central right and left ducts extending to upper
common hepatic duct (obstructive on right), this was balloon
dilated. Metallic biliary stenting with two 8mm Wallstents
deployed side
by side and extended into the right and left hepatic ducts
crossing the stricture at the confluence of the right hepatic
ducts. Ursodiol was started. The next day, IR removed the right
and left PTCs that were thru the wall stents as stents were in
satisfactory position. LFTs trended down post procedure.
Post procedure, she was hypertensive requiring iv hydralazine.
She was transferred to the SICU overnight for management. She
was extubated and then transferred back to the med-[**Doctor First Name **] unit.
Her case was presented at the Tumor Board and she was found to
be unresectable. After discussing findings with the patient and
her family, an Oncology Consult was obtained. Dr. [**Last Name (STitle) **] met
with her and discusses possible options. A chest CT was
recommended to evaluate for any possible metastatic lesions for
staging. This showed a few scattered peripheral lung nodules as
described, with the largest measuring 5 mm in the right upper
lobe. Small bilateral pleural effusions and mild intralobular
septal thickening at the lung bases was noted. A density in the
subcarinal station may represent fluid in a pericardial recess
versus an enlarged lymph node. Calcified granuloma in the lung
and several in the spleen were consistent with prior
granulomatous exposure. A follow up outpatient appointment with
Oncology was set up to discuss options.
PT declared her safe for discharge to home. VNA services were
arranged. She was discharged with stable vital signs.
Medications on Admission:
asa 81', labetalol 200'', lasix 20', simvastatin 400', metformin
1000', glyburide 2.5'
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 21
days.
Disp:*21 Tablet(s)* Refills:*0*
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): Increased dose.
Disp:*90 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Unresectable cholangiocarcinoma
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] if you develop
fever, chills, abdominal pain, increased yellowing of eyes or
skin, [**Male First Name (un) 1658**] colored stools or other concerning symptoms.
You will be following up with Dr [**Last Name (STitle) **] as an outpatient for
further evaluation of treatment options
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-3-5**]
9:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12766**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-3-5**] 9:30
[**Hospital Ward Name 23**] Building [**Location (un) 24**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2138-2-20**]
ICD9 Codes: 4271, 4019, 4240, 4168, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4225
} | Medical Text: Admission Date: [**2118-5-20**] Discharge Date: [**2118-6-8**]
Date of Birth: [**2051-6-14**] Sex: M
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 66 year-old
male with a history of hepatitis C virus and hepatocellular
carcinoma who presented on [**5-20**] for orthotopic liver
transplant.
PAST MEDICAL HISTORY:
1. Hepatocellular carcinoma.
2. Hepatitis C.
3. Gastroesophageal reflux disease.
4. Hepatic encephalopathy.
5. Coronary artery disease with two vessel disease, status
post stenting of right coronary artery and mid left anterior
descending artery.
MEDICATIONS ON ADMISSION:
1. Flomax .4 mg po q.d.
2. Hydroxizine 25 mg prn.
3. Aspirin 325 po q.d.
4. Colchicine .6 mg b.i.d.
5. Prozac 20 mg po q.d.
6. Ranitidine 150 mg po b.i.d.
7. Metoprolol 50 mg po b.i.d.
SOCIAL HISTORY: The patient is a recent smoker having quit
two weeks prior to admission. Was smoking one pack per day.
Lives with his wife in [**Name (NI) 24979**] [**State 350**].
PHYSICAL EXAMINATION ON PRESENTATION: Temperature 97.6.
Heart rate 62. Blood pressure 178/77. Respiratory rate 18.
O2 saturation 98% on room air. On examination prior to
admission, HEENT examination was within normal limits.
Cranial nerves were intact. Heart sounds were normal with no
murmur or bruit. Chest was clear to auscultation and
percussion. Abdomen was soft and nontender, no palpable
masses and no peripheral edema.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**First Name3 (LF) 111032**]
MEDQUIST36
D: [**2118-6-8**] 01:13
T: [**2118-6-8**] 13:27
JOB#: [**Job Number **]
ICD9 Codes: 5715, 9971, 5119, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4226
} | Medical Text: Admission Date: [**2184-12-8**] Discharge Date: [**2184-12-13**]
Date of Birth: [**2110-5-31**] Sex: F
Service: CARDIOTHOR
HISTORY OF THE PRESENT ILLNESS: This a 74-year-old caucasian
female with a known history of coronary artery disease,
status post myocardial infarction in [**2184-8-21**]. She
had post-infarct chest pain and right arm pain, which was not
responding to medical management and subsequently
catheterized at the [**Hospital6 1129**], which
showed nonconductive lesion to PTCAs or stenting. Therefore,
she was ultimately consulted to cardiothoracic surgery for
definitive operative management of her coronary artery
disease and unstable angina. The report, from the cardiac
catheterization from the [**Hospital6 1129**] is
not available at the time of this discharge. Please refer to
the operative note on this patient to look for further
details about preoperative coronary artery lesions.
PAST MEDICAL HISTORY: History on presentation revealed for
the myocardial infarction in [**2184-8-21**]; diverticulosis
with no flares or GI bleeds for over 25 years; bell palsy
greater than 30 years ago and a right sided facial droop.
She had bilateral vein stripping for varicose veins 25 years
and five years ago as well as a total abdominal hysterectomy
33 years ago. She is additionally a hypertensive patient.
She is on Fosamax for osteoporosis. The patient has
hyperlipidemia.
MEDICATIONS ON DISCHARGE:
1. Zestril 10 mg p.o. b.i.d.
2. Norvasc 10 mg p.o.q.d.
3. Atenolol 100 mg p.o.t.i.d.
4. Plavix 75 mg p.o.q.d.
5. Isordil 60 mg p.o.t.i.d.
6. Aspirin 325 mg p.o.q.d.
7. Fosamax 70 mg p.o.q.week.
8. Vitamin B6 q. day.
9. Vitamin E 400 IU q.d.
10. Multivitamins q.d.
11. Calcium 1000 mg q.d.
12. Zocor 20 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: History is significant for her mother dying
of TB at the age of 70. Father had questionable death
secondary to TB in his 70s as well. The patient has had all
of her siblings die "at any early age" less than 60 years
ago, from coronary artery disease. She has no tobacco or
alcohol history. She speaks primarily Polish and lives with
her 75-year-old husband, who also is in generally good
health.
PHYSICAL EXAMINATION: On examination, she was noted to be
5 foot tall, 140 pounds. Blood pressure 120/80 with 64
pulse regular in sinus. She is in no acute distress. There
was no evidence of cervical bruit. Trachea was midline.
Mucous membranes moist. She did have a slight right-sided
facial droop including the right mouth angle and ptosis on
the right eye. Heart was regular rate and rhythm with no
murmurs, rubs, or gallops. Lungs were clear. Abdomen was
benign. Lower extremities were warm and well perfused with
palpable pulses distally from the femoral to the popliteal to
the dorsalis pedis pulses and posterior tibialis bilaterally.
She was, therefore, evaluated in the preadmission testing
facility and then sent to be admitted to the Cardiac Surgical
Care Unit on [**2184-12-8**]. She went to the operating room,
where she underwent coronary artery bypass grafting times
four, including LIMA to LAD, saphenous vein graft
sequentially to OM1 and then OM2 and left radial artery graft
to the right posterior descending artery. This was done with
general endotracheal anesthesia with indications of unstable
angina, known coronary artery disease. Dr. [**Last Name (STitle) 1537**] performed
the procedure with the assistance of Dr. [**Last Name (STitle) 25067**]. The
pericardium was left open. She had a right femoral A-line,
right IJ Swan-Ganz catheter, two ventricular and two atrial
pacing wires, two mediastinal tubes and one left pleural
tube, means arterial pressure on transfer from the operating
room was 97 with a right atrial pressure of 10 and pulmonary
artery diastolic pressure of 17 with a mean of 23. She was
in sinus rhythm at 76. She was being supported with
nitroglycerin .5 mcg/kg per minute. The radial artery graft
was kept sedated with propofol drip at 10 mcg/kg per minute.
Upon transfer to the Cardiac Surgical Recovery Unit she was
rapidly extubated on the night of surgery; she was apaced at
90. She had a temperature of 101.1 maximum. Blood pressure
was 102/91. Lungs were clear. She was alert and
neurologically intact. Regular rate and rhythm was noted.
Extremities were benign. She had a hematocrit of 22, down
from 27, immediately postoperatively. She was transfused one
unit for this and then given Lasix. Lopressor was held. BUN
and creatinine were 17 and .9 respectively. She was put on
perioperative Vancomycin dosing times three. Chest tubes
remained for high outputs. She was ultimately transferred to
the floor by postoperative day #2.
After transfusion of one unit of packed red cells, the
patient hemodynamically improved with blood pressures rising
to the 140s. She was in sinus rhythm in the 60s. She was
alert and oriented. Chest tubes were discontinued on
postoperative day #2 and at the same time she was transferred
to the General Cardiac Floor. She was put on Lasix,
Lopressor, Captopril, and oral nitrates. The hematocrit was
28 after the packed cell transfusion, as well as the BUN and
creatinine of 22 and .9.
On the floor, she did well. She had a very uncomplicated
postoperative course. During the ensuing 48 to 72 hours post
transfer from the unit she was ambulating with assistance and
a level 3 and 4. She had no sternal wound drainage. She had
no fever. She was sinus rhythm throughout the remainder of
her hospital stay. The chest-tube sites remained clean, dry,
and intact without any evidence of drainage. The hematocrit
on the day of discharge was 31 with the BUN and creatinine of
17 and .7.
By postoperative day #4, Dr. [**Last Name (STitle) 1537**] felt that she was
appropriate for discharge to home. She does not requiring
any visiting nursing assistance as her daughter is [**Name8 (MD) **] RN and
lives with her full time. Additionally, she will have a
wound in 7 to 10 days at the Wound Check Clinic here on the
[**Location (un) **] of the [**Hospital1 69**], Far 6
Building as well as seeing Dr. [**Last Name (STitle) 1537**] at 30 days post CABG for
followup. She is also to see her primary care physician or
cardiologist in three weeks from the time of discharge.
Therefore, medications can be titrated appropriately. The
patient discharge medications included the following:
DISCHARGE MEDICATIONS:
1. Isosorbide mononitrate, which is Imdur 60 mg p.o.q.d.
times three months.
2. Aspirin 325 mg p.o.q.d.
3. Lasix 20 mg p.o.q.d. times 7 days.
4. K-Dur 20 mEq p.o.q.d. times 7 days.
5. Fosamax 70 mg p.o.q. week.
6. Zocor 20 mg p.o.q.d.
7. Vitamin E 400 IU p.o.q.d.
8. Multivitamin p.o.q.d.
9. Captopril 25 mg p.o.t.i.d.
10. Lopressor 100 mg p.o.b.i.d.
11. Protonix 40 mg p.o.q.d.
12. Percocet 5, 325 one to two tablets p.o.q.4 to 6 p.r.n.
13. Colace 100 mg p.o.b.i.d.
CONDITION ON DISCHARGE: Stable sinus rhythm, afebrile,
stable sternum. Temperature 99, 70 in sinus, 140/70, blood
pressure 98% on two liters, 92% room air saturation.
Examination was noted as previously stated with left radial
harvest site. Well approximated suture line with no drainage
or erythema. Extremities revealed trace peripheral edema.
Post chest x-ray showed some bilateral pleural effusions;
however, small and limited with bilateral plate-like
atelectasis. There was no pneumothorax noted upon removal of
her tubes.
PLAN: Followup plan is as stated.
DISCHARGE STATUS: As stated.
DIAGNOSES:
1. Unstable angina.
2. Coronary artery disease.
3. Known history of MI in [**2184-8-21**]; status post CABG
times four, LIMA to LAD, left saphenous vein graft from OM1
to OM2, as well as a left radial artery graft to the right
posterior descending artery.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2184-12-13**] 10:31
T: [**2184-12-13**] 10:52
JOB#: [**Job Number 36693**]
ICD9 Codes: 4111, 412, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4227
} | Medical Text: Admission Date: [**2115-7-13**] Discharge Date: [**2115-7-26**]
Date of Birth: [**2043-2-28**] Sex: M
Service: MEDICINE
Allergies:
Demerol / Actos
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Intubation
Tracheostomy/[**First Name3 (LF) 282**] placement [**2115-7-24**]
History of Present Illness:
Mr. [**Known lastname **] is a 72-year-old gentleman with a past medical
history significant for VF arrest s/p AICD placement in [**2102**],
CHF with EF of 15%, afib, DM, COPD, HTN, and recent admission
([**6-20**] to [**7-10**]) syncope complicated by hemodynamically unstable
afib with RVR, CCU transfer, aspiration pneumonia, intubation,
and subsequent inability to take POs due to deconditioning with
D/C to rehab and readmission ([**7-11**] to [**7-12**]) after he pulled out
his PICC and was unable to receive IV medications who presents
from rehab due to unresponsiveness.
.
Notably, during his extended admission, he was found to have
severe aspirations and a subsequent aspiration pneumonia. Speech
and swallow reevalutated him multiple times with subsequent
recommendation of strict NPO. The patient refused Dobbhoff tube
placement, and requested that a [**Month/Year (2) 282**] be placed. A [**Month/Year (2) 282**] was placed
on [**2115-7-5**]. He pulled out this [**Date Range 282**] on [**2115-7-6**]. He was placed on
TPN as a bridge to another g-tube (which has not been placed yet
pending reevaluation scheduled for [**7-15**]). As stated above, he
pulled out his PICC and returned to the hospital [**7-11**]. In the
ED, he had a PICC placed, but then pulled this out so he was
given a peripheral IV and discharged to [**Hospital **] rehab MACU on
PPN.
.
Normally pt is not oriented, but he is usually able to
communicate. However, today at [**Hospital 100**] rehab MACU he was noted to
be somnolent, tachypneic, and pale. He was on tele and noted to
have several runs of NSVT. He reportedly had been up the whole
night and complained of abdominal discomfort. He otherwise
denied feeling short of breath, chest pain, palpitations. His
mental status deteriorated and he became much less responsive.
.
In the ED, patient was unable to give a history. On exam the
patient was dry with course rhonchi bilaterally. He was
intubated for airway protection and started on fentanyl/versed.
EKG: showed native left bundle with intermittent pacing and he
was noted to have 8 beats of NSVT. He would [**Last Name (un) 25177**] have
bradycardia to the 30s before his pacer would start pacing.
Cardiology was consulted for ST elevations? and they felt his
EKG was at baseline and not concerning. The patient was given
lidocaine bolus for non sustained vtach. He had a head CT which
showed "No evidence of acute intracranial abnormalities, but air
in the masticator spaces." CXR showed R PNA so he was given vanc
and levofloxacin. UA was negative. Abd CT showed distended
gallbladder and bilateral pleural effusions. RUQ U/S showed
distended gallbladder with thickened wall and sludge, concerning
for acute cholecystitis. Surgery was consulted but had not yet
seen pt in ED. He was ordered for zosyn.
.
On the floor, pt is sedated and intubated. Hemodynamically
stable.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
sCHF- TTE 20-25%, dry weight 198 lbs.
Paroxysmal atrial fibrillation- on Coumadin
CAD -Cath showed [**2-22**] showed single vessel LCx disease
ACID after VF arrest in [**2102**], [**Company 1543**] [**Last Name (un) 24119**] VR 7232Cx
COPD
Barrett's esophagus with high grade dysplasia.
Post-cryotherapy x 3, BARRx [**2-23**]
S/p GI bleed- UGIB from a gastric ulcer [**12/2102**]
S/p Appendectomy [**2063**]
S/p Bone tumor excision from shoulder [**2057**]
Portal vein thrombosis
Social History:
Occupation: Retired from [**Location (un) 86**] police force and security
service at [**Location (un) 745**] [**Hospital 3678**] Hospital
Housing: Lives independently at Blakes Estate senior center (a
retirement community), but found to be in squalor in [**6-27**].
Family: Closest family is cousin [**First Name5 (NamePattern1) **] [**Name (NI) 23636**]), lives down the
street from him. HCP is [**Name (NI) **] [**Name (NI) 25176**]. Adopted. Never married,
no children.
Tobacco: 45 year 1-2ppd history, quit 11 years ago.
Alcohol: None
Drugs: None
Family History:
Adopted. Does not know his family history.
Physical Exam:
Vitals: T:96.1 BP: 110/68 P: 82 R: 19 O2: 100%
General: sedated, intubated
HEENT: Sclera anicteric, pipoint reactive pupils, ET tube in
place
Neck: JVP not elevated
Lungs: bilateral rhonchi
CV: Regular rate and rhythm, no murmurs
Abdomen: soft, non-distended, bowel sounds present
GU: + foley
Ext: venous stasis changes, warm, well perfused, 2+ pulses,
trace pretibial edema
At discharge:
37.1, 71-98, 92-131/52-83, 100%, TBB -2500 (-300)
PS 5/5, 0.4, RSBI 84
Trach, awake, following commands, moving all extremities. Lungs
clear anteriorly. Heart regular. Abdomen soft, NT, ND, with
normal bowel sounds. Extremities without peripheral edema.
Pertinent Results:
Labs at admission:
[**2115-7-12**] 06:55AM BLOOD WBC-7.2 RBC-3.86* Hgb-9.1* Hct-29.7*
MCV-77* MCH-23.5* MCHC-30.6* RDW-20.1* Plt Ct-321
[**2115-7-13**] 11:40AM BLOOD Neuts-76.9* Lymphs-15.6* Monos-7.1
Eos-0.3 Baso-0.1
[**2115-7-13**] 11:40AM BLOOD PT-20.3* PTT-41.6* INR(PT)-1.9*
[**2115-7-12**] 06:55AM BLOOD Glucose-148* UreaN-71* Creat-1.3* Na-139
K-4.2 Cl-102 HCO3-27 AnGap-14
[**2115-7-13**] 11:40AM BLOOD ALT-33 AST-47* AlkPhos-155* TotBili-1.5
[**2115-7-13**] 11:40AM BLOOD cTropnT-0.02*
[**2115-7-13**] 11:40AM BLOOD Lipase-14
[**2115-7-12**] 06:55AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.3
[**2115-7-14**] 04:11PM BLOOD Triglyc-87
[**2115-7-16**] 07:35AM BLOOD Vanco-18.6
[**2115-7-13**] 11:40AM BLOOD Digoxin-1.3
[**2115-7-13**] 12:36PM BLOOD Type-ART Temp-38.1 Rates-16/ Tidal V-500
PEEP-5 FiO2-100 pO2-394* pCO2-43 pH-7.41 calTCO2-28 Base XS-2
AADO2-277 REQ O2-53 -ASSIST/CON Intubat-INTUBATED
Imaging:
HIDA [**7-15**]
RADIOPHARMACEUTICAL DATA:
3.8 mCi Tc-[**Age over 90 **]m DISIDA ([**2115-7-15**]);
1.9 mCi Tc-99m DISIDA ([**2115-7-15**]);
HISTORY: 82 year old male with abdominal pain.
INTERPRETATION: Serial images over the abdomen show uptake of
tracer into the
hepatic parenchyma. Tracer activity is noted in the small bowel
at 23 minutes.
The gallbladder is not visualized at 60 minutes. 60 minutes
following morphine
administration, there is faint uptake lateral to the common bile
duct, which is
atypical for but could represent evidence of partial delayed
gallbladder
uptake.
IMPRESSION: Abnormal study, without definite visualization of
gallbladder.
Although this cpuld be due to the prolonged fasting status,
acute or chronic
cholecystitis cannot be excluded.
Unilateral Upper Ext Vein
FINDINGS: Occlusive thrombus is present within the right
axillary vein,
extending to the mid and proximal portions of one of the
brachial veins. A
venous catheter traverses this region, eventually exiting that
brachial vein
into a superficial branch. The right IJ, second brachial vein,
cephalic vein,
basilic vein, and subclavian vein are patent. No fluid
collections are
present.
IMPRESSION: Occlusive thrombus within the right axillary vein
and one of two
brachial veins (the one containing a venous catheter). These
findings were
discussed by Dr. [**Last Name (STitle) **] with Dr. [**Last Name (STitle) 12933**] at 1:20 p.m. on [**2115-7-14**].
The study and the report were reviewed by the staff radiologist.
Abd U/S
INDICATION: 72-year-old man with abdominal pain, NPO. Assess for
acute
cholecystitis.
COMPARISON: Abdominal CT performed earlier in the day and CTA
abdomen of
[**2115-7-7**] and a portable abdominal ultrasound of [**7-6**], [**2114**].
FINDINGS: The gallbladder is markedly distended containing a
large amount of
echogenic sludge. Areas of the sludge appear mass-like and may
be consistent
with tumefactive sludge. The gallbladder wall is thickened,
though this may
be due to known heart failure. There is no intra- or
extra-hepatic biliary
dilation. The common bile duct is normal measuring up to 6 mm in
diameter.
The pancreas is not well seen. There is a large pleural
effusion, better
evaluated on the recent CT. A small amount of perihepatic
ascites is present.
The main portal vein is patent with appropriate direction of
flow.
IMPRESSION: Markedly distended gallbladder containing sludge.
Nonspecific GB
wall thickening which could reflect heart failure. Nondiagnostic
son[**Name (NI) 493**]
[**Name2 (NI) 515**] sign. Given these findings, the possibility of acute
acalculous
cholecystitis cannot be excluded. If further evaluation is
required, HIDA
scan is recommended.
Findings were discussed with Dr. [**Last Name (STitle) **] at approximately 6 pm on
[**2115-7-13**], in person.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**]
Approved: SUN [**2115-7-14**] 6:33 PM
CT abd
INDICATION: 72-year-old man with abdominal pain, intubated and
septic.
Please evaluate for acute process.
COMPARISON: [**2115-7-7**].
TECHNIQUE: MDCT-acquired images were obtained from the lung
bases to the
pubic symphysis after the administration of 130 cc of Optiray
intravenous
contrast and oral contrast. Coronal and sagittal reformatted
images were also
displayed.
FINDINGS:
CT ABDOMEN: There are at least moderate bilateral pleural
effusions, which
are unchanged in size since the prior study. There is adjacent
bibasilar
compressive atelectasis. The visualized portion of the right
lower lobe is
completely collapsed. An NG tube is noted within the stomach.
However, the
side port is at the GE junction and could be advanced a few
centimeters.
Heart size is enlarged without pericardial effusion. Leads are
noted going to
the right atrium, right ventricle, and left ventricle.
The spleen, adrenal glands, pancreas, abdominal loops of bowel
are within
normal limits. The gallbladder remains distended. Overall
unchanged
appearance since the [**2115-7-7**] study. Small amount of
stranding around
the gallbladder may also be due to patient's fluid overload
state, as there is
a small amount of perihepatic ascites and perisplenic ascites.
An IVC filter is noted in place with infrarenal position.
Accessory right
upper renal artery supplies the lower right kidney.
There is no free air. There is no retroperitoneal or mesenteric
lymphadenopathy. There is diffuse calcified plaque
atherosclerotic disease.
CT PELVIS: The prostate is grossly unremarkable. There is
diverticulosis
without evidence of diverticulitis. The rectal wall appears
somewhat
edematous and featureless, though unable to determine if this
might be
resulting from acute or chronic colitis, vs underdistention.
Foley catheter
is noted within the bladder. Air within the bladder is likely
due to recent
instrumentation.
There is no inguinal or pelvic lymphadenopathy. There is no free
fluid within
the pelvis.
BONE WINDOWS: No concerning osseous lesions are identified.
IMPRESSION:
1. The gallbladder remains distended, which is unchanged in
appearance since
the [**2115-7-7**] study. This again may represent the
patient's fasting
state (please correlate clinically). However, if there is a
concern for acute
cholecystitis, ultrasound is recommended for further evaluation.
2. Large bilateral pleural effusions, which appear stable since
the [**7-7**], [**2114**] study. There is adjacent compressive atelectasis with
collapse of
the visualized aspect of the right lower lobe.
3. Trace amount of perihepatic and perisplenic ascites and
diffuse anasarca,
unchanged.
4. Somewhat featureless and minimally thickened appearance of
the rectum,
similar to the prior study from [**2115-7-7**], may be related to
chronic or acute
colitis, though underdistention and third-spacing is a
possibility.
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) **]
Approved: SAT [**2115-7-13**] 7:59 PM
CT head
FINDINGS: There is no acute intracranial hemorrhage, edema, or
mass effect.
There is preservation of [**Doctor Last Name 352**]-white matter differentiation. The
ventricles
and sulci are normal in size and configuration.
There is no fracture. There is air in the soft tissues of the
masticator
spaces, left greater than right. There is mild mucosal
thickening of the
maxillary sinuses bilaterally.
IMPRESSION:
1. No evidence of acute intracranial abnormalities.
2. No fracture seen. Air in the masticator spaces, left greater
than right,
of uncertain etiology.
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) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**]
Approved: SAT [**2115-7-13**] 7:56 PM
[**7-13**]
FINDINGS: The ET tube ends 5.4 cm above the level of the carina.
The NG tube
passes below the level of the diaphragm, although the inferior
extent cannot
be assessed. A right pacemaker/ICD with associated right atrial
and right
ventricular leads is again noted. Abandoned left pacemaker leads
are seen.
There are moderate right and small left pleural effusions, not
significantly
changed in size compared to [**2115-6-30**]. Associated
compressive
atelectasis at the right base as well as minimal left basilar
atelectasis are
also unchanged. The is possibly mild interstitial pulmonary
edema. Moderate
cardiomegaly is unchanged. The mediastinal contours are
unchanged. Old right
rib fractures.
IMPRESSION:
1. ETT appropriately positioned. NG tube tip not assessed,
correlate with
subsequent CT.
2. Moderate cardiomegaly, moderate bilateral pleural effusions,
and possible
mild intersitial pulmonary edema.
The study and the report were reviewed by the staff radiologist.
EKG [**7-13**]
Probable atrial fibrillation with ventricular demand pacing.
Compared to the
previous tracing of [**2115-7-3**] no diagnostic change.
Micro:
[**2115-7-13**] 8:52 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2115-7-14**]):
[**9-10**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2115-7-16**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
ESCHERICHIA COLI. RARE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
Blood 8/27 pending
Urine [**7-13**] negative
Labs prior to discharge:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2115-7-24**] 01:19 7.2 3.74* 8.6* 27.6* 74* 23.0* 31.2 19.3*
202
Source: Line-aline
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2115-7-24**] 01:19 202
Source: Line-aline
[**2115-7-24**] 01:19 15.0* 75.4* 1.3*
Source: Line-aline
[**Year (4 digits) **] USE ONLY
[**2115-7-24**] 01:19
Source: Line-aline
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2115-7-24**] 16:16 114*1 17 0.7 136 4.1 96 31 13
[**2115-7-24**] 01:19 165*1 18 0.6 137 3.9 97 36* 8
Source: Line-aline
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2115-7-24**] 16:16 8.0* 3.2 1.9
[**2115-7-24**] 01:19 7.9* 2.8 2.0
Source: Line-aline
Brief Hospital Course:
Mr. [**Known lastname **] is a 72 YOM with CHF with EF of 15%, AICD, afib, DM,
COPD, HTN, and recent admission complicated by aspiration and
malnourishment, on PPN who presented from rehab with increased
somnolence.
.
MICU COURSE:
# Somnolence/AMS: The patient reportedly was more lethargic and
tachypneic at rehab and was intubated in the ED for airway
protection. He had a Head CT that was negative for acute
process. His somnolence was thought to be from systemic
infection given the patient was not on sedating medications, EKG
appeared baseline, and there were no gross electrolyte
abnormalities. Sources of infection were presumed initially to
be pneumonia within stable right pleural effusion and/or
cholecystitis given CT abdomen that showed distended gall
bladder and RUQ U/S that confrimed distended gallbladder
containing sludge. UA and blood cultures were negative. The
patient was started on Vanc/zosyn to cover for HAP and
cholecystitis. Surgery was consulted and did not think the
patient had cholecystitis given his CT abdomen looked similar to
CT from [**7-7**] and thought the findings could be due to lack of PO
intake on TPN. They recommended HIDA scan which was
inconclusive. The patient's abdominal exam remained stable and
he was not felt to have had cholecystitis. The patient did not
exhibit septic physiology and did not require IV fluids or
pressors to maintain urine output and blood pressure. He did
not have elevated WBC or fevers. Sputum was sent for culture
and grew sensation gram negative rods, and he was switched to
Ceftriaxone on [**7-17**] and finished an 8 day course. Due to RUE
DVT, he was taken down to IR for replacement L sided PICC but
b/l UE dvts were discovered and piccs were exchanged for b/l
midline IVs. The right midline (older midline) was removed on
[**7-25**]. His mental status improved on minimal sedation.
.
Intubation: The patient was intubated for airway protection in
the setting of altered mental status. He was noted to have some
mild white secretions. He has a history of aspiration and had
previously been NPO. His vent settings were weaned to minimal
support. He was sedated initially with fent/midax but this was
changed to propofol as he was expected to be extubated soon. He
was extubated on [**7-19**] for approx 8 hours after aggressive
diuresis with lasix gtt. He was reintubated later that day for
poor oxygenation, difficulty clearing secretions and increased
work of breathing.
IP evaluated the patient for trach/[**Month/Day (2) **] according to goals of
care discussion with HCP and patient. They placed trach/[**Month/Day (2) **] on
[**7-24**]. His vent settings were weaned and he was started on
pressure support. Trache collar was attempted on [**7-25**] and
continued through the day until discharge on [**7-26**]. Sutures
should be removed at 2 weeks from [**7-24**] on [**2115-8-7**]. Trache was
placed for airway protection for secretions so plan would be to
keep it in for that reason and if anything decrease size. Valve
can be attempted for speech upon discharge.
# DVT in upper extremities: Both line associated however still
has left midline in place. Lovenox was started as above.
Discharge with plan to transition to coumadin given atrial
fibrillation.
# Pleural Effusions: The patient was noted to have a right sided
pleural effusion which had been present on chest x rays seince
[**2114-9-17**]. He was not noted to be hypoxic, but thought to
be in respiratory distress at rehab. His ABG did not indicate he
had a large A-a gradient. His effusions were thought to be a
combination of CHF with recent aspiration pneumonia, but a
superimposed pneumonia could not be ruled out. He was started
on vanc/zosyn as above to empirically cover for pneumonia. He
was on a lasix drop on [**7-17**]- [**7-25**]. He was changed to the
equivalent home dose of his lasix on [**7-26**] at 40mg daily. His
electrolytes should be checked on [**7-27**] to ensure stability and
assess need for replacement.
.
# Malnutrition: Patient wanted [**Month/Year (2) 282**] tube last admission in
setting of severe aspiration. However, he subsequently pulled
out G tube. He has also pulled multiple PICCs placed for TPN.
Plan was for repeat swallow eval on Monday with reconsideration
of goals of care pending the results. The patient was intubated
for airway protection and extubated on [**7-19**] briefly before being
reintubated for airway protection [**12-19**] work of breathing and
increased secretions. He was given PPN. NGT was attempted but
was unable to be placed [**12-19**] turbinate swelling. Discussion with
HCP regarding [**Name2 (NI) **] tube resulted in IP consult for trach/[**Name2 (NI) **]
placement.
.
# Atrial fibrilation: Patient currently intermittantly V paced.
He received lidocaine in the ED for concern of Vtach though he
did not show evidence of this in the ICU. He was continued on
his home dose digoxin 0.1 mg IV every 2 days, Lopressor 2.5 mg Q
6 hr. His lovenox was held in the setting of possible procedure
and he was on a Heparin drip. Lovenox was restarted on [**7-25**].
.
# sCHF: The patient appeared euvolemic and was not hypotensive.
He was on a lasix gtt for several days and changed to lasix
through the [**Month/Day (4) 282**] tube on [**7-25**]. He was restarted on aspirin at 81
mg daily given the addition of lovenox to his regimen. He was
restarted on beta blocker with metoprolol tartrate on [**7-25**]. [**Month/Day (4) **]
inhibitor should be added as possible after discharge.
.
# CAD: The patient's lopressor was initially held and then
restarted. He was continued on home digoxin. His aspirin was
initially held in the setting of being NPO then restarted at 81
mg daily.
.
# DM: The patient was continued on fingersticks with insulin
sliding scale
.
# goals of care: Patient is full code. HCP is [**Name (NI) **] [**Name (NI) 25176**].
Goals of care discussion was held with patient and HCP while
extubated and it was determined that he would proceed with
trache/[**Name (NI) 282**].
Medications on Admission:
digoxin 0.1 mg IV every 2 days
Lopressor 2.5 mg Q 6 hr
Lasix 20 mg IV Q day
Albuterol neb 2.5 mg Q6 PRN
Aspirin 325 mg Q day
Atrovent neb 0.5 mg Q6 PRN
Insulin SS
Lovenox 70 mg SQ Q12
Discharge Medications:
1. insulin lispro 100 unit/mL Solution Sig: insulin sliding
scale Subcutaneous ASDIR (AS DIRECTED).
2. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours).
5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation QID (4 times a day).
6. ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO BID (2
times a day).
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
13. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
15. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day).
16. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day): started on [**7-26**].
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Mid-line, non-heparin dependent: Flush with 10 mL Normal
Saline daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
pneumonia
acute on chronic CHF
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to [**Hospital1 69**] with
decreased mental status. While you were here you were treated
for a course of pneumonia. You also had fluid on your lungs
which improved with lasix infusion. You were initially
intubated with a breathing tube and when we tried to remove it
on [**7-19**], you were not able to breathe well on your own because of
increased sputum, so it was replaced. Before it was replaced, we
discussed if you would like to proceed with a more permanent
breathing tube, or tracheostomy, and feeding tube ([**Month/Day (2) 282**]) which
you decided with your health care proxy you wanted.
While you were here, some of your medications were changed.
Please see the attached medication list for your list of
medications.
CHANGE digoxin from IV to [**Month/Day (2) 282**] tube
CHANGE lopressor from IV to Metoprolol 12.5 mg by [**Month/Day (2) 282**] twice a
day
CHANGE lasix from IV to 40mg by [**Month/Day (2) 282**] tube daily
CHANGE aspirin from 325mg to 81mg daily
INCREASE lovenox to 80mcg every 12 hours
START Ranitidine twice a day while on the ventilator and for 24
hours after
START chlorhexadine twice a day while on the ventilator and for
24 hours after
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You should follow-up with your doctors as your nursing facility
ICD9 Codes: 5070, 4271, 4280, 496, 5859, 3572, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4228
} | Medical Text: Admission Date: [**2110-5-7**] Discharge Date: [**2110-6-17**]
Date of Birth: [**2049-10-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Nausea
Abdominal Pain
Major Surgical or Invasive Procedure:
Ultrasound-guided imaging for vascular access,
inferior vena cava catheter placement with inferior vena cava
imaging and G2 IVC filter.
.
1. Laparoscopic-assisted retroperitoneal pancreatic
necrosectomy.
2. Retroperitoneal abscess drainage and irrigation.
.
1. Exploratory laparotomy with protracted extensive lysis
of adhesions.
2. Small bowel resection with primary enteroenterostomy
anastomosis.
3. Gastrojejunostomy.
4. Open cholecystectomy.
5. Feeding jejunostomy tube placement.
History of Present Illness:
This is a 60 year old male s/p recent necrosectomy on [**2110-3-18**] for
gallstone pancreatitis now with abdominal pain, N/V. He was
discharged on [**2110-5-6**] toleratng a regular diet and doing well.
He currently has one drain in place. He is tentatively schedule
to go to the OR on [**2110-5-14**] for pancreatic debridement.
Past Medical History:
PMH: Necrotizing Pancreatitis
CAD, DMII, HTN, Hyperlipidemia, CRI ([**Date range (1) 76919**] dialysis),
suicide attempt (antifreeze)
PSH:
- s/p Pancreatic debridement [**2110-3-18**]
-colectomy for diverticulitis w/ ostomy s/p revision and
takedown
approx 8y ago.
-ventral hernia repair with mesh
-L knee repair
-L shoulder repair
-back surgery
Social History:
lives with wife at home. Retired town administrator, non-smoker,
rare EtOH
Family History:
non contributory
Physical Exam:
VS: 98.8, 115, 120/78, 16, 99 3L
NAD
CV: Reg tachy
Chest: CTA
Abd: + Abd tenderness, no rebound, no guarding. Drain with
thick, [**Doctor Last Name 352**] drainage
Ext: WNL, +2 pulses bilat.
Pertinent Results:
[**2110-5-7**] 01:55PM BLOOD WBC-5.5 RBC-3.47* Hgb-9.4* Hct-29.5*
MCV-85 MCH-27.0 MCHC-31.8 RDW-14.3 Plt Ct-337
[**2110-5-13**] 04:55AM BLOOD WBC-4.7 RBC-4.00*# Hgb-10.4*# Hct-33.2*#
MCV-83 MCH-26.0* MCHC-31.4 RDW-14.3 Plt Ct-383
[**2110-5-14**] 04:49AM BLOOD Glucose-157* UreaN-23* Creat-1.0 Na-136
K-4.7 Cl-103 HCO3-25 AnGap-13
[**2110-5-13**] 04:55AM BLOOD ALT-12 AST-18 LD(LDH)-158 AlkPhos-84
Amylase-51 TotBili-0.4
[**2110-5-13**] 04:55AM BLOOD Lipase-42
[**2110-5-14**] 04:49AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.0
.
CHEST (PRE-OP PA & LAT) [**2110-5-6**] 9:21 AM
IMPRESSION: Bibasilar atelectasis without other abnormalities.
.
CT CHEST W/CONTRAST [**2110-5-13**] 5:32 PM
IMPRESSION:
1. Small left main pulmonary embolus of unclear chronicity.
2. No significant change in appearance of peri-pancreatic air
and fluid collections.
3. No change in multiple hypoattenuating renal lesions.
4. Interval decrease in hypoattenuating liver lesions likely
indicative of subcapsular fluid collection.
5. No significant change in right middle lobe pulmonary nodule.
6. Cholelithiasis without evidence of cholecystitis.
.
ECHO [**2110-5-14**]
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. 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. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2110-5-15**] 9:59 AM
IMPRESSION: Left cephalic vein thrombosis in the mid distal
upper arm. No evidence of deep vein thrombosis.
.
CTA ABD W&W/O C & RECONS [**2110-5-16**] 12:40 PM
IMPRESSION:
1. Compared to prior exam from [**2110-5-13**], there is decreased
size of collection containing fluid and gas within the
pancreatic bed. Extensive peripancreatic stranding and fluid
extending down the root of the mesentary is grossly unchanged.
Small fluid collections are seen surrounding the residual
pancreatic tissue within the head and neck consistent with
pseudocysts, not significantly changed from prior exam.
2 Arterial vasculature including the celiac, hepatic, splenic,
left gastric, gastroduodenal arteries are intact. The portal
vein is patent. The splenic vein and SMV are not visualized and
likely obliterated, unchanged.
3. Cholelithiasis without evidence of cholecystitis.
4. Bilateral lower lobe atelectasis and small left pleural
effusion.
.
Cardiology Report ECG Study Date of [**2110-5-16**] 11:36:36 AM
Sinus tachycardia. Low voltage in the limb leads. Diffuse
non-specific
ST-T wave changes. Compared to the previous tracing ST-T wave
changes are
new.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
120 178 78 334/439 3 21 73
.
CT ABDOMEN W/CONTRAST [**2110-5-19**] 3:09 PM
IMPRESSION:
1. Increased size of left pleural effusion with associated
relaxation atelectasis. There is increased size of perisplenic
fluid collection.
2. No significant change in size and appearance to pancreatic
collection containing fluid and gas with an intraluminal drain.
No fistula is demonstrated, however, for better evaluation of a
fistulous connection, injection of contrast into the drains
would be of use. Of note, this should only be performed after
the current contrast within the bowel has passed.
3. Cholelithiasis.
.
CHEST (PA & LAT) [**2110-5-22**] 4:16 PM
FINDINGS: In comparison with earlier study of this date, there
is again evidence of increased opacification at the left base
consistent with pleural effusion and atelectasis. Much improved
lung volumes since the previous study. Right subclavian catheter
tip lies either at the cavoatrial junction or into the upper
aspect of the right atrium itself.
.
CT ABDOMEN W/CONTRAST [**2110-5-25**] 4:21 PM
IMPRESSION:
1. Slight increase in size of a pancreatic gas and
fluid-containing collection with two drains well positioned
within the collection. No evidence of oral contrast
extravasation to suggest a fistula.
2. Stranding extends from the pancreatic collection to the
descending colon, however, there is no definite evidence of a
fistula.
3. Complex pseudocyst about the pancreatic head is approximately
unchanged in size but contains new focus of gas, possibly
tracking from the adjacent collection.
4. Unchanged large left pleural effusion and left lower lobe
atelectasis.
5. Cholelithiasis.
6. Unchanged subxiphoid calcified mass.
.
ERCP BILIARY ONLY BY GI UNIT [**2110-5-30**] 1:25 PM
IMPRESSION: No contrast filling of the pancreatic or biliary
ducts.
.
CHEST (PORTABLE AP) [**2110-6-4**] 7:34 AM
IMPRESSION:
1. Stable severe left pleural effusion with mild left to right
shift of the cardiomediastinal structure and stable left lower
lobe atelectasis.
2. Right internal jugular line tip is in the right atrium and
needs to be positioned.
.
ABDOMEN (SUPINE & ERECT) [**2110-6-9**] 10:19 AM
IMPRESSION: No evidence of ileus or small bowel obstruction is
visualized. No pneumoperitoneum is noted.
.
CT ABDOMEN W/CONTRAST [**2110-6-13**] 1:27 PM
IMPRESSION:
1. Slight interval decrease in size of gas- and fluid-containing
collection in the pancreatic bed. Consideration may be given to
slightly retracting both drains which are coiled several times
within the collection. No new collections are seen.
2. Interval progression of ascites, which is now moderate in
amount.
3. Increased anasarca.
4. Chronic thrombus seen in left sided pulmonary arteries,
unchanged since [**2110-5-13**].
.
ABDOMEN (SUPINE & ERECT) [**2110-6-14**] 11:29 AM
NG tube tip is in the stomach. The side port is just distal to
the GE junction. Multiple surgical clips project in the left
hemi abdomen. There is no evidence of obstruction. Few small
bowel loops are prominent on the right side, measuring up to 25
mm. Patient has known ascites.
.
Brief Hospital Course:
This is a 60 yo male admitted with nausea and vomiting. He is
well known to the service. He is s/p pancreatic necrosectomy
[**2110-3-18**]. His admitting diagnosis was:
1. Status post fulminant emphysematous pancreatitis.
2. Pancreatic necrosis.
3. Retroperitoneal abscess.
He received a PICC and TPN and he received antinausea meds as
needed and he was pre-op'd for the OR.
A pre-op CT showed Small left main pulmonary embolus and
pancreatic pseudocyst w/ multiple air fluid level and PE (12mm
filling defect in prox LL pulm a).
He was started on Heparin and the vascular service was consulted
for IVC Filter. He had a filter placed on [**2110-5-15**].
the next day he went to the OR on [**2110-5-16**] for:
1. Laparoscopic-assisted retroperitoneal pancreatic
necrosectomy.
2. Retroperitoneal abscess drainage and irrigation.
He had placed under direct laparoscopic vision two 19-French
[**Doctor Last Name 406**] drains into the abscess cavity which were exteriorized out
through the sinus tract on the left flank
and then secured at the skin level and positioned into an ostomy
appliance bag to serve for postoperative passive drainage.
In the PACU he was septic, with Hypotension and tachycardia. He
had brief support with Levophed, but then fluid support only. He
was admitted to the TSICU for one night and recovered well.
Pain: He pain was well controlled with a PCA.
Abd/GI: He remained NPO with TPN and drain care. The drain fluid
was showed:
GRAM POSITIVE COCCI, GRAM NEGATIVE ROD(S), and GRAM POSITIVE
ROD(S). He was treated with Vancomycin, Cipro, and Flagyl.
The contents look feculent and so he continued to be NPO.
A CT showed no significant change in size and appearance to
pancreatic collection containing fluid and gas with an
intraluminal drain.
No fistula is demonstrated, however, for better evaluation of a
fistulous connection, injection of contrast into the drains
would be of use. Cholelithiasis.
He went for EGD on [**5-30**] for a pancreatic duct stent placement.
Contrast injection in duodenal bulb suggestive of fistulous
tract not consistent with PD. Contrast drained rapidly.
Unsuccessful cannulation of pancreatic duct (cannulation).
Stricture of the area of the papilla
.
Anticoag: He continued with Heparin and then switched to Lovenox
for his PE.
Post-op Pleural Effusion: On POD 6A CXR noted increased
opacification at the left base consistent with pleural effusion
and atelectasis. He received Lasix with over a Liter response.
[**2110-6-3**] he went back to the OR for
1. Exploratory laparotomy with protracted extensive lysis
of adhesions.
2. Small bowel resection with primary enteroenterostomy
anastomosis.
3. Gastrojejunostomy.
4. Open cholecystectomy.
5. Feeding jejunostomy tube placement.
Pain: He had a PCA for pain control.
GI/ABD: He was NPO, NGT with an IVF and TPN. We were able to
wean the TPN and ramp up tubefeedings. He was tolerating
tubefeeding. However, after NGT removal he had continued nausea
and bilious emesis. A NGT was placed and ~1-liter of bile was
draining. Clamp trials were done after several days and we were
able to remove the NGT.
A CT abdomen was performed on [**2110-6-13**] showed Slight interval
decrease in size of gas- and fluid-containing collection in the
pancreatic bed. Consideration may be given to slightly
retracting both drains which are coiled several times within the
collection. No new collections are seen. Interval progression of
ascites, which is now moderate in amount. Increased anasarca.
Chronic thrombus seen in left sided pulmonary arteries,
unchanged since [**2110-5-13**].
He had 2 drain in the left flank. One drain was removed prior to
discharge.
Overall, he continued to do well and tolerate tubefeedings and
sips for comfort. He continued to have daily emesis (large
volume and bilious). This emesis will likely take several weeks
to settle out. A NGT is not necessary and he will likely
continue to vomit occasionally. His Gastrojejunostomy is open
and patent and there is no mechanical reason that he can not
empty his stomach. Due to the complexity of the pancreatitis and
abscess, he needs more time for the emesis to resolve.
Medications on Admission:
pancrease 1-2caps''', lipitor 80', celexa 40mg, trazodone 100',
colace 100'', protonix 40', Lorcet 10/650mg PRN, MOM, [**Name (NI) 8472**] 60
units, [**Name (NI) **] SS, metformin ?dose
Discharge Medications:
1. Octreotide Acetate 100 mcg/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Acetaminophen 160 mg/5 mL Solution Sig: 1000 (1000) mg PO TID
(3 times a day).
4. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q4H (every 4
hours) as needed: J-tube.
5. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back pain: on for 12 hours, off for 12 hours .
8. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) Units
Subcutaneous once a day.
11. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day) as needed for diarrhea.
12. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. 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:
[**Hospital3 2857**] - [**Location (un) 9188**]
Discharge Diagnosis:
Pancreatic Fluid Collection
Pulmonary Embolism
Nausea
Vomiting
.
1. Fulminant emphysematous pancreatitis.
2. Postoperative sepsis.
3. Retroperitoneal abscess.
4. Status post laparoscopic retroperitoneal pancreatic
necronectomy.
5. Failure to thrive.
6. Gallstones.
7. Duodenal stenosis.
8. Duodenal fistula.
9. Small intestinal obstruction.
10.Status post numerous intra-abdominal operations from
this procedure and prior diverticulitis and complications.
Discharge Condition:
Good
Continues to vomit about daily. Vomiting will likely continue
for some time.
Tolerates tubefeedings and sips for comfort.
Discharge Instructions:
You were admitted for nausea, vomiting, abdominal pain secondary
to pancreatitis.
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 have persistent vomiting and cannot keep in fluids or
your medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**11-26**] lbs) for 6 weeks.
* Continue with drain care and flushing of the left sided drain.
* Monitor your incision for sign of infection (redness or
increased drainage).
* Keep incision clean and dry.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2110-7-11**] 9:00
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2110-7-11**]
10:30
Completed by:[**2110-6-17**]
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4229
} | Medical Text: Admission Date: [**2113-11-27**] Discharge Date: [**2113-12-6**]
Date of Birth: [**2113-11-27**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 66131**] is a newborn born at 35-6/7 weeks
and admitted to the NICU with respiratory distress. He was
born at 8 p.m. in the evening of [**11-27**]. Birth weight
2,665 grams. He was born to a 29-year-old G1, P0 now 1 mother
with an [**Name (NI) 37516**] of [**2113-12-26**]. Prenatal labs were blood
type O-positive, antibody negative, RPR nonreactive, HBsAg
negative, rubella immune, GBS unknown. This pregnancy was
uncomplicated until the mother presented on the day of
delivery in spontaneous labor.
Intrapartum course was notable for spontaneous rupture of
membranes 14 hours prior to delivery and no maternal fever or
other sepsis risk factors. The infant was born via
spontaneous vaginal delivery emerging vigorously with Apgars
of 8 and 8 at 1 and 5 minutes. He was then noted to develop
persistent grunting and work of breathing and was brought to
the NICU.
PHYSICAL EXAM ON ADMISSION: Birth weight 2,665 grams which
is 50-75th percentile, head circumference 34.5 cm (90th
percentile), length 48 cm which is 50th-75th percentile. His
temperature was 98.2, heart rate 150s, respiratory rate 60s,
blood pressure 74/41 with a mean of 45, O2 saturation 92-94%
on room air. He was a well-developed, premature infant who
had audible grunting at rest, moderate increase in work of
breathing, and responsive during the exam. His skin was warm
and pink with no rash. He had molding on his head and
fontanels were soft and flat. Ears: Patent. Nares: Patent and
intact palate. Neck was supple without lesions. His chest:
Breath sounds were coarse with moderate aeration, but did
have grunting, flaring, and retracting. Cardiac: There was
normal rate and rhythm without murmur. Abdomen was soft,
nondistended, and nontender with quiet bowel sounds, no mass,
no hepatosplenomegaly. GU: The infant was normal male with
palpable testes and patent anus. He had warm skin with
capillary refill of 1.5 seconds. Hips and back were normal.
Neurologic exam was normal for gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: He
presented initially with grunting, flaring, and retracting,
and was placed in nasal cannula O2. He remained in nasal
cannula O2 until day of life 4 when he then weaned to room
air where he has been stable on room air since that time. He
has had no issues with apnea or bradycardia and has not
required any methylxanthine therapy.
Cardiovascular: He has remained hemodynamically stable
without any murmur or abnormal blood pressure readings.
Fluid, electrolytes, and nutrition: He was NPO on admission
and IV fluids were started at that time. Enteral feedings
were started on day of life 2. He reached full enteral
feedings and came off IV fluid by day of life 4. He is
presently taking Enfamil 20 with iron or breast milk ad-lib
with a minimum of 100 mL per kilogram per day and is feeding
very well. His most recent weight is 2,460 grams.
GI: He has tolerated all of his feedings. Peak bilirubin
level was 14.2 on day of life 6. He received a total of 5
days of phototherapy.
Hematology: His blood type is O-positive, DAT negative. He
remains pink and well perfused.
Infectious disease: CBC and blood culture were screened on
admission. Ampicillin and gentamicin were given for 48 hours
and discontinued subsequently when the blood culture remained
negative. The initial CBC was within normal limits with 57
polys and 4 bands.
Neurologic: The infant has maintained a normal neurologic
exam for gestational age.
Sensory: Hearing screen was performed and the infant passed
in both ears.
Ophthalmology: There has been no ophthalmologic exams due to
maturity of gestational age.
Psychosocial: The infant has not had issues requiring social
service at this time.
The infant's condition at discharge is good and will be going
home to the parents. The pediatrician is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24613**] of
[**Hospital 2312**] Pediatrics, phone #[**Telephone/Fax (1) 37109**].
CARE AND RECOMMENDATIONS AFTER DISCHARGE: Ad-lib feeds of
breast feeding supplemented with breast milk or E 20 ad-lib.
MEDICATIONS: The only medication is Tri-Vi-[**Male First Name (un) **] 1 mL per day.
CAR SEAT TEST: The infant has passed the car seat test and
can be positioned in an upright car seat.
STATE NEWBORN SCREEN: Was sent on [**2113-11-30**] and the
results are pending.
IMMUNIZATIONS RECEIVED: The hepatitis vaccine was given on
[**2113-11-29**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1. Born at less than 32
weeks gestation; 2. Born between 32 and 35-weeks gestation
with 2 of the following: Daycare during the RSV season, a
smoker in the house, neuromuscular disease, airway
abnormalities, or school-age siblings; or 3. With chronic
lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS: The infant has a follow-up
appointment with Dr. [**Last Name (STitle) 24613**] on [**2113-12-8**].
DISCHARGE DIAGNOSES:
1. Prematurity
2. Rule out sepsis
3. Respiratory distress
4. Hyperbilirubinemia
5. Recent circumcision.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2113-12-6**] 01:44:31
T: [**2113-12-6**] 04:44:38
Job#: [**Job Number 66132**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4230
} | Medical Text: Admission Date: [**2147-8-4**] Discharge Date: [**2147-9-15**]
Date of Birth: [**2102-12-7**] Sex: M
Service: Vascular
CHIEF COMPLAINT: Fever and hypotension.
HISTORY OF PRESENT ILLNESS: The patient was seen in the
Emergency Department on [**2147-8-4**] with the onset of fever
and hypotension.
The patient is a 44-year-old white gentleman with a past
medical history of end-stage renal disease secondary to
ureteral reflux nephropathy. He underwent a living-related
renal transplant and has a history of mesenteric ischemia
requiring a [**Doctor Last Name 4726**]-Tex superior mesenteric artery aorta bypass
graft in [**2145-12-25**].
The patient now presents after a prior admission for
occlusion, status post t-PA, of the superior mesenteric
artery with a 24-hour to 36-hour history of increasing
weakness, malaise, and fever. Temperature was 102.8. The
patient admits to chills. He denies chest pain, shortness of
breath, or cough. There was no bright red blood per rectum.
He denies any associated symptoms or abdominal discomfort or
pain. He is now admitted for further evaluation and
treatment.
PAST MEDICAL HISTORY:
1. History of end-stage renal disease.
2. History of peripheral vascular disease.
3. History of gastroesophageal reflux disease.
4. History of a 25-pack-year smoking history.
5. History of squamous cell carcinoma of the lower lip.
6. History of [**Doctor Last Name 15532**] esophagus.
7. History of duodenitis.
PAST SURGICAL HISTORY:
1. Living-related renal transplant in [**2130-5-25**].
2. Aorta superior mesenteric artery bypass with
polytetrafluoroethylene in [**2145-11-25**].
3. T-PA of superior mesenteric artery graft times two in
[**2147**].
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION: (His medications included)
1. Coumadin 3 mg by mouth every day.
2. Imuran 50 mg by mouth once per day.
3. Prednisone 10 mg by mouth once per day.
4. Levoxyl 125 mcg by mouth once per day.
5. Furosemide 20 mg by mouth once per day.
6. Bactrim single strength by mouth every Monday, Wednesday,
and Friday.
SOCIAL HISTORY: The patient is divorced. He has one child.
He is an electronic technician.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed vital signs with a temperature of 100.3 degrees
Fahrenheit, heart rate was 108, blood pressure was 75/55,
respiratory rate was 16, and oxygen saturation was 99% on 2
liters. General appearance revealed a male sitting in bed in
no acute distress. Oriented times three. Lung examination
revealed left inspiratory basilar crackles. Heart
examination revealed distant heart sounds; regular. No
murmurs, gallops, or rubs. The abdomen was slightly
distended and tympanic. Diminished bowel sounds. There was
no guarding. There was a right iliac fossae renal transplant
noted. Rectal examination was without abscess and was
guaiac-positive. Extremity examination was without edema.
The feet were warm. There were no ulcerations. Pulse
examination revealed intact femoral pulses and popliteal
pulses bilaterally with triphasic dorsalis pedis pulse on the
right and a palpable posterior tibialis pulse on the right
with a triphasic dorsalis pedis pulse on the left with a
palpable posterior tibialis pulse on the left.
PERTINENT LABORATORY VALUES ON PRESENTATION: Admission
laboratories revealed white blood cell count was 3.6 and
hematocrit was 26.5 (down from 28). INR was 3. Blood urea
nitrogen was 17. Creatinine was 1.2. Potassium was 3.9.
PERTINENT RADIOLOGY/IMAGING: A single view chest x-ray
revealed no infiltrate or effusions. Heart mediastinal
shadows were okay.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was placed
in the Vascular Intensive Care Unit. Linezolid, Flagyl, and
Levaquin were instituted after cultures were obtained.
The patient was transfused two units of packed red blood
cells with a post transfusion hematocrit of 28. The Renal
Transplant Service followed the patient. He another unit of
packed red blood cells for his hematocrit of 28.
The Endocrinology Service was consulted because of the
patient's elevated thyroid-stimulating hormone of 51.
Recommendations were to check FT4 and antimorph antibodies.
His levothyroxine dose required adjustment. The patient
remained in the Vascular Intensive Care Unit. His hematocrit
after three units of packed red blood cells was 33.
It was felt that he would require further evaluation for a
gastrointestinal bleed. The Infectious Disease Service was
consulted and the Gastrointestinal Service was consulted.
The Infectious Disease Service did see the patient. They
felt, in light of the patient's previous perirectal abscess,
Escherichia coli to the cecum, bacteremia, and superior
mesenteric artery thrombosis, he improved in house. The
evaluation at this time was unrevealing for potential
sources. Recurrent abscesses with computed tomography scans
were negative. Clostridium difficile has been negative, but
blood can interfere with Cytoxan assay. They recommended
continuing current antibiotics, check transthoracic
echocardiogram, repeat blood cultures if fever recurs, send
stools for Clostridium difficile, Cytoxan D, and recommended
change to Bactrim from single strength to double strength.
These recommendations were followed through on.
The echocardiogram demonstrated biventricular hypokinesis
consistent with diffuse process (i.e. toxic/metabolic).
There were no computed tomography or Doppler evidence of
endocarditis.
Blood cultures from admission were no growth but not
finalized. Repeat cultures were done on [**9-8**] which were
pending. Urine cultures were finalized at no growth, and
repeat urine cultures on [**9-7**] had not been finalized.
At the time Gastrointestinal Service saw the patient, stool
culture were unremarkable except for yeast. The chest x-ray
was without infiltrates or effusions.
Recommendations indicated the patient would require
endoscopic examination with upper and lower endoscopies to
rule out ischemic colitis, but this could only be done once
the patient's INR was below 1.5. Coumadin was discontinued
on admission.
Initial computed tomography demonstrated a hydronephrotic
native atrophic left kidney of uncertain clinical
significance. There were no secondary signs of inflammation.
The upper left collecting system in the past has shown
various decrease of dilatation and decompression. There was
a diffuse large-bowel and small-bowel dilatation without
evidence of obstruction. The superior mesenteric artery
bypass was patent.
A repeat computed tomography of the abdomen done on [**8-12**]
did not reveal any source of the patient's fevers. An
ultrasound of the gallbladder was negative for cholelithiasis
or intrahepatic ductal dilatation. Blood cultures done on
[**2147-8-12**] grew Enterococcus to the cecum. It was
susceptible to streptomycin, linezolid, and methacycline.
Resistant to vancomycin, penicillin, and levofloxacin, and
ampicillin. All cultures were negative.
The patient then underwent on [**2147-8-14**] and upper
esophageal endoscopy. This showed a normal esophagus. There
was localized erythema of the mucosa. No bleeding was noted
in the antrum of the stomach. These findings were compatible
with gastritis. There was no evidence of active bleeding.
The duodenum was normal.
The patient then underwent a colonoscopy. Although there was
neither blood nor obvious lesions identified, the preparation
was poor and small mucosal lesions might have been missed.
If further bleeding occurs, it is likely to be colonic. Then
it would be appropriate to do a repeat study after a better
preparation.
The patient underwent a white blood cell tagged study on [**2147-8-22**]. This demonstrated findings consistent with
infectious or inflammatory process with increased activity in
the loops of the small bowel within the upper pelvis.
Recommendations included a positron emission tomography scan
be considered for anatomical localization of findings if
clinically warranted.
On [**8-8**], there was one blood culture which grew [**Female First Name (un) 564**]
parapsilosis.
The patient continued to spike fevers and rigors despite
antibiotics. Cultures from [**8-19**] grew 2/4 bottles of
gram-negative rods on the blood cultures.
On [**8-22**], the Gastrointestinal Service was consulted again,
and the patient underwent an upper endoscopy the same day.
It demonstrated a normal esophagus and a normal stomach. The
duodenum showed gastrografin through the duodenum. There was
no bleeding noted around the site of erosion.
General Surgery was consulted after the endoscopic findings.
Total parenteral nutrition was begun. Antibiotics were
continued.
On [**2147-8-26**], the patient had a drop in blood pressure
and hematocrit requiring a transfusion of three units of
packed red blood cells.
He was transferred to the Surgical Intensive Care Unit for
continued monitoring and care. The drop in the hematocrit
was secondary to a spontaneous bleeding into the neck, not
intra-abdominal bleeding.
The patient was stabilized. The patient underwent a right
axillar bifemoral bypass graft on [**2147-8-30**]. He
returned to surgery on [**2147-8-31**] and underwent a repair
of duodenal fistula, gastrostomy, and jejunostomy. A #14
French jejunostomy tube was placed, and a #16 French Foley
gastrostomy tube was placed. The superior mesenteric artery
graft was removed with a redo aorta superior mesenteric
artery bypass with superficial femoral vein from the left
leg. At the time of repair, antibiotics included fluconazole
400 mg intravenously q.24h. (this was day 21), linezolid 600
mg q.12h. (this was day 19), meropenem 1 g q.12h. (this was
day 17).
His postoperative hematocrit remained stable at 33.6. His
INR was 1.3. Partial thromboplastin time was 68. Blood urea
nitrogen was 9. Creatinine was 0.7. His ALT, AST, and
alkaline phosphatase were unremarkable.
The patient was continued on total parenteral nutrition. His
protein needs were 55 to 70 of protein per kilogram with 30
to 32 calories per kilogram with a total calorie need of 1400
cc to 1500 cc. Goal rate for the total parenteral nutrition
was 1200 cc per 24 hours.
The patient was transferred to the Vascular Intensive Care
Unit on [**2147-9-2**] for continued care. Tube feeds were
started on [**2147-9-5**]. The meropenem was discontinued
on [**2147-9-6**]. Cefepime 2 g was started intravenously
q.12h. The Foley catheter was discontinued on [**2147-9-6**].
Physical Therapy was requested to see the patient in
anticipation for discharge planning. They felt that he would
be at a level that would be safe for discharge to home after
two to three more sessions (and this was on [**2147-9-7**]).
The patient underwent G2 study which was negative for
duodenal leak. On [**2147-9-12**], the Infectious Disease
Service signed off with recommendations of continuing the
cefepime for a total of four weeks, the fluconazole for a
total of four weeks, and we could convert him to oral agents
once he was allowed to use his gastrointestinal tract.
Linezolid should be continued until central venous access is
discontinued. The last dose of cefepime and fluconazole will
be [**2147-9-28**].
The patient was to follow up in the Infectious Disease Clinic
on [**2147-9-29**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient
will require monitoring of his liver function tests/renal
function on a weekly basis while on fluconazole and cefepime.
Total parenteral nutrition was slowly tapered, and his tube
feeds were increased to meet goal at 60 cc per hour. Tube
feeds were brought to goal on [**9-10**], and cycling was
begun at 60 cc per hour (2 p.m. to 8 a.m.). A regular diet
was instituted. Total parenteral nutrition was discontinued.
The patient had a peripherally inserted central catheter line
on [**9-11**] under fluoroscopy. His patient-controlled
analgesia was discontinued, and he was converted to Vicodin
on [**2147-9-11**]. Physical Therapy continued to work with
the patient. He continued to progress in his endurance and
mobility.
During the remainder of his hospital course, he continued to
show improvement. Reglan was begun with improvement in his
oral tolerance. His central line was discontinued, and
linezolid was discontinued. Case Management was in the
process of screening.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
MEDICATIONS ON DISCHARGE:
1. Regular insulin sliding-scale four times per day before
meals and q.h.s. as follows: glucose of less than 120 use no
insulin; glucose of 121 to 160 use 2 units subcutaneously,
glucose of 161 to 200 use 4 units subcutaneously, glucose of
201 to 240 use 6 units subcutaneously, glucose of 241 to 280
use 8 units subcutaneously, glucose of 281 to 320 use 10
units subcutaneously, glucose of 321 to 360 use 12 units
subcutaneously, glucose of 361 to 400 use 14 units
subcutaneously, glucose of greater than 400 use 16 units
subcutaneously.
2. Cefepime 2 g intravenously q.12h. (to be continued until
[**2147-9-28**]).
3. Dulcolax suppository per rectum at bedtime as needed.
4. Hydrocodone/acetaminophen tablets one to two tablets by
mouth q.4-6h. as needed (for pain).
5. Protonix 40 mg by mouth once per day.
6. Reglan 10 mg by mouth before meals and at bedtime.
7. Bactrim single strength one tablet by mouth twice per
day.
8. Levothyroxine 125 mcg by mouth every day.
9. Azathioprine 50 mg by mouth once per day.
10. Prednisone 10 mg by mouth q.48h.
11. Acetaminophen 325 mg to 650 mg by mouth q.6h. as needed.
12. Fluconazole 400 mg once per day (until [**2147-9-28**]).
13. Metoprolol 12.5 mg by mouth twice per day (hold for a
systolic blood pressure of less than 80 or a heart rate of
less than 60).
DISCHARGE DIAGNOSES:
1. Enterococcal cecum septicemia.
2. Candidiasis septicemia.
3. Graft erosion of the duodenum.
4. Blood loss anemia; corrected.
5. Status post renal transplant (on immunosuppression).
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] status post discharge from
rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2147-9-12**] 16:19
T: [**2147-9-12**] 16:29
JOB#: [**Job Number 109763**]
ICD9 Codes: 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4231
} | Medical Text: Admission Date: [**2147-2-11**] Discharge Date: [**2147-2-20**]
Date of Birth: [**2068-3-18**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
female with multiple medical problems who comes to us from
[**Name (NI) **] [**Name (NI) 34648**] for respiratory distress and hypotension.
She has been on a tracheostomy since [**2146-9-28**] when she
had a coronary artery bypass graft at an outside hospital and
had failure to wean. She was transferred to [**Hospital **]
Rehabilitation for ventilatory weaning and was given the
diagnosis of tracheobronchomalacia and had two stents placed
in the distal trachea and left main stent. These stents are
made of silicone.
On the day prior to admission, the patient developed
respiratory distress, shortness of breath, cyanosis, and
hypoxia. Her ventilator settings at that time were assist
control with a tidal volume of 600, a respiratory rate of 12,
an FIO2 of 0.5, and a positive end-expiratory pressure of 6.
This resulted in an arterial blood gas with a pH of 7.12, a
carbonate dioxide of 104, and an O2 of 36.
She arrived to [**Hospital1 69**] alert.
She was being bagged through her tracheostomy and was
hemodynamically stable. She had an urgent bronchoscopy, as
the original thought was that perhaps her stents had been
displaced causing blockage and hypoxia. The bronchoscopy
showed that her stents were in place. Instead, she had
significant mucous plugging (greater on the left). These
were removed with some difficulty. Subsequently, her
clinical status improved, and she was transferred to the
Intensive Care Unit for followup and stabilization.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post myocardial
infarction and coronary artery bypass graft in [**2146-9-28**] at [**Hospital6 1708**].
2. Congestive heart failure (with an ejection fraction of
30%); per [**Hospital1 **] notes.
3. Failure to wean; status post coronary artery bypass
graft with tracheostomy placement.
4. History of methicillin-resistant Staphylococcus
epidermitis bacteremia and sepsis; status post coronary
artery bypass graft.
5. Atrial fibrillation; status post coronary artery bypass
graft.
6. A recent diagnosis of tracheobronchomalacia with
placement of silicon stents.
7. Type 2 diabetes.
8. Peripheral vascular disease; status post aortic femoral
bypass.
9. Chronic obstructive pulmonary disease.
10. Peptic ulcer disease; status post a total gastrectomy.
11. Prior gastrointestinal bleed.
12. Gastroesophageal reflux disease.
13. Abdominal hernia repair.
MEDICATIONS ON ADMISSION: (Medications on admission
included)
1. Prednisone 20 mg by mouth once per day.
2. Combivent meter-dosed inhaler 4 puffs inhaled q.4h. as
needed.
3. Bumex 1 mg intravenously once per day.
4. Zestril 5 mg by mouth once per day.
5. Regular insulin sliding-scale
6. Lantus 12 units subcutaneously once per day.
7. Lansoprazole 30 mg by mouth once per day.
8. Epogen 40,000 units subcutaneously ever week.
9. Multivitamin one tablet by mouth once per day.
10. Aspirin 81 mg by mouth once per day.
11. Linezolid 600 mg q.12h.
12. Bactrim 10 cc q.12h.
13. Flagyl 500 mg q.8h.
14. Morphine as needed.
15. Ativan as needed.
16. Tube feeds through percutaneous endoscopic gastrostomy
tube.
ALLERGIES: PENICILLIN and INTRAVENOUS CONTRAST.
SOCIAL HISTORY: The patient has a 40-pack-year smoking
history. She recently quit smoking. One to two alcoholic
drinks per day. She lives with sister [**Female First Name (un) 123**] in [**Name (NI) 1559**].
PHYSICAL EXAMINATION ON PRESENTATION: Examination on
admission revealed vital signs with a temperature of 97.1
degrees Fahrenheit, her blood pressure was 106/43 (on a
Levophed drip), her heart rate was 92, her respiratory rate
was 17, and her oxygen saturation was 100% on assist control
with a tidal volume of 450, respiratory rate 18, FIO2 of 0.7,
and a positive end-expiratory pressure of 5. The patient was
intubated and sedated with equal and symmetric pupils that
were minimally reactive. She had moist mucous membranes.
Her neck was a difficult examination as the tracheostomy
collar was in place. Her heart was regular. There were no
murmurs, rubs, or gallops appreciated. Lungs prior to the
urgent bronchoscopy revealed decreased air movement on the
right with minimal breath sounds on the left. Status post
bronchoscopy, there was improved air movement bilaterally.
The abdomen was soft, slight distended, with no
hepatosplenomegaly. There were positive bowel sounds. There
was a vertical scar. Extremity examination revealed
extremities which were cool distally with dopplerable distal
pulses. No edema or clubbing.
PERTINENT LABORATORY VALUES ON PRESENTATION: Initial
laboratories revealed her white blood cell count was 6.5, her
hematocrit was 31.7, and her platelets were 298. Sodium was
143, potassium was 4.7, chloride was 107, bicarbonate was 31,
blood urea nitrogen was 37, creatinine was 0.9, and her blood
glucose was 194. Her liver function tests were normal with
an alkaline phosphatase of 150 and a total bilirubin of 0.2.
Her albumin was 2.4. Her calcium was 7.4, her phosphate was
5.5, and her magnesium was 2.3. Creatine kinase was 27. Her
troponin was pending.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed
hyperinflation on the right with left main stem with discrete
cutoff prior to the bronchoscopy.
An electrocardiogram revealed a normal sinus rhythm with no
acute ischemic changes.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY FAILURE ISSUES: The patient had respiratory
failure that was thought to be secondary to mucous bronchial
plugging as well as pneumonia. Status post bronchoscopy,
her arterial blood gas levels markedly improved. In
addition, she markedly improved with appropriate antibiotic
use.
Two days prior to discharge, the patient was on assist
control with a tidal volume of 550, respiratory rate of 15,
with two spontaneous breaths per minute, an FIO2 of 50%, and
a positive end-expiratory pressure of 8. Her oxygen
saturations were in the mid 90s, and her arterial blood gas
levels were appropriate.
2. PNEUMONIA ISSUES: Originally, the patient was kept on
her original antibiotics including linezolid and
levofloxacin. Subsequently, sputum cultures grew out
Klebsiella and Serratia which were sensitive to ceftriaxone.
Levaquin was continued for double coverage of Serratia. A
10-day course of these antibiotics is anticipated with the
date of completion for both the clindamycin and ceftriaxone
being on [**2-25**]. The patient was continued on
linezolid, and blood cultures were taken which were negative.
Given the fact that we had a source of Serratia and
Klebsiella in the sputum with no evidence of positive blood
cultures, linezolid was discontinued. The antibiotics that
the organisms were sensitive were started.
3. HYPOTENSION/SHOCK ISSUES: Initially, the patient came
to us with a low blood pressure with required a Levophed drip
to be maintained. She remained on the Levophed drip for
approximately four days into her admission. Different
pressors including dobutamine and dopamine were used, but
discontinued due to side effects of tachypnea, tachycardia,
and vasodilation.
An echocardiogram was performed which showed an ejection
fraction of 25% to 30% with 3+ mitral regurgitation and 2+
tricuspid regurgitation.
The source of her hypotension was thought to be two-fold; one
cardiogenic and the second reason was thought to be related
to septicemia. With treatment of her pneumonia with
antibiotics as well as initiation of digoxin, she has been
able to maintain her blood pressures adequately without the
need for pressors. At the time of discharge, she had been
off any pressors or drips for greater than four days.
4. ADRENAL INSUFFICIENCY ISSUES: The patient came to us on
prednisone. A cortical stimulation test was performed which
was difficult to interpret due to her baseline levels of
prednisone. It was decided to start her on stress doses of
steroids for seven days. She received fludrocortisone by
mouth and hydrocortisone intravenously, which was
discontinued on the day prior to discharge.
5. DIABETES ISSUES: Fingerstick blood glucose goals for
this patient was 110. Initially, she was written for a
sliding-scale; however, it was thought that with stress-dose
steroids this increased her glucose and was difficult to
maintain just on a sliding-scale. Therefore, an insulin drip
was started which will be discontinued following the
completion of her stress-dose steroids.
6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient came
to us with a percutaneous endoscopic gastrostomy tube and
received tube feeds per Nutrition consultation. She had her
electrolytes repleted as needed.
7. SEDATION ISSUES: The patient remained on a Versed drip
and Fentanyl drip during her time here, which were weaned
approximately 20% per day toward her discharge. She was
given Haldol as needed to aid with the sedation weaning. At
times the patient was very agitated during examination but
was able to be calmed with verbal preparation.
8. PROPHYLAXIS ISSUES: The patient was maintained on
subcutaneous heparin three times per day, pneumatic boots,
and a proton pump inhibitor.
9. CONSENT AND COMMUNICATION: Consent and communication
for the patient's care was obtained through her sister
[**Female First Name (un) 123**]. [**Female First Name (un) 123**] can be reached at telephone number
[**Telephone/Fax (1) 52352**].
10. CODE STATUS ISSUES: The patient's code status is do not
resuscitate.
NOTE: The remainder of this dictation will be completed at a
future date.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 37631**]
MEDQUIST36
D: [**2147-2-18**] 08:21
T: [**2147-2-18**] 08:24
JOB#: [**Job Number 52353**]
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4232
} | Medical Text: Admission Date: [**2100-10-22**] Discharge Date: [**2100-10-27**]
Date of Birth: [**2038-4-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Poor wound healing
Major Surgical or Invasive Procedure:
[**2100-10-25**] Sternal Debridement with Placement of VAC Dressing
History of Present Illness:
This is a 62 year old female with coronary artery disease s/p
coronary artery bypass graft x 4 on [**2100-9-24**]. Post-op course was
eventful for atrial fibrillation and was discharged on post-op
day 5. She returned on [**10-11**] for post-op visit with superficial
sternal wound (per note, 4-5cm in length and 0.5-1cm in depth).
Keflex was started and wound was debrided. She has been packing
it with wet to dry dressing changes [**Hospital1 **]. Starting 3 days ago she
stared using peroxide instead of saline though. She is being
admitted today for IV antibiotics and more definitive wound
care.
Past Medical History:
History of NSTEMI [**2090**] (PCI of LAD and RCA)
Hypertension
Hyperlipidemia
Obesity
Type II Diabetes
mild PVD
GERD
insomnia
History of left parietal CVA [**2091-11-17**]
depression
moderate arthritis
restless leg syndrome
s/p cholecystectomy
s/p bladder extension
Social History:
Lives with: husband and son
Occupation: retired (worked in quality control of books)
Tobacco: none
ETOH: none
Family History:
Non-contributory
Physical Exam:
General: NAD, overweight female
Skin: Dry [x] intact [x]
HEENT: PERRLA [X] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] - decreased at bases
Inferior pole to mid-incision, about 5 cm area, tract
superiorly,
1.0 cm deep with areas deeper while assessing with q-tip,
Heart: RRR [x] Irregular [] murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x] obese
Extremities: Warm [x], well-perfused [x] LLE wound healed
Edema 1+ edema bilateral
Varicosities: None [] small spider veins
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: no bruits
Pertinent Results:
[**2100-10-22**] 06:00PM BLOOD WBC-7.1 RBC-4.32# Hgb-12.3# Hct-36.1#
MCV-84 MCH-28.5 MCHC-34.2 RDW-14.6 Plt Ct-296
[**2100-10-25**] 03:51PM BLOOD WBC-7.5 RBC-3.95* Hgb-10.9* Hct-33.1*
MCV-84 MCH-27.5 MCHC-32.9 RDW-14.7 Plt Ct-380
[**2100-10-26**] 02:24AM BLOOD WBC-7.2 RBC-3.67* Hgb-10.3* Hct-30.6*
MCV-83 MCH-28.2 MCHC-33.9 RDW-14.6 Plt Ct-309
[**2100-10-27**] 04:18AM BLOOD WBC-5.8 RBC-3.64* Hgb-10.2* Hct-30.9*
MCV-85 MCH-28.0 MCHC-33.1 RDW-14.6 Plt Ct-249
[**2100-10-22**] 06:00PM BLOOD Glucose-222* UreaN-17 Creat-0.9 Na-135
K-4.6 Cl-97 HCO3-25 AnGap-18
[**2100-10-25**] 08:57AM BLOOD Glucose-107* UreaN-32* Creat-2.0*# Na-136
K-4.6 Cl-98 HCO3-27 AnGap-16
[**2100-10-26**] 02:24AM BLOOD Glucose-57* UreaN-29* Creat-1.8* Na-136
K-4.4 Cl-104 HCO3-25 AnGap-11
[**2100-10-27**] 04:18AM BLOOD Glucose-117* UreaN-28* Creat-1.7* Na-132*
K-4.9 Cl-102 HCO3-24 AnGap-11
[**2100-10-22**] 06:00PM BLOOD %HbA1c-7.6* eAG-171*
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted with superficial sternal wound
infection/dehiscence. Cultures were taken and empiric
intravenous antibiotics were initiated. Her creatinine increased
to 2.0 and her ACE inhibitors, Lasix, and metformin were
stopped. On [**10-25**], she was brought to the operating room.
Dr. [**Last Name (STitle) **] performed superficial wound debridement and placement of
a VAC dressing. She remained on intravenous antibiotics until
wound cultures were finalized. Wound cultures showed only sparse
growth of Serratia and only rare growth of Klebsiella with
sensitivities to Ciprofloxacin. At discharge, she was
transitioned to PO Ciprofloxacin and VAC dressing was continued.
Her creatinine was trending downward and on the day of
discharge, it was 1.7. She be monitored closely by VNA services
who will draw weekly CBC and chem 7, in addition to change VAC
every three days. She is scheduled to follow up with Dr. [**First Name (STitle) **]
on [**11-8**].
Medications on Admission:
AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 1
Tablet(s) by mouth once a day
CEPHALEXIN - (Prescribed by Other Provider) - 500 mg Capsule -
1
Capsule(s) by mouth four times a day
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth twice a day
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Solution - 80 units daily AM
LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1
(One) Tablet(s) by mouth once a day
METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet -
1
(One) Tablet(s) by mouth twice a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth three times a day
OXYBUTYNIN CHLORIDE - (Prescribed by Other Provider) - 10 mg
Tablet Extended Rel 24 hr - 1 (One) Tablet(s) by mouth once a
day
PAROXETINE HCL - (Prescribed by Other Provider) - 20 mg Tablet
-
1 (One) Tablet(s) by mouth once a day
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq
Tab
Sust.Rel. Particle/Crystal - 1 Tab(s) by mouth every twelve (12)
hours
PRAMIPEXOLE - (Prescribed by Other Provider) - 0.25 mg Tablet -
1 (One) Tablet(s) by mouth twice a day
PRASUGREL [EFFIENT] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 (One) Tablet(s) by mouth once day
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth once day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 (One) Tablet(s) by mouth once a day
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg
iron) Tablet - 1 (One) Tablet(s) by mouth once a day
GLUCOSAMINE HCL - (Prescribed by Other Provider) - Dosage
uncertain
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by
Other Provider) - Tablet - 1 (One) Tablet(s) by mouth once a
day
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - (OTC) - 20 mg Tablet,
Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day
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. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO bid ().
Disp:*60 Tablet(s)* Refills:*2*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO once a day
for 6 weeks.
Disp:*84 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company **]
Discharge Diagnosis:
Superficial Sternal Wound Dehiscence
Coronary artery disease, s/p CABG on [**2100-9-24**]
Obesity
Type II Diabetes Mellitus
Hypertension
Peripheral Vascular Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - VAC dressing in place
Discharge Instructions:
**VNA to draw weekly CBC with diff, and chem 7 weekly while on
antibiotic therapy - fax results to [**Telephone/Fax (1) 5793**]**
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:
Surgeon: Dr. [**First Name (STitle) **] [**2100-11-8**] @ 1PM.
Please call to schedule appointments with your
Cardiologist: Dr. [**Last Name (STitle) 11493**] in [**3-22**] weeks
Primary Care Dr. [**Last Name (STitle) 19219**] in [**3-22**] 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**
**VNA to draw weekly CBC with diff, and chem 7 weekly while on
antibiotic therapy - fax results to [**Telephone/Fax (1) 5793**]**
Completed by:[**2100-10-27**]
ICD9 Codes: 412, 4019, 2724, 311, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4233
} | Medical Text: Admission Date: [**2184-1-11**] Discharge Date: [**2184-1-19**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
admission prior to percutaneous AVR
Major Surgical or Invasive Procedure:
[**2184-1-13**]
1. Percutaneous aortic valve replacement with a 29-mm
[**Company 1543**] CoreValve device, model number MCS-P3-943,
serial number [**Serial Number 87703**].
2. Balloon aortic valvuloplasty.
3. Ascending aortography.
History of Present Illness:
[**Age over 90 **]M with critical AS s/p balloon valvuloplasty [**4-29**], NYHA stage
IV diastolic CHF, CAD s/p CABG [**2167**], tachy-brady s/p PPM [**4-28**],
and CKD stage III (baseline Cr 2.2) admitted electively prior to
percutaneous AVR scheduled for Tues [**1-13**]. He has been having
progressive dyspnea on exertion and can only walk a few steps
before having to rest. He has no anginal symptoms. He has had
worsening leg edema, orthopnea (sleeps in recliner), cough
productive of clear sputum. No PND, fevers, chills, weight loss,
fatigue, poor appetite, palpitations. He reports that his
symptoms are currently "much worse" than before his
valvuloplasty in [**2181**].
.
On arrival to the floor, patient is resting comfortably, no SOB,
does have CP in L sternum from a fall in the bathroom earlier
this week (reproducible, not worse with inspiration, currently
[**12-1**] and improved from initial trauma).
.
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. Cardiac review of systems is notable for
absence of chest pain, paroxysmal nocturnal dyspnea, syncope or
presyncope.
Past Medical History:
Critical AS s/p balloon valvuloplasty [**4-29**]
NYHA stage IV diastolic CHF
CAD s/p CABG [**2167**] (LIMA-D1, SVG-OM1, SVG-RPDA, SVG-1st RPL)
Tachy-brady s/p PPM [**4-28**]
CKD stage III (baseline Cr 2.2)
HTN
Pulmonary hypertension
Benign prostatic hypertrophy
Hypertension
GERD
History of remote GI bleed
Chronic back pain
Spinal fusion
Appendectomy
Social History:
Former pipe smoker. Quit 20 years ago. No alcohol use.
Family History:
There was no family history of premature coronary artery
disease.
Physical Exam:
ADMISSION PHYSICAL:
PHYSICAL EXAMINATION:
VS: Tm 98, 133/69, 73, 18, 100% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP at angle of jaw, 1x1cm mobile non-tender
lymph node in L anterior cervical chain; carotid bruits b/l
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, muted S2. III/VI systolic murmur peaking
early, at RUSB, radiating to carotids.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Rales [**11-24**] lower lung
fields b/l, poor inspiratory effort
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ pitting edema to knees b/l
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:
[**2184-1-14**] Echo:
Conclusions
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. An aortic
CoreValve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet motion and
transvalvular gradients. Mild to moderate ([**11-23**]+) aortic
regurgitation is seen with an anterior perivalvular leak and
minimal posterior jet of aortic regurgitation. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Well seated aortic CoreValve prosthesis with normal
gradient. Mild-moderate perivalvular aortic regurgitation. Mild
symmetric left ventricular hypertrophy with preserved global
biventricular systolic function. Dilated ascending aorta.
CLINICAL IMPLICATIONS:
Based on [**2179**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2184-1-14**] 18:04
[**2184-1-19**] 05:50AM BLOOD WBC-6.5 RBC-2.76* Hgb-8.5* Hct-25.1*
MCV-91 MCH-30.6 MCHC-33.6 RDW-13.5 Plt Ct-183
[**2184-1-19**] 05:50AM BLOOD UreaN-32* Creat-1.7* Na-132* K-4.2 Cl-102
[**2184-1-18**] 06:30AM BLOOD UreaN-31* Creat-1.6* Na-134 K-4.1 Cl-103
[**2184-1-17**] 03:55AM BLOOD Glucose-94 UreaN-31* Creat-1.6* Na-133
K-4.0 Cl-103 HCO3-24 AnGap-10
Brief Hospital Course:
HOSPITAL COURSE:
[**Age over 90 **]M with critical AS s/p balloon valvuloplasty [**4-29**], NYHA stage
IV diastolic CHF, CAD s/p CABG [**2167**], tachy-brady s/p PPM [**4-28**],
and CKD stage III (baseline Cr 2.2) admitted electively prior to
percutaneous AVR scheduled for Tues [**1-13**].
.
ACTIVE ISSUES:
# Aortic stenosis: Critical AS s/p balloon valvuloplasty [**4-29**],
NYHA stage IV diastolic CHF. Symptoms progressing since
valvuloplasty now with severe limitation of function. Poor
surgical candidate given age and prior CABG. Pt admitted for
percutaneous AVR. Pt diuresed gently with lasix given preload
dependence. Csurg was consulted and pre-op workup with panorex,
UA/UCx, etc was completed. On hospital day 2, pt had flash
pulmonary edema as lasix was held in the am. He was transferred
to the CCU after morphine, lasix bolus, and on a non-rebreather.
He was given diuril and lasix gtt, and produced good UOP. He was
transitioned from CPAP to high-flow neb, and able to tolerate.
On hospital day 3, he was taken for core valve.
.
# CAD: s/p CABG in [**2167**], has stable coronary artery and graft
disease on cath in [**10-30**] (prox Cx 100% stenosis, prox RCA 100%
stenosis, all grafts widely patent. LIMA to first Diagonal, SVG
to OM, SVG to first RPL, SVG to RPDA). Pt's EKG's were
unchanged, and pt had no chest pain during the admission. He was
continued on ASA 81mg.
.
# Acute on chronic left ventricular diastolic dysfunction due to
aortic stenosis: Last EF 55-60% ([**2182**]). Pt is currently in stage
IV diastolic CHF with severe limitation of function. Pt
presented with fluid overload on exam and by CXR. He was given
cautious diuresis initially. However, as above, pt had flash
pulmonary edema, and required transfer to CCU overnight for
brief use of CPAP, and diuresis with lasix and diuril.
He was maintained on a fluid restricted, low sodium diet.
.
# Tachy-brady s/p PPM [**4-28**]: EP evaluation and interrogation of
ICD/PPM to determnine whether it needs to be suppressed during
the valve procedure, which will involve rapid right ventricular
pacing (up to 200 bpm) during balloon valvuloplasty and 110 BPM
during valve placement. EP interrogated pacer and followed
throughout hospital course.
.
# Stage III CKD: Baseline Cr 2.2. His Cr was monitored, and was
2.1 prior to core valve replacement.
.
# HTN: Well-controlled on admission, with brief hypertension in
setting of flash pulmonary edema. He was diuresed as above.
.
INACTIVE ISSUES:
# GERD: Continued on omeprazole.
.
# BPH: Continued doxazosin.
.
Brief CCU course: Patient was transferred to the CCU on a
non-rebreather in severe respiratory distress and impending
respiratory failure secondary to flash pulmonary edema,
confirmed by chest xray imaging. He was started on Bipap with
improvement in his oxygenation and ventilation. His foley
catheter became displaced during transfer necessitating removal
and replacement with coude catheter with subsequent mild
hematuria. The patient was diuresed with diuril and a lasix gtt
once his catheter was in proper postion. He diuresed well, and
was weaned off Bipap within 3 hours to 50% face mask. The next
morning he was taken to the OR for his valve procedure.
.
The patient was brought to the Hybrid room on [**2184-1-13**] where the
patient underwent 1. Percutaneous aortic valve replacement with
a 29-mm
[**Company 1543**] CoreValve device, model number MCS-P3-943,
serial number [**Serial Number 87703**].
2. Balloon aortic valvuloplasty.
3. Ascending aortography.
with Drs. [**Last Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 914**].
Overall the patient tolerated the procedure well and
post-procedurally was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
post-procedure day 1 found the patient extubated, alert and
oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. EP interrogated the PPM.
Beta blocker was initiated and the patient was gently diuresed
toward the pre-procedure weight. The patient was transferred
to the telemetry floor for further recovery. He did develop
hematuria and urology was consulted. Continuous bladder
irrigation was initiated. He failed a void trial and he will be
discharged home with a Foley Catheter. He is to follow-up with
his local urologist within 5 days of discharge. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. The patient remained on the Core Valve
pathway and had an echo and neuro evaluation prior to discharge.
By the time of discharge on post-procedure day 6, the patient
was ambulating freely, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged
home in good condition with appropriate follow up instructions.
He will follow-up locally, in [**State 3914**].
Medications on Admission:
Furosemide 40 mgs twice daily.
Glucosamine sulfate 500 mgs daily.
Aspirin 81 mgs once daily.
Omeprazole (Prilosec) 20 mgs once daily.
Doxazosin (Cardura) 2 mgs once daily.
Salsalate 750 mgs three times daily.
Calcium-vitamin D (Oscal D) 500 mgs twice daily.
Nitroglycerin patches (nitroglyn) 2% ointment. Place 0.5 inches
onto the skin 3 times daily.
Psyllium 5.8 g (Metamucil), 1 packet twice daily
Polycarbophil (Fibercon) 625 mgs at bedtime
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*0*
6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
Disp:*60 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 87704**] Home Health & Hospice
Discharge Diagnosis:
Stage 3 CKD,CAD,AS/AI,Pulm
HTN,PPM,HTN,BPH<GERD
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Groin puncture site- healing well without erythema or drainage
Discharge Instructions:
see attached discharge instructions for Transcatheter Aortic
Valve Implation
Followup Instructions:
Urologist- Dr. [**First Name8 (NamePattern2) 5036**] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 87705**], Tuesday, [**2184-1-27**]
11:15am
Follow up with your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 87706**] within
2 weeks
Completed by:[**2184-1-19**]
ICD9 Codes: 4241, 2761, 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4234
} | Medical Text: Admission Date: [**2125-9-14**] Discharge Date: [**2125-11-10**]
Date of Birth: [**2125-9-14**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] is a 2,020 gm
product of a 32 [**5-28**] week gestation, estimated date of
confinement [**2125-11-3**], born to a 30 year old gravida
1, para 0 mom with prenatal screens, blood type A positive,
antibody negative, RPR nonreactive, Rubella immune, hepatitis
B surface antigen negative, Group B Streptococcus status
unknown.
Pregnancy complicated by unstoppable preterm labor.
This infant was born by cesarean section for decelerations
and nonreassuring fetal heart tracing. He had Apgar scores
of 8 at one minute and 9 at five minutes of age. He was
transported to the Newborn Intensive Care Unit for management
of prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2,020 gm, 75th
percentile. Head circumference 31.5 cm, 75th percentile.
Length 45 cm, 75th percentile. Temperature 99, heart rate
169, respiratory rate 54, blood pressure 42/35 with a mean
arterial pressure of 40. Blood glucose is 49. Head, eyes,
ears, nose and throat, normocephalic infant, atraumatic.
Anterior fontanelle open and flat, red reflex present
bilaterally. Lips, gums and palate intact. Neck supple.
Lungs, clear breath sounds bilaterally. Positive grunting
and intercostal retractions. Cardiovascular, heart, regular
rate and rhythm, no murmur. Femoral pulses 2 plus
bilaterally. Abdomen soft with active bowel sounds, no
masses or distention. Genitourinary, normal premature male,
testes palpable bilaterally. Anus patent. Spine midline.
Hips stable. Clavicles intact. Normal neurological
examination with normal tone for gestational age.
HOSPITAL COURSE: Respiratory - The infant was placed on CPAP
for grunting, flaring and retracting shortly after admission
to the Newborn Intensive Care Unit. Caffeine citrate was
started on day of life number 1 for periodic breathing.
Caffeine was discontinued on day of life Number 18 at a
corrected age of 35 3/7 weeks. Periodic breathing with
bradycardia and desaturations persisted through a corrected
age of 40 weeks. A pneumogram at the corrected age of 40
weeks showed frequent drops in saturation to 65 to 85 percent
in conjunction with periodic breathing and short episodes of
central apnea and frequent bradycardia to 56 to 70
beats/minute. No acid reflux noted on pneumogram. At this
time, caffeine citrate was restarted and arrangements made
for discharge to home on a cardiorespiratory monitor.
Cardiovascular - [**Known lastname 40920**] blood pressure has been stable
throughout his hospitalization. A murmur was auscultated on
day of life Number 1 and an echocardiogram on day of life
Number 2 showed a patent foramen ovale and small muscular
ventriculoseptal defect. No evidence of compromise.
Cardiology, Dr. [**Last Name (STitle) 57100**], to follow up in two to four months.
Fluids, electrolytes and nutrition - [**Known lastname 2795**] was started on
intravenous fluids of D10/W at 80 cc/kg upon admission to the
Newborn Intensive Care Unit. Enteral feeds were started on
day of life Number 4. Feeding progression was halted on day
of life Number 6 with onset of increased cells, abdominal
distention, bilious aspirates and guaiac positive stools. A
blood culture at this time was positive for Escherichia coli,
see infectious disease section. Enteral feeds were restarted
on day of life Number 10 with advancement to 130 cc/kg/day by
day of life Number 13. Caloric density advanced to 24
calories, Special Care formula or breastmilk. Total fluids
increased to 150 cc/kg/day without incident. Formula was
switched to Enfamil AR on day of life Number 34 with concerns
for reflux. Reglan was started on day of life Number 31 for
reflux concerns. Last electrolytes on day of life Number 9
were sodium 137, potassium 4.4, chloride 104, and bicarbonate
of 23. Weight at time of discharge was 3,575 gm. Length was
51 cm. Head circumference was 35.5 cm.
Hematology - Hematocrit on admission to the Newborn Intensive
Care Unit was 51.6. No blood products were given during his
hospitalization. The last hematocrit on [**10-10**] was 31.7.
Infectious disease - Increased spells, increased heme
positive stools and abdominal distention and bilious aspirate
prompted sepsis evaluation of day of life Number 6. A
complete blood count at that time showed a white count of
8,000, hematocrit of 49, platelet count 284 with 71 percent
polys and 2 percent bands. The blood culture drawn at that
time grew out Escherichia coli. The infant had been started on
vancomycin and gentamicin at that time. Antibiotics were
switched to gentamicin and Zosyn on day of life Number 9 and
then to cefotaxime on day of life Number 11. He had a 14 day
course of antibiotics. Cerebrospinal fluid and urine were
negative.
Neurology - No head ultrasound indicated for this 32 [**5-28**]
weeker.
Sensory - A hearing screen was performed with automated
auditory brain stem responses, he passed in the left ear.
The right ear has been referred for re-evaluation.
Ophthalmology, eye examination not indicated for this 32 [**5-28**]
weeker.
Psychosocial - Parents are loving and invested. They have
gone through training for the cardiac minor and caffeine
dosing.
CONDITION ON DISCHARGE: Stable without recent spells on
caffeine citrate.
DISCHARGE DISPOSITION: To home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37243**], [**First Name3 (LF) 392**]. Phone Number
[**Telephone/Fax (1) 57101**].
CARE/RECOMMENDATIONS: Feeds - Ad lib demand feeds of Enfamil
AR.
Medications - Caffeine citrate 23 mg daily and Reglan 0.3 mg
q. 8 hours.
Screenings - The infant passed his carseat position
screening. Last state newborn screen was sent on [**9-28**]
and no abnormal results have been reported.
Immunizations received - The infant received his first
hepatitis B vaccine on [**10-8**]. He will need his two
month immunizations including his second hepatitis B vaccine
at 60 days of age, after that [**11-13**].
Immunizations recommended - Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: Born at less than 32 weeks; Born between 32 and
35 weeks with two of the following, daycare during
respiratory syncytial virus season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; or with chronic lung disease. We are
recommending Synagis immunization for this baby given his
periodic breathing pattern and ventriculoseptal defect
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.
FOLLOW UP: A follow up appointment Dr. [**Last Name (STitle) 57100**], Cardiology at
[**Hospital3 1810**] will be scheduled for two to four months.
DISCHARGE DIAGNOSIS: Prematurity at 32 6/7 weeks.
Respiratory distress.
Escherichia coli sepsis.
Hyperbilirubinemia.
Apnea of prematurity.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2125-11-10**] 07:41:58
T: [**2125-11-10**] 08:14:11
Job#: [**Job Number 57102**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4235
} | Medical Text: Admission Date: [**2160-8-20**] Discharge Date: [**2160-8-29**]
Date of Birth: [**2115-6-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Head Bleed
Major Surgical or Invasive Procedure:
[**2160-8-22**]: Stereotactic ventriculocysterostomy
History of Present Illness:
HPI: 45 yo Male who presented to an OHS [**8-19**] with decreased left
visual fields in both eyes. He denied any headache, difficulty
with speech, nausea or vomiting, or weakness. Diagnosed with
Embolic stroke of PCA. His neurological exam declined overnight,
and a repeat CT Scan 0400 [**8-20**] demonstrated hemorrhagic
conversion of stroke. Transferred to [**Hospital1 18**] for further care.
Given large
doses of Ativan for EtOH withdrawal and intubated en route by
[**Location (un) **].
Past Medical History:
1. Hypertension - not on medications for > 1 year.
2. Dyslipidemia
3. Cocaine abuse
4. EtOH abuse with 6-12 drinks daily
Social History:
Social Hx: Unknown
Family History:
Family Hx: Unknown
Physical Exam:
PHYSICAL EXAM:
O: T: BP: 133/76 HR: 76 R:17 O2Sats:100% intubated
Gen: WD/WN. Intubated
HEENT: Normocephalic, Atraumatic. Pupils: 1-1.5, sluggish. EOMs:
unable to follow commands.
Mental status: Intubated. Opens eyes to noxious stimuli only.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 1 to 1.5
mm bilaterally. Visual fields are full to confrontation.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Moves all extremities spontaneously.
Toes downgoing bilaterally
Exam on Discharge:
AA, Oriented x 3. NAD. PERRLE, EOMI, Incision C/D/I with
sutures. No pronator drift. MAE [**4-22**]. Sensation intact to light
touch.
Pertinent Results:
Labs on Admission:
[**2160-8-20**] 07:08PM BLOOD WBC-5.9 RBC-4.01* Hgb-13.0* Hct-38.9*
MCV-97 MCH-32.3* MCHC-33.3 RDW-13.2 Plt Ct-164
[**2160-8-20**] 07:08PM BLOOD PT-12.6 PTT-21.6* INR(PT)-1.1
[**2160-8-20**] 07:08PM BLOOD Glucose-170* UreaN-6 Creat-0.6 Na-139
K-4.3 Cl-106 HCO3-24 AnGap-13
[**2160-8-20**] 07:08PM BLOOD ALT-340* AST-310* AlkPhos-61 TotBili-0.7
[**2160-8-20**] 07:08PM BLOOD Albumin-3.8 Calcium-8.1* Phos-2.7 Mg-2.1
IMAGING:
-------------------
CTA Head [**8-21**]:
FINDINGS: Initial non-contrast images through the brain
demonstrates a 7 x 4 cm region of heterogeneous intraparenchymal
hemorrhage involving the
paramedian right occipital lobe. There may be some
intraventricular extension of hemorrhage, as well as a small
subdural component tracking along the falx. There is marked
associated mass effect throughout the right hemisphere as well
as dilatation of the right temporal [**Doctor Last Name 534**]. There are
approximately 3-4 mm of leftward shift of midline structures.
There is extensive low attenuation surrounding the hemorrhage.
Following administration of intravenous contrast, the high
cervical internal
carotid arteries are symmetric, though do appear somewhat small
in caliber. There is mild irregularity and calcification within
the carotid segments bilaterally, otherwise, the petrous
segments are normal. There is a small posterior communicating
artery infundibulum on the right side. Within the cavernous
segment of the left internal carotid artery, just beyond the
anterior genu, there is a linear 3 mm posteriorly oriented
outpouching compatible with a small aneurysm. There is a small
left-sided posterior communicating artery infundibulum. The
middle and anterior cerebral arteries are symmetric and patent.
The vertebral arteries are codominant and give rise to a
normal-appearing basilar artery. The posterior cerebral arteries
do appear patent bilaterally. There is pansinus disease with a
hypoplastic right frontal sinus. The ophthalmic arteries are
patent and no intraorbital abnormalities identified. There may
be some blood layering within the posterior thecal sac at the
upper
cervical spine (3:7).
IMPRESSION:
1. Large right occipital lobe intraparenchymal hematoma with
marked
associated mass effect and dilatation of the right temporal
[**Doctor Last Name 534**].
2. Narrow 3-mm aneurysm of the cavernous segment of the left
internal carotid artery.
3. Pansinusitis.
Head CT [**8-21**]:
HEAD CT WITHOUT IV CONTRAST: There is no significant change in
right-sided
intraparenchymal hemorrhage of the right occipital
parietotemporal lobe. There is edema with extensive effacement
of the sulci throughout the entire right hemisphere. There is
mass effect upon the right lateral ventricle, and approximately
3 mm of left shift of midline, which is not changed since the
prior evening. The temporal [**Doctor Last Name 534**] of the right lateral ventricle
is again seen to be dilated. There is no definite change since
the prior evening. Visualized paranasal sinuses and soft tissues
appear unchanged, with sinus mucosal disease, most severe in the
left maxillary sinus.
IMPRESSION:
1. No significant change since the prior evening, with no
evident increase in the size of hemorrhage.
2. Continued severe mass effect upon the right hemisphere, with
extensive
effacement of sulci and compression of the right lateral
ventricle and
dilation of the temporal [**Doctor Last Name 534**].
ECHO [**8-22**]
The left atrium is mildly dilated. A patent foramen ovale is
present. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are mildly thickened (?#). There is no valvular
aortic stenosis. The increased transaortic velocity is likely
related to high cardiac output. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Patent foramen ovale. Normal global and regional
biventricular systolic function.
CT HEAD W/O CONTRAST [**2160-8-22**]
FINDINGS: There is a large right parieto-occipital
intraparenchymal
hemorrhage measuring 6.7 x 3.5 cm with persistent
perihemorrhagic edema and mass effect on the occipital [**Doctor Last Name 534**] of
the right lateral ventricle.
There has been interval decompression of the right temporal [**Doctor Last Name 534**]
due to a
right ventriculostomy with the tip terminating in the
suprasellar cistern.
There is persistent near-complete opacification of the left
maxillary sinus and anterior ethmoid mucosal thickening. There
are no short-term interval changes.
IMPRESSION: Interval placement of a ventriculostomy catheter
with
decompression of the right temporal [**Doctor Last Name 534**]. No other short-term
interval
changes.
SHOULDER RIGHT [**2160-8-25**]
FINDINGS: There is no glenohumeral joint dislocation. There is a
curvilinear density adjacent to the superior posterior lateral
aspect of the right humeral head which may represent a small
fracture fragment from [**Doctor Last Name **]-[**Doctor Last Name 3450**] deformity. AC joint is intact.
If there is high clinical concern for intra-articular
derangement, MRI could be performed when the patient is more
stable.
Brief Hospital Course:
Patient is a 45M who presented to an OSH on [**8-19**] after
complaining of left sided visual difficulty(in both eyes). He
was admitted to an OSH with diagnosis of embolic stroke of the
PCA. In the overnight hours of [**8-20**], he hand an abrupt MS change
and a CT scan was performed, which showed hemorrhagic
conversion. He was subsequently transferred to [**Hospital1 18**] for
definitive care. He was admitted to the neurosurgery service in
the intensive care unit for ongoing monitoring. Additionally,
given his ETOH history, he was administered a "banana" bag and
placed on DT watch. On [**8-22**],he was taken to the OR for
stereotactic 3rd ventriculostomy to release the right temporal
[**Doctor Last Name 534**] which was entrapped. Post-operatively he was returned to
the ICU. He was extubated in the ICU and was doing well. He was
transferred to the step down unit on [**2160-8-23**]. He had an elevated
WBC count of 14.7 but this normalized and no active infection
was detected. He was transferred to the floor on [**8-24**] and he was
received PT and OT. On [**8-25**] he was reaching for an object in his
room and he dislocated his shoulder. This has happened to him in
the past. Orthopedics was consulted and they reduced it at the
bedside. On [**8-26**] he was neurologically intact. He was impulsive
and his gait was worse than the previous day. PT and OT felt
that he would benefit from rehab. He was screened for rehab and
continued to ambulate with assistance while awaiting placement.
The patient continued to have cognitive deficits and required
redirection at times. He was found an appropriate rehab
facility and was discharged on [**2160-8-29**].
Medications on Admission:
NONE
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for muscle spasm.
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Right Occipital IPH
Entrapped Right ventricle
Pansinusitis
Patent Foramen Ovale
Right Shoulder dislocation
Cerebral edema
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
-Please return to the office in [**6-27**] days(from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
ICD9 Codes: 431, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4236
} | Medical Text: Admission Date: [**2161-7-31**] Discharge Date: [**2161-8-19**]
Date of Birth: [**2110-12-9**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 50-year-old man
with past medical history of hypertension only, who was
transferred from an outside hospital for tachypnea, ARF, and
hyponatremia. The patient reported that his symptoms started
with right shoulder pain on [**2161-7-24**]. On [**2161-7-25**] he had
chills, fever, and fatigue. His symptoms then began to
include diarrhea, frequent urination, nausea and vomiting,
and feeling thirsty. He presented to his primary care
physician [**Last Name (NamePattern4) **] [**2161-7-27**] complaining of dry cough, and an
inability to take liquids down. On that day he had a chest
x-ray that showed a right upper lobe infiltrate and a white
count of 24.8. He then presented to an outside hospital on
[**2161-7-28**]. He was treated there with Levaquin,
Zithromax/ceftriaxone and vancomycin. He was febrile to
101.2. His creatinine then went from 1.1 to 3.6 at transfer,
and his sodium went from 133 to 124, and his white count went
from 24.8 to 36 at transfer. He also had increasing
shortness of breath and tachypnea and worsening infiltrate on
chest x-ray. His arterial blood gas on transfer was
7.5/33/65 on three liters nasal cannula. His first arterial
blood gas at the [**Hospital Unit Name 153**] was 7.47/29/56.
REVIEW OF SYSTEMS: He complained of dry cough, thirst, dry
throat, and indigestion relieved with water. He denied
exertional angina, chest pain, or paroxysmal nocturnal
dyspnea. He reported increasing dyspnea over the past two
days. There was no sputum production. He reported dark
stools. He complained of indigestion but denied exertional
angina on arrival.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Status post
appendectomy. 3. Status post vertebral fracture.
MEDICATIONS: 1. Cardizem CD 240 q.d. 2. Norvasc 5 mg q.d.
3. Tigan 300 q.i.d. p.r.n.
ALLERGIES: Iodine and codeine.
SOCIAL HISTORY: The patient is married and lives in [**Location 7661**].
He works at [**Company 39532**]. He does not drink or smoke. He worked
26 years with heavy metals and arsenic and eight years as a
driver for mentally retarded patients. His wife smokes 2??????
packs per day x 20 years. At [**Company 39532**] the patient works in
the freezers.
FAMILY HISTORY: Myocardial infarction in brother in his 40s,
colon cancer in uncle.
LABORATORY DATA: His laboratory studies were significant for
a white count of 31.3, hematocrit 38.8, sodium 124,
creatinine 2.4. The patient's baseline creatinine was 1 to
1.1.
PHYSICAL EXAMINATION: Temperature 101.2, heart rate 116,
saturating 95% on five liters nasal cannula, respiratory rate
34-40, blood pressure 140/70. The patient had increasing
respiratory effort but was able to talk in full sentences.
His pupils were icteric, extraocular movements intact,
conjunctival edema, alert and oriented x 3. Cranial nerves
II-XII were intact. There was increasing jugular venous
pressure. Neck was supple. Skin was warm. The right upper
half of his lungs had decreased breath sounds and bronchial
breath sounds at the apex with E to A changes. Decreased
breath sounds were heard bilaterally at the bases. The heart
was regular rate and rhythm, S1 and S2, and tachycardic. No
murmurs, rubs or gallops were noted. There was no cyanosis,
clubbing, or edema. Abdomen was obese, distended, soft, no
[**Doctor Last Name **] sign, no fluid wave or shifting dullness.
LABORATORY DATA: Chest x-ray showed multifocal pneumonia
with a right upper lobe opacification, a small right
effusion, and a small left effusion.
Other significant laboratory studies included an albumin of
2.2. An EKG showed sinus tachycardia at 116 with a left
axis, normal intervals and peaked T waves in V2 to V5.
ICU COURSE: 1. Respiratory failure: The patient was
intubated in the ICU on [**2161-8-1**] after an arterial blood gas
revealed 7.5/33/65 on three liters nasal cannula. He was
intubated for hypoxemia. The patient remained intubated
until [**2161-8-11**] when he was extubated. On transfer to the
medicine floor he was saturating 98% on two to three liters
nasal cannula.
2. Pneumonia: Chest CT on [**2161-8-4**] showed multifocal
pneumonia, most severe in the right upper lobe with extensive
necrosis, positive air-fluid levels, evolving lung abscess
which involves other lobes bilaterally in the lungs with
small right pleural effusion. The patient was initially
treated with Zosyn and Levaquin but due to a drug reaction,
the Zosyn was discontinued on [**2161-8-9**] secondary to a rash.
His antibiotics were changed to Levaquin and clindamycin.
The patient was also intermittently treated with vancomycin.
On transfer to the floor he was on Levaquin and clindamycin
IV. A BAL on [**2161-8-4**] showed 4+ PMNs, sparse yeast, and
rhinovirus. A Legionella urinary antigen was negative. A
BAL from [**2161-8-1**] was the same. All blood cultures grew
nothing. The effusions were never tapped while the patient
was in the ICU.
3. Acute renal failure: On admission the patient's
creatinine was 3.6. His creatinine rose to 7.6 on [**2161-8-3**]
and the patient required hemodialysis via Quinton catheter.
He received hemodialysis on [**2161-8-4**], [**2161-8-5**], [**2161-8-7**],
[**2161-8-8**], and [**2161-8-10**]. After his last dialysis, his
creatinine was increased to 8.6 from 7.4. On the day before
transfer out of the ICU the patient began having increasing
urine output of more than two liters a day, presumed to be
post ATN diuresis. A renal biopsy during the ICU stay was
consistent with acute interstitial nephritis, presumed to be
caused by Zosyn or erythromycin, which the patient was receiving
for bowel motility. On [**2161-8-4**] his peripheral eosinophils were
only 3%. The renal team followed the patient during his entire
hospital stay and the patient was receiving Solu-Medrol IV
for the AIN ( interstitial nephritis) when he left the ICU.
4. Hyponatremia: The patient's sodium was 130 on the day of
admission. It dropped to 118 on the same day and remained in
the low 120s. Serum osmolality was 261 and urine osmolality
was 238. Hemodialysis corrected his hyponatremia and on
transfer to the floor his sodium was 135 and stable.
5. Anemia: The patient's hematocrit on admission was 36.6.
It dropped steadily over his ICU course. Stools were guaiac
negative. Hemolysis laboratory studies were negative with a
reticulocyte count of 1%. His anemia was thought to be
secondary to sepsis or renal failure. The patient required
transfusion of two units on [**2161-8-5**], and again one further
unit on [**2161-8-12**] with appropriate bumps in his hematocrit.
Renal team started Epogen TIW.
6. Rash: The patient developed a drug rash beginning on
[**2161-8-8**], morbilliform and erythematous. It was thought to
be associated with antibiotics. His erythromycin was
discontinued and then the Zosyn was also discontinued.
Dermatology was consulted and they felt the rash was a drug
reaction/hypersensitivity, likely due to Zosyn, and the rash
improved with Benadryl and Sarna.
HOSPITAL COURSE POST TRANSFER OUT OF ICU: 1. Pneumonia:
The patient was continued on IV clindamycin and IV Levaquin
until transfer out of the ICU. His Levaquin was then
switched to p.o. and his clindamycin was kept as IV. ID
signed off but suggested the patient required likely a six-
to eight-week course with serial CT scans of the chest to
determine actual length of course. The patient was slowly
weaned off his oxygen over the course of his stay, and on
discharge was on no oxygen, was saturating between 95 and 97%
on room air, and could walk comfortably without desaturating.
A chest CT on [**2161-8-15**] showed continued right lung
consolidation mostly in the upper lobe which was slightly
better with cavitation and abscess, also some congestive
heart failure and volume overload, and moderate-sized
bilateral effusions which were slightly bigger than
previously, and the CT was felt to be consistent with
pneumococcal pneumonia or Legionella pneumonia. Chest x-ray
at discharge showed improving pulmonary edema, persistent
opacification of the right upper lobe, not significantly
changed, small left pleural effusion. On transfer the
patient will require at least six weeks of antibiotics. He
will have a chest CT to follow up in three weeks after
discharge, and then see the ID doctor in four weeks to
further determine his course of antibiotics.
2. Acute renal failure: As mentioned earlier, the patient
had acute interstitial nephritis by biopsy, but also was
thought to have acute tubular necrosis and continued to have
a post-ATN diuresis during the rest of his hospital course
with his creatinine slowly decreasing each day with three to
four liters of urine output each day, clear, yellow. The
patient's Foley catheter was discontinued and his creatinine
on discharge was 2.0. He never required further hemodialysis
after [**2161-8-10**]. His medications were renally dosed. He
continued on IV Solu-Medrol until [**2161-8-17**] when his
Solu-Medrol was changed to 40 mg oral prednisone. He will
continue to take 40 mg of oral prednisone for at least two
weeks and then scheduled to follow up with the renal fellow
who will determine his course of antibiotics and taper. He
also should require laboratory studies every other day to
monitor his renal function, specifically BUN and creatinine
as well as electrolytes. On balance think most of this is ATN
rather than AIN.
3. Anemia: Prior to transfer to the floor the patient's
hematocrit dropped to 23.2. His anemia was thought to be
from sepsis and acute renal failure. He received one unit of
packed red blood cells which appropriately bumped his
hematocrit to 28 and he never required further transfusions.
His hematocrit hovered around 30 for the rest of his hospital
course. He was continued on Epogen until the renal team
discontinued it two days prior to discharge. The patient
received one further dose of Epogen prior to discharge. His
hematocrit is stable and will need to be checked every other
day when he goes to rehabilitation.
4. Hyponatremia: The patient's hyponatremia resolved after
his initial course, and his sodium remained stable.
5. Rash: The patient's rash slowly resolved over the rest of
his hospital stay. He was treated only with Benadryl and
Sarna, and it was thought to be related to the allergy to
Zosyn.
6. Nutrition: The patient received tube feeds in the [**Hospital Unit Name 153**].
He had a swallowing study on transfer to the floor which
showed that he only aspirated thin liquids, but his mental
status was markedly decreased during the study due to
narcotics. The patient slowly advanced his diet to a regular
renal diet with Boost supplementation. On discharge he was
tolerating this well.
7. Infectious disease: The patient's white count was stable
throughout the rest of his hospital course until two days
before discharge. He was afebrile the entire time. Blood
cultures, urine cultures, sputum cultures were all sent, as
well as several C. difficiles which were all negative. The
patient's white count was stable at 19 on discharge, and he
was feeling quite well. The increased white count also
corresponded with change of his steroids from Solu-Medrol to
prednisone. The patient's clindamycin and Levaquin were
continued. His white count should be checked approximately
every other day on discharge to rehabilitation in order for
us to observe if it is rising and if he needs further work-up
of his infection if it exists.
On discharge to rehabilitation the patient felt very well.
He was able to walk 150 feet with just a little bit of
support. He was on room air and was eating a regular diet.
FOLLOW-UP PLANS: He will follow up in three weeks with chest
CT followed by an appointment with the ID fellow in four
weeks. He will also follow up with the renal fellow, Dr.
[**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**], in two weeks, as well as with his primary care
physician.
DISCHARGE MEDICATIONS:
1. Diltiazem extended release 240 q.d.
2. Levaquin 500 mg p.o. q.d.
3. Amlodipine 5 mg p.o. q.d.
4. Prednisone 40 mg p.o. q.d.
5. Folate 1 mg p.o. q.d.
6. Pantoprazole 40 mg p.o. q.d.
7. Clindamycin 600 mg p.o. t.i.d.
8. Nystatin oral suspension 5 mL p.o. q.i.d. swish and
swallow for thrush.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Last Name (NamePattern1) 8141**]
MEDQUIST36
D: [**2161-8-19**] 11:34
T: [**2161-8-19**] 11:52
JOB#: [**Job Number 51920**]
ICD9 Codes: 486, 5845, 2761, 0389, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4237
} | Medical Text: Admission Date: [**2181-10-17**] Discharge Date: [**2181-11-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Respiratory arrest
Major Surgical or Invasive Procedure:
Intubation (in the field prior to admission)
PICC line placement [**10-22**]
History of Present Illness:
[**Age over 90 **]F vasculopathic female with h/o dementia, non-verbal at
baseline, DM2, PVD s/p bilateral AKAs, who presented from her NH
on [**10-17**] after being found in respiratory distress. She was noted
to have a fever to 102 (axillary) and O2 sat to 82%RA. EMS was
called. En route she was noted to have a sat of 80% on NRB. By
report, tube feeds were suctioned from her airway. She was
confirmed full code and pt was intubated. In the ED, she had a
low-grade temp of 99.4 (temporal), hemodynamically stable,
intubated, ABG noted to be 7.39/33/412. On exam she had equal
and reactive pupils and bilateral breath sounds. Stat labs were
significant for anemia to 26, renal failure with Cr 1.7, and
lactate of 4.5. Tox screen positive for barbiturates, c/w pt's
home med regimen. CXR revealed no obvious infiltrate. EKG showed
NSR, with 1mm ST elevations in V2-V4. Blood cultures were drawn
and patient was given vanc/levo/clinda for presumptive
HC-associated aspiration PNA. She was then admitted to the ICU.
.
MICU course:
-BP was initially low on arrival to the ICU (92/40) with poor
UOP but quickly came up with fluid boluses, with SBP mainly in
the 150-180s for the past 3 days. BP meds have been uptitrated.
-She was covered initially with vanco/zosyn empirically for
HCAP. She was pan-cultured and sputum cx revealed MSSA.
Extubated on [**10-19**].
-There was initial concern for possible ACS as the cause of her
respiratory distress given slight ST elevations in precordial
leads V2-4, and initial trop elevation to 0.39. Trop has trended
down to 0.30 and CK peaked at 364.
-Creatinine has been stable 1.7-2.0, unknown baseline.
-Developed transaminitis--> seen by hepatology who felt most
likely etiology to be ischemic, recommended discontinuing hydral
(as can be hepatotoxic) and maintaining MAP at 90+ for adequate
hepatic perfusion.
.
Her mental status is now felt to be at baseline, which is
non-responsive. She is satting well on 2L nasal cannula. She is
being called out to the floor.
Past Medical History:
# peripheral vascular disease status post AKA bilaterally
# diabetes mellitus type 2
# hypertension
# dementia
# seizure disorder
# right DVT in [**2173-8-10**]
# Anemia
# s/p G-tube
Social History:
The patient is a resident at [**Hospital3 2558**]. At baseline, she
has dementia and is nonverbal. She is dependent on all ADLs.
Mobility is limited to a recliner with assistence. There is no
history of smoking or tobacco.
Family History:
NC
Physical Exam:
VS: 98.0 77 92/40 14 100%
Gen: intubated and sedated elderly AA female
HEENT: OP clear, adentulous, MM slightly dry, surgical pupils
PERRL
Neck: No JVD, no LAD
Cor: RRR no m/r/g
Pulm: CTAB
Abd: obese, soft, NTND, G tube site+BS,
Extrem: bilateral AKAs, stump sites appear normal without e/o
erythema or inflammation
Skin: no rashes noted
Neuro: sedated, does not follow commands. Dolls eye intact.
Pertinent Results:
=======
Labs
=======
[**2181-10-31**] 07:10AM BLOOD WBC-10.9 RBC-3.04* Hgb-8.6* Hct-24.7*
MCV-81* MCH-28.4 MCHC-34.8 RDW-18.2* Plt Ct-369
[**2181-10-30**] 07:00AM BLOOD WBC-10.5 RBC-2.98* Hgb-8.6* Hct-24.3*
MCV-82 MCH-28.9 MCHC-35.4* RDW-18.0* Plt Ct-317
[**2181-10-28**] 05:52AM BLOOD WBC-11.9* RBC-3.40* Hgb-10.0* Hct-27.9*
MCV-82 MCH-29.3 MCHC-35.8* RDW-18.0* Plt Ct-290
[**2181-10-27**] 06:10AM BLOOD WBC-11.9* RBC-2.92* Hgb-8.4* Hct-23.8*
MCV-81* MCH-28.8 MCHC-35.5* RDW-18.0* Plt Ct-268
[**2181-10-26**] 04:59AM BLOOD WBC-13.8* RBC-3.27* Hgb-9.2* Hct-27.0*
MCV-83 MCH-28.2 MCHC-34.2 RDW-16.8* Plt Ct-253
[**2181-10-25**] 05:29AM BLOOD WBC-13.1* RBC-3.40* Hgb-9.5* Hct-28.2*
MCV-83 MCH-27.8 MCHC-33.5 RDW-16.8* Plt Ct-229
[**2181-10-24**] 07:00AM BLOOD WBC-11.6*# RBC-2.98* Hgb-8.2* Hct-24.8*
MCV-83 MCH-27.6 MCHC-33.1 RDW-16.9* Plt Ct-210
[**2181-10-23**] 06:00AM BLOOD WBC-7.4 RBC-3.23* Hgb-8.9* Hct-27.1*
MCV-84 MCH-27.5 MCHC-32.8 RDW-16.2* Plt Ct-196
[**2181-10-22**] 07:00AM BLOOD WBC-7.1 RBC-3.40* Hgb-9.6* Hct-28.6*
MCV-84 MCH-28.3 MCHC-33.6 RDW-15.7* Plt Ct-195
[**2181-10-21**] 07:35AM BLOOD WBC-6.2 RBC-3.11* Hgb-8.5* Hct-26.5*
MCV-85 MCH-27.4 MCHC-32.1 RDW-14.8 Plt Ct-148*
[**2181-10-20**] 01:58AM BLOOD WBC-7.1 RBC-2.67* Hgb-7.4* Hct-22.5*
MCV-84 MCH-27.7 MCHC-32.9 RDW-14.5 Plt Ct-140*
[**2181-10-19**] 03:13AM BLOOD WBC-8.0 RBC-2.77* Hgb-7.7* Hct-23.1*
MCV-84 MCH-27.9 MCHC-33.3 RDW-15.2 Plt Ct-140*
[**2181-10-18**] 07:10PM BLOOD WBC-9.8 RBC-3.00* Hgb-8.4* Hct-24.9*
MCV-83 MCH-28.0 MCHC-33.6 RDW-15.3 Plt Ct-138*
[**2181-10-18**] 02:47AM BLOOD WBC-11.0 RBC-2.69* Hgb-7.7* Hct-22.9*
MCV-85 MCH-28.5 MCHC-33.4 RDW-15.2 Plt Ct-146*
[**2181-10-17**] 04:26PM BLOOD WBC-10.1 RBC-2.98* Hgb-8.3* Hct-26.1*
MCV-88 MCH-27.8 MCHC-31.8 RDW-14.7 Plt Ct-172
[**2181-10-17**] 12:45PM BLOOD WBC-7.8 RBC-3.03* Hgb-8.6* Hct-26.2*
MCV-87 MCH-28.4 MCHC-32.8 RDW-14.5 Plt Ct-202
[**2181-10-31**] 07:10AM BLOOD Glucose-150* UreaN-89* Creat-4.5* Na-132*
K-3.3 Cl-93* HCO3-25 AnGap-17
[**2181-10-30**] 07:00AM BLOOD Glucose-85 UreaN-87* Creat-4.4* Na-130*
K-3.3 Cl-92* HCO3-25 AnGap-16
[**2181-10-28**] 05:52AM BLOOD Glucose-84 UreaN-91* Creat-4.2* Na-127*
K-4.2 Cl-91* HCO3-22 AnGap-18
[**2181-10-27**] 06:10AM BLOOD Glucose-126* UreaN-91* Creat-4.0* Na-126*
K-4.5 Cl-90* HCO3-22 AnGap-19
[**2181-10-26**] 04:59AM BLOOD Glucose-187* UreaN-85* Creat-3.7* Na-126*
K-4.6 Cl-91* HCO3-22 AnGap-18
[**2181-10-25**] 05:29AM BLOOD Glucose-165* UreaN-80* Creat-3.3* Na-125*
K-4.7 Cl-94* HCO3-21* AnGap-15
[**2181-10-24**] 07:00AM BLOOD Glucose-155* UreaN-73* Creat-3.2* Na-131*
K-4.5 Cl-99 HCO3-22 AnGap-15
[**2181-10-23**] 06:00AM BLOOD UreaN-64* Creat-2.5* Na-134 K-4.4 Cl-101
HCO3-23 AnGap-14
[**2181-10-22**] 07:00AM BLOOD Glucose-202* UreaN-51* Creat-1.8* Na-136
K-3.8 Cl-103 HCO3-24 AnGap-13
[**2181-10-21**] 07:35AM BLOOD Glucose-136* UreaN-44* Creat-1.6* Na-137
K-3.1* Cl-104 HCO3-23 AnGap-13
[**2181-10-20**] 01:58AM BLOOD Glucose-133* UreaN-46* Creat-1.7* Na-139
K-3.8 Cl-107 HCO3-23 AnGap-13
[**2181-10-19**] 03:13AM BLOOD Glucose-76 UreaN-49* Creat-1.9* Na-138
K-4.2 Cl-106 HCO3-23 AnGap-13
[**2181-10-18**] 02:47AM BLOOD Glucose-148* UreaN-49* Creat-2.0* Na-137
K-4.6 Cl-105 HCO3-22 AnGap-15
[**2181-10-18**] 02:47AM BLOOD Glucose-174* UreaN-49* Creat-2.1* Na-133
K-6.7* Cl-103 HCO3-23 AnGap-14
[**2181-10-17**] 04:26PM BLOOD Glucose-334* UreaN-42* Creat-1.9* Na-131*
K-5.7* Cl-100 HCO3-20* AnGap-17
[**2181-10-31**] 07:10AM BLOOD ALT-95* AST-31 AlkPhos-61 TotBili-0.7
[**2181-10-30**] 07:00AM BLOOD ALT-108* AST-29 LD(LDH)-318* AlkPhos-58
TotBili-0.6
[**2181-10-28**] 05:52AM BLOOD ALT-141* AST-33 AlkPhos-62 TotBili-1.2
[**2181-10-27**] 06:10AM BLOOD ALT-162* AST-34 AlkPhos-60 TotBili-1.3
[**2181-10-26**] 04:59AM BLOOD ALT-218* AST-46* AlkPhos-73 TotBili-1.8*
[**2181-10-25**] 05:29AM BLOOD ALT-277* AST-62* AlkPhos-75 TotBili-1.7*
[**2181-10-24**] 07:00AM BLOOD ALT-347* AST-92* AlkPhos-74 TotBili-1.6*
[**2181-10-23**] 06:00AM BLOOD ALT-504* AST-157* AlkPhos-85 TotBili-1.5
[**2181-10-22**] 07:00AM BLOOD ALT-840* AST-383* LD(LDH)-347* AlkPhos-94
TotBili-1.3
[**2181-10-21**] 07:35AM BLOOD ALT-1342* AST-1027* LD(LDH)-498*
AlkPhos-84 TotBili-1.3
[**2181-10-20**] 01:58AM BLOOD ALT-2245* AST-3656* LD(LDH)-2530*
AlkPhos-66 TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2181-10-19**] 03:13AM BLOOD ALT-783* AST-1611* AlkPhos-63 Amylase-33
TotBili-0.3
[**2181-10-18**] 02:47AM BLOOD CK(CPK)-322*
[**2181-10-18**] 02:47AM BLOOD CK(CPK)-364*
[**2181-10-18**] 12:12AM BLOOD CK(CPK)-310*
[**2181-10-17**] 04:26PM BLOOD ALT-35 AST-162* LD(LDH)-565* CK(CPK)-250*
AlkPhos-81 Amylase-79 TotBili-0.1
[**2181-10-18**] 02:47AM BLOOD CK-MB-6 cTropnT-0.30*
[**2181-10-18**] 02:47AM BLOOD CK-MB-6 cTropnT-0.31*
[**2181-10-18**] 12:12AM BLOOD CK-MB-6 cTropnT-0.35*
[**2181-10-17**] 04:26PM BLOOD CK-MB-6 cTropnT-0.39*
[**2181-10-20**] 01:58AM BLOOD Hapto-300*
[**2181-10-17**] 04:26PM BLOOD calTIBC-300 Ferritn-1825* TRF-231
[**2181-10-26**] 04:59AM BLOOD TSH-0.17*
[**2181-10-28**] 05:52AM BLOOD T3-37* Free T4-0.55*
=======
Micro
=======
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2181-10-29**]):
Feces negative for C.difficile toxin A & B by EIA.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2181-10-25**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
RESPIRATORY CULTURE (Final [**2181-10-20**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. HEAVY GROWTH.
Please contact the Microbiology Laboratory ([**7-/2479**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
=======
Radiology
=======
CXR - [**10-17**] - The endotracheal tube is seen in situ with its tip
approximately 12 mm from
the carina. This should be withdrawn. The lungs are low volume,
most likely
due to poor inspiratory effort. There is atelectasis at the left
lung base
with a probable area of consolidation. Followup to clearance is
recommended.
CXR [**10-18**] - Moderate enlargement of the cardiac silhouette has
progressed, with worsening left atrial enlargement, mild
pulmonary edema and vascular engorgement, new small-to-moderate
left and small right pleural effusion. Left lower lobe is fully
opacified, probably atelectasis. Mediastinal contour is now
bulging at the level of the AP window and pulmonary artery. This
could be due to pulmonary arterial dilatation alone, but
possibility of aortic aneurysm or mediastinal adenopathy is
raised, particularly since the right hilus is not enlarged.
With the chin down, the tip of the ET tube rests less than a
centimeter from the carina, 3 cm below optimal placement. No
pneumothorax.
CXR [**10-20**] - Interval extubation. Slight worsening of left
pleural effusion and adjacent retrocardiac opacity which may be
due to atelectasis or infectious consolidation. Minimal haziness
at right base may reflect motion artifact, but small pleural
effusion or focal right basilar parenchymal process could
produce a similar appearance.
CXR [**10-22**] - The right PICC line was inserted with its tip
terminating in the right atrium approximately 3 cm below the
cavoatrial junction. The cardiomediastinal silhouette is
unchanged including cardiomegaly and bulging of the main
pulmonary artery. There is additional worsening of the left
upper lobe opacity that might represent developing pneumonia.
The bilateral pleural effusions are small, unchanged.
CXR [**10-24**] - IMPRESSION: Little overall change except for slight
pulling back of the PICC line.
Abd u/s - [**10-20**] - IMPRESSION: Patent hepatic vasculature with
appropriate flow.
=======
Neurology
=======
EEG - Markedly abnormal portable EEG due to the very low
voltage
and slow background. This indicates a widespread and moderately
severe
encephalopathy. Medications, metabolic disturbances, infection,
and
anoxia are among the most common causes, but this tracing cannot
specify
the etiology. There were no areas of prominent focal slowing,
and there
were no epileptiform features, including at the times of
clinically
noted abnormal movements.
Brief Hospital Course:
# Respiratory failure / MSSA Pna: DDx includes aspiration
pneumonitis vs aspiration PNA, ACS, PE, PTX, infection/sepsis,
medications/overdose, hypoglycemia or seizure. ACS ruled out
with biomarkers trending down, no elevated CKMB, no acute ECG
changes. She did not have relative hypoxia nor [**Name (NI) **] gradient on
ABGs. Initial fever concerning for infxn so started empirically
on Vanc/Zosyn for possible HCAP although afebrile here.
Extubated [**10-19**] and satting well on 2L nasal cannula. Has sputum
gram stain showing 4+ MSSA so Vanco changed to Nafcillin and
Zosyn DC'd. Patient lost IV access on [**10-28**] and was transitioned
to Nafcillin to complete her 14 day couorse of antibiotics.
Blood cultures were persistently negative.
.
# Change in mental status: Pt has longstanding dementia. Pt's
baseline mental status prior to this hospital stay was saying
[**2-11**] words at a time and holding family's hands.Since her stay in
the ICU, pt only withdraws to painful stimuli, but has
occasionally opened her eyes for family members. EEG negative
for nonconvulsive status epelepticus. Worsening mental status
likely [**2-10**] to multiple etiologies, including infection, acute
renal failure, anoxic encephalopathy, hepatic encephalopathy and
worsening baseline dementia. Likelihood of recovering baseline
mental status considered very minimal at this time. Likelihood
for recovery of baseline mental status given multiple medical
issues is considered very unlikely.
# Elevated LFTs: On presentation her LFTs were ALT 32, AST 165.
LFTs were rechecked due to a mildly elevated INR which was
attributed to nutritional deficiency. The followup set of LFTs
was AST 783 ALT 1611, and [**10-20**] were 2245/3656. Liver was
consulted and recommended RUQ US with Dopplers which was done
and was normal with no thrombus. Etiology thought to be shock
liver secondary to hypotension. LFTs trended down over the
course of admission.
# Acute renal failure / Hyponatremia: Renal function worsened
over the course of admission and was oliguric for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1644**] period
of time. The likely etiology was pre-renal azotemia and ATN from
hypotension. Although patient was on naficillin, urine eos were
negative. Family chose not to pursue dialysis. Given
hyponatremia and totaly body overload, patient was diuresed with
Lasix which improved both the serum sodium and body edema.
Patient was also free water restricted with minimal tube feed
volumes. In addiion, urine output improved immensely on lasix.
However, the Cr worsened despite improved urine ouput. Once
total body edema improved, lasix were stopped in the hope that
this would help decrease serum Cr.
.
# UTI: Pt had worsening leukocytosis and UA suspicious for
infection, but urine cx was negative. Pt was treated empirically
with Ciprofloxacin for 7 days.
.
# vaginal yeast infection: on day of discharge pt was noted to
have vaginal yeast infection and was started on miconidazole
cream for an anticipated 7 days
.
#. DM2: Patient continued on NPH with ISS
#. PVD: Stumps appear clean.
#. Anemia - unknown baseline. Normocytic. Iron studies c/w
anemia of chronic disease. Also Guaiac positive. HCts stable.
# HTN ?????? Patient was continued on metoprolol and amlodipine.
Lisinopril was held in the setting of ARF. Patient remained
persistently hypertensive, but systolic BPs into the 170s were
tolerated given concern that patient might be septic and desire
to maintain liver and kidey perfusion given above problems.
[**Name (NI) **] was discharged on this two drug regimen.
.
# Seizure disorder: Pt has prior hx of seizure d/o. EEG
negative. Phenobarbital dosed by level.
# FEN: TF's at 30 cc/hr via PEG tube, replete lytes prn
.
# Code/Family Meeting: During this admission, patient required
intubation and agressive care. Patient was made DNR/DNI as of
[**10-24**] by HCP, in agreement with the rest of the patient's
family. Multiple family meetings were held once the patient was
transferred from the ICU to the floor. Family appreciated the
gravity and irreversibility of the patient's situation. Given
the patient's renal failure, family decided not to pursue
dialysis and not to pursue PICC line access for IV care once
patient self d/cd her line. Family chose a "comfort oriented"
plan that includes no escalation of care, no HD, and no ICU
transfer. A palliative care consult was requested to help
organize Hospice care at the [**Hospital3 **], which family
considers "patient's home". They understand that hospice care
will mean more volunteer time, more nursing assessment, and
additional health aide time.
.
# Communication:
-- Daughter [**Name (NI) 8392**] [**Telephone/Fax (1) 102571**]
-- Daughter [**Name (NI) 2563**] [**Telephone/Fax (1) 102572**]
Medications on Admission:
Avandia 4 mg p.o. b.i.d.
sliding scale insulin
Insulin 16 NPH q.p.m.
Dulcolax p.r.n.
MoM
tylenol
artificial tears
senna
FeSo4 325 [**Hospital1 **]
Phenobarbital 90 mg p.o. daily
Hyoscyamine 0.125 tid
Lopressor 150 mg p.o. b.i.d.
tube feeds per G-tube
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Last Name (STitle) **]: One
(1) Appl Ophthalmic PRN (as needed).
3. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID
(3 times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) nebulizer Inhalation every twelve (12)
hours.
Disp:*10 bottles* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: Two (2)
Tablet, Sublingual Sublingual QID (4 times a day).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
8. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Last Name (STitle) **]: Sixteen
(16) units Subcutaneous once a day.
Disp:*1 bottle* Refills:*2*
9. Scopolamine Base 1.5 mg Patch 72 hr [**Last Name (STitle) **]: One (1) patch
Transdermal every seventy-two (72) hours as needed for oral
secretions.
10. Tylenol 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every 6-8 hours as
needed for pain.
11. Morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: 3-10 mg PO q4h:PRN as
needed for pain.
Disp:*50 ml* Refills:*0*
12. Phenobarbital 30 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO every
seventy-two (72) hours: please dose by serum drug level if
possible.
Disp:*30 Tablet(s)* Refills:*2*
13. Miconazole Nitrate 2 % Cream [**Last Name (STitle) **]: One (1) Appl Vaginal Q 24H
(Every 24 Hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
MSSA pneumonia
Shock liver
Acute renal failure
Hyponatremia
Urinary tract infection
Secondary:
# peripheral vascular disease status post AKA bilaterally
# diabetes mellitus type 2
# hypertension
# dementia
# seizure disorder
# right DVT in [**2173-8-10**]
# Anemia
Discharge Condition:
Stable, afebirle
Discharge Instructions:
You were admitted for a pneumonia requiring antibiotic therapy.
Your hospital course was complicated by injury to your liver,
likely from your low blood pressure as a consequence of the
infection in your lung. You improved on IV antibiotics. You also
developed failure of your kidneys. This was felt to be secondary
to your low blood pressure. The decision was made not to pursue
dialysis. You are being discharged back to [**Hospital3 **] with
Hospice care. Your medications will be continued as below.
Please return to the hospital if you have any shortness of
breath, worsening cough or any other concerning symptoms.
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 5762**] as needed.
Completed by:[**2181-11-2**]
ICD9 Codes: 5845, 2761, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4238
} | Medical Text: Admission Date: [**2140-7-27**] Discharge Date:
Date of Birth: [**2097-10-3**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 42 year old
female who has been having headaches and confusion for three
weeks prior to admission. She describes her headaches as
around the clock type, squeezing frontal headaches that
radiate down her temples bilaterally. She rates them as a
four out of ten. She also reports that she has been confused
with these headaches. She cannot remember what to say and
has a hard time coming up with the words. She has difficulty
sequencing events and sometimes gets distressed. Also prior
to admission, she had several episodes of projectile vomiting
without preceding nausea. She denies any recent weight loss,
fevers or night sweats.
PAST MEDICAL HISTORY: None.
MEDICATIONS ON ADMISSION: She was taking Vicodin for pain
and swelling of her left calf.
ALLERGIES: Penicillin.
SOCIAL HISTORY: She smokes two packs of cigarettes per day,
no alcohol use. She is a manager of [**Company 2486**], and lives
at home with her husband and 17 year old daughter.
PHYSICAL EXAMINATION: On physical examination, her vital
signs were 98.2, pulse 72, blood pressure 142/72, respiratory
rate 18, and oxygen saturation 99% in room air. In general,
she is awake, alert and oriented female. Head, eyes, ears,
nose and throat examination - No evidence of trauma. Neck -
No carotid bruits or thyromegaly. Pulmonary - The lungs are
clear bilaterally. Cardiac - regular rate and rhythm, no
murmurs. The abdomen is soft, nontender. Extremities - 2+,
no edema. Mental status - She is awake and hypervigilant.
She states the date was three days off prior to examination
date. Language was fluent with good comprehension and
repetition, but had anomia for low and intermediate frequency
of words. Bilateral praxis. Difficulties when attempts to
brush her hair. She had a left ptosis. The pupils were
equal to light and dark. Facial strength and sensation was
intact. Hearing was intact. Tongue was midline. Motor
normal tone and bulk throughout. No fasciculations.
Reflexes were 2+ throughout and downgoing toes. Her gait was
normal. She can do tandem walk.
LABORATORY DATA: White blood cell count was 10.4, hematocrit
41.4, platelet count 603,000. Sodium 139, potassium 4.0,
bicarbonate 23, blood urea nitrogen 13. Prothrombin time was
12.3 and INR was 1.0 and partial thromboplastin time was
25.4.
Head CT demonstrates two left sided masses, one frontal and
one parietal occipital with massive surrounding edema and
subfalcine herniation.
HOSPITAL COURSE: The patient was admitted to the Neurology
Intensive Care Unit where she was given Decadron, pan CT of
her body, blood pressure was to be kept less than 160, and
neurologic checks were every hour. On [**2140-7-27**], she
continued to have a right parietal drift, slow finger fine
movements on the right. IPs were [**4-11**]. On [**2140-7-27**], Dr. [**First Name (STitle) **]
spoke with the patient and discussed the possibility of
having her brain tumors resected. The patient and the family
agreed to proceed with
the surgery. The patient was transferred to the surgical
floor also on [**2140-7-27**], out of the Intensive Care Unit. She
was awake, alert and oriented and remained stable. She was
preopped for a craniotomy on [**2140-7-28**]. She was seen by
Neurology/Oncology, Dr. [**Last Name (STitle) 724**], who also recommended the
resection of her brain tumor and then most likely starting
radiation after the surgery. On [**2140-7-28**], the patient did
have craniotomy and had the metastatic tumor removed.
Postoperatively, she is awake, alert and oriented to person
and place, however, not time. Her speech was fluent and she
had good repetition to naming. Cranial nerves II through XII
are intact. Her extraocular movements were full. The pupils
are equal, round, and reactive to light and accommodation.
Her postoperative hematocrit was 36.8. She was continued on
Decadron and neurologic checks and remained in the recovery
room overnight for monitoring. She was moved to the floor on
[**2140-7-29**], where she got a physical therapy and occupational
therapy consultation and was tolerating regular diet. On
[**2140-7-29**], the patient was seen by thoracic surgery for a lung
lesion that was 3.3 by 4.2 centimeters in the superior
segment of the left lower lung and basically recommended to
wait for her pathology results and that she follow-up in the
thoracic oncology center She was also seen by the
hematology/oncology service who felt that most likely her
cancer represents a metastatic lung cancer. Based on her CT
scan, the patient would have a Stage IV (T2, NO M1) lung
cancer if the pathology returns as a NFVLV. They
recommended to continuing to wait for the pathology results.
The patient on [**2140-7-30**], remained awake, alert and oriented
times three. Her blood sugar was in the 101 to 159 range.
She was moving all extremities. Her extraocular movements
were full, no drift, visual fields were intact. Her Decadron
was decreased to 6 mg q8hours. She was ask to increase her
activity. During the day of the [**2140-7-30**], the patient did
complain of a headache that was not relieved by her Percocet.
She remained neurologically intact. At that point, we did
decide to do a head CT which showed no new blood, continuing
edema that was not worse than the magnetic resonance scan
that was done on [**2140-7-29**], which also showed extensive edema
and some enhancement around the border of the previous sites
of the brain tumors. She remained neurologically intact
overnight and did better with some increased pain medication.
Her headaches were more under control. She ask to see Social
Work and they recommended her to follow-up with an agency
when she was discharged. She has been seen by physical
therapy who at this point is helping her with discharge
planning. We will await further guidance from them before
she is discharged and to make sure she is safe to go home.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with the
Brain [**Hospital 341**] Clinic a week from Monday. She should call for
that appointment. She also needs to call the thoracic
oncology service and she was given both telephone numbers for
her appointments. She is to keep the incision clean, dry and
intact. She will return on [**2140-8-5**], to [**Hospital Ward Name 121**] Five to have
her staples removed between 9:00 a.m. and 12:00 p.m. She
should have no strenuous activity. She should return if her
headache becomes worse and is not relieved with pain
medication or if she develops any vomiting or fevers.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice a day.
2. Dilantin 100 mg p.o. three times a day.
3. Neurontin 300 mg one three times a day.
4. Nicotine Patch 21 mg per 24 hours, change q24hours.
5. Famotidine 20 mg one p.o. twice a day.
6. Decadron taper.
7. Percocet one to two p.o. q4-6hours p.r.n. pain.
DISCHARGE STATUS: The patient is discharged neurologically
intact. Again, prior to discharge, we are awaiting physical
therapy final clearance for discharge.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern4) 26792**]
MEDQUIST36
D: [**2120-7-31**] 08:26
T: [**2140-7-31**] 09:23
JOB#: [**Job Number 27379**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4239
} | Medical Text: Admission Date: [**2187-3-3**] Discharge Date: [**2187-3-16**]
Date of Birth: [**2126-12-22**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
left sided numbness and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
60 year-old man with a history of uncontrolled hypertension
with sudden onset ~5:10pm of left-sided numbness and weakness.
Pt reports he was driving home from church when he had sudden
onset of "numbness" in his left arm. He describes the numbness
as
a flaccid feeling, and also decreased sensation. He drove for
another ~10-15 minutes and then pulled in to a parking lot. He
fell when he tried to get out of the car due ot left leg
weakness. A cardiologist was also in the parking lot and called
EMS. On arrival of EMS, BP 240/120, FS 234.
Pt arrived at [**Hospital1 18**] ED at 6pm and "code stroke" was initiated.
Initial BP 235/115. NIHSS 8. Head CT with right basal ganglia
bleed so no TPA given.
Of note, pt did report some strange phenomena, such as "I was
totured in the past so the CT may show the implants." He also
later told me something like "My feet were implanted by the
Eastern Europeans, they do good work don't they?"
60M h/o untreated severe hypertension and otherwise
unknown history (does not see doctors) presents with sudden
onset
left sided weakness and decreased sensation. Exam with left
hemibody sensory loss and left-sided weakness of arm>leg>face.
Most likely localization is deep right subcortical white or grey
matter given lack of cortical signs. This is confirmed by right
basal ganglia bleed on CT.
Past Medical History:
I don't like docotors"
1. Hypertension, uncontrolled. Pt reports having his BP checked
at a health fair at work. "It was so high that the nurse went
and
got the doctor. But it's really not a problem for me. When it
gets high I just have a nose bleed and that relieves the
pressure."
Social History:
Lives with a friend [**Name (NI) **], who is his health care proxy. [**Name (NI) 1403**]
as a politician, "I'm running for governor of [**State 350**] you
know." No tobacco, EtOH or drugs. Has no family.
Family History:
Mother with HTN. No stroke, DM.
Physical Exam:
PE: T 96 BP 235/118 HR 90s O2 sat 95% RA
General: Overweight man, in no acute distress
HEENT: NC/AT Sclera anicteric. OP clear
Neck: Supple
Lungs: Clear to auscultation anterolaterally
CV: RRR, nl S1, S2, no murmur. 2+ carotids without bruit
Abd: Soft, obese, nontender, normoactive bowel sounds
Extr: No edema, warm and well perfused
Neurologic Examination:
Mental Status: Alert and oriented to person, place and date,
cooperative with exam, normal affect
Attention: Can say months of year backward
Language: Fluent, mild dysarthria, no paraphasic errors, naming
and repetition intact
No neglect. No grasp.
Cranial Nerves: Visual fields are full to finger counting.
Pupils
equally round and reactive to light, 3 to 2 mm bilaterally,
brisk. Extraocular movements intact, no nystagmus. Left face
severely decreased LT, pin. Normal oropharyngeal movement.
Tongue
midline, no fasciculations.
Sensation: Absent light touch, pin felt as dull on left arm and
chest and pin absent on left leg.
Motor: Normal bulk. Left arm flaccid. No fasiculations. No
tremor. Left arm plegic, except perhaps some slight movement of
finger flexors. Left leg: IP nearly full, ham 4, some movement
at
ankle and toes.
Reflexes: DTRs 3+ at knees,
Coordination: Finger-nose-finger intact on right.
Pertinent Results:
[**2187-3-3**] 06:40PM GLUCOSE-249* UREA N-8 CREAT-0.9 SODIUM-138
POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-24 ANION GAP-20
[**2187-3-3**] 06:40PM CK(CPK)-161
[**2187-3-3**] 06:40PM CK-MB-5 cTropnT-<0.01
[**2187-3-3**] 06:40PM CALCIUM-9.9 PHOSPHATE-2.8 MAGNESIUM-1.8
[**2187-3-3**] 06:40PM WBC-9.5 RBC-5.03 HGB-15.2 HCT-43.5 MCV-86
MCH-30.3 MCHC-35.0 RDW-13.0
[**2187-3-3**] 06:40PM PLT COUNT-296
[**2187-3-3**] 06:40PM PT-11.7 PTT-25.2 INR(PT)-1.0
* * *
[**2187-3-3**] CT HEAD
FINDINGS: There is a focal hyperdense area measuring 1.7 cm
consistent with intraparenchymal hemorrhage located in the
region of the posterior limb of the right internal capsule/basal
ganglia. There is associated surrounding edema. There is no
evidence of mass effect, shift of normally midline structures,
or hydrocephalus. The [**Doctor Last Name 352**]-white matter differentiation is
relatively well preserved. There is no effacement of the sulci
or ventricles. Bone windows demonstrate no evidence offracture.
The visualized paranasal and mastoid air cells are well aerated.
IMPRESSION: Focal intraparenchymal hemorrhage in the region of
the right
basal ganglia/posterior limb of the right internal capsule with
adjacent
edema.
* * *
[**2187-3-3**] EKG
Sinus rhythm
ST junctional depression is nonspecific
* * *
[**2187-3-5**] EEG
IMPRESSION: This is an abnormal 24-hour EEG telemetry due to the
presence of slow background rhythm with intermittent bursts of
generalized slowing in the delta frequency range bifrontally
predominant. In addition, there is independent intermittent
slowing
over the right fronto-central region with sharp features. The
first
abnormality represents an encephalopathic pattern most likely
due to
medication effect. The second abnormality suggests subcortical
dysfunction over the right fronto-central region with possible
cortical
dysfunction. There were no clear epileptiform discharges
recorded.
* * *
[**2187-3-7**] ECHO
Conclusions:
The left atrium is mildly 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>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen.
The left ventricular inflow pattern suggests impaired
relaxation. There is no pericardial effusion.
No intracardiac mass/thrombus identified (cannot definitively
exclude).
* * *
[**2187-3-12**] HEAD CT
There has been slight enlargement of the area of low attenuation
surrounding the right thalamus suggestive of worsening edema
around the right thalamic hemorrhage. Small amount of
intraventricular hemorrhage is present.
There has been mild dilatation of the lateral ventricles since
the previous examination especially involving the body and
frontal [**Doctor Last Name 534**] of the lateral ventricle. This might indicate an
element of obstructive hydrocephalus due to the intraventricular
hemorrhage. No midline shift is seen. There is no other
interval change noted.
IMPRESSION: Interval mild enlargement of the lateral ventricles
suggestive of possible early obstructive hydrocephalus due to
the presence of intraventricular hemorrhage. Minimal worsening
of the edema surrounding the right-sided thalamic hemorrhage
since the previous exam of [**2187-3-8**]. Correlation with
neurologic symptoms and followup is recommended.
* * *
[**2187-3-13**]
Left leg ultrasound
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the left common
femoral,
superficial femoral, and popliteal veins were performed. Normal
flow,
augmentation, compressibility, and waveforms are demonstrated.
Intraluminal thrombus is not identified.
IMPRESSION: No evidence of DVT.
* * *
[**2187-3-14**] Video Swallow
PROCEDURE: Video oropharyngeal swallow exam was performed in
conjunction with speech and swallow therapy department. Varying
consistencies of barium were administered under constant video
fluoroscopic monitoring. Penetration was seen with first
teaspoon of nectar-thick liquid and with straw sips of nectar.
Deep laryngeal penetration was observed with thin liquids. No
aspiration was seen but it was felt that patient was at
significant risk to aspirate thin liquids or solids secondary to
impassability, pharyngeal residue, and swallow delay. For
complete details and recommendations, please refer to the
complete speech and swallow therapy department note available on
CareWeb.
* * *
[**2187-3-13**] CHEST X-RAY
Left internal jugular vascular catheter and feeding tube remain
in place. The feeding tube has been withdrawn slightly in the
interval but still terminates within the stomach. Cardiac and
mediastinal contours are stable. There has been improved
aeration at the lung bases with near complete resolution of
bibasilar atelectasis with only very minimal residual left
basilar atelectasis remaining.
IMPRESSION: No evidence of pneumonia.
Brief Hospital Course:
Briefly, this is a 60M h/o untreated severe hypertension and
otherwise unknown history (does not see doctors) who presented
with sudden onset left sided weakness and decreased sensation.
Exam revealed left hemibody sensory loss and left-sided weakness
of arm>leg>face. Right basal ganglia/thalamic bleed was noted on
CT. The pt was initially admitted to the ICU on labetalol gtt.
The pt r/o for MI with 3 sets of CE. Once the pts BP had
stabilized the pts labetolol gtt was weaned off and he was
transferred to the neurology service.
* * *
#Neuro/R basal ganglia/thalamic bleed:
The likely source of the pts bleed was felt ot be due to
uncontrolled HTN. His coags were wnl. The pt remained on q 2 hr
neuro checks for his first 6 days after admission. His SBP was
initially managed aggressively in the ICU on labetolol gtt with
goal SBP 150-160. After transfer to the floor, his BP was very
difficult to control. He was administered IV Hydral and IV
metoprolol frequently. He was started on metoprolol (ultimately
titrated up to 100 mg po tid), captopril (aggressively titrated
up to 100 mg tid), as well as norvasc 10 mg po qd (after his bp
was still resistant). The pts mental status was noted to wax
and wane in an encephalopathic manner. Given increased
somnolence on [**3-7**], head CT was repeated but revealed no new
bleed or change in the old bleed. On [**3-8**], the pts L pupil was
noted to be intermittently dilated larger than the R pupil (and
more sluggish to constrict to light). Head CT was again
repeated and revealed no new changes. ABG on 35% shovel mask on
[**3-8**]: 7.39/42/140, which showed his somnolence was not due to
any respiratory changes. As per below, UA, UCx, and CXR were
unrevealing as sources of his somnolence. During the pts first
week after admission, he was often unarousable or arousable to
only deep sternal rub. It was noted the pt seemed agitated at
night, perhaps contributing to increased daytime somnolence, so
the pt was started on Zyprexa 5 mg qhs. The pt was noted to be
able to spontaneously move his RUE and RLE, but he did not move
his LUE or LLE.
Over the course of his stay he was noted to have significant
obstructive sleep apnea, likely worsened by his stroke causing
decreased pharyngeal tone. He started on CPAP of 6 on [**3-10**], and
his mental status improved significantly. Later on in his stay
he began to move his left leg more as well, withdrawing to
noxious stimuli, albeit less vigorously than with the right leg.
He was still unable to move his left arm at all, and had
continued dysarthria, although this was improved from admission.
His agitation improved with time as well, and the zyprexa was
discontinued, as this was thought to contribute to his
somnolence. By the time of discharge he was sleeping a lot, but
in general was much more awake, and able to engage in
conversation. Lastly, he had a repeat head CT on [**3-12**], which
was read by radiology as possible indicative of early
obstructive hydrocephalus, but upon further review with the
neurology team this was not felt to be the case. His bleed was
stable on follow-up CT and as his mental status continuously
improved no further imaging was performed.
.
#CV: As per above, the pts BP was initially managed aggressively
in the ICU on labetolol gtt with goal SBP 150-160. After
transfer to the floor, his BP was very difficult to control. He
was administered IV Hydral and IV metoprolol frequently. He was
started on metoprolol (ultimately titrated up to 100 mg po tid),
captopril (aggressively titrated up to 100 mg tid), as well as
norvasc 10 mg po qd (after his bp was still resistant). He was
started on atorvastatin 10 mg po qd for TG 210 and LDL 140. He
ruled out for MI. TTE revealed the pt has impaired LV
relaxation c/w diastolic dysfunction, EF >55%. On [**3-16**] he had a
TEE to evaluate for clot, as he had grown coag negative staph
from a peripheral blood culture, but no clot was identified per
the cardiology attending. The full read of the TEE was pending
at the time of discharge.
.
ID: The pts WBC after admission slowly rose to a peak of 18 on
[**3-8**] with 85% PMN but no bands. The likely source was either a
stress response vs infection. UA and Ucx were negative, and CXR
showed no clear infiltrate or aspiration pneumonitis. On [**3-9**]
the pts WBC decreased to 13. On [**3-13**] he became febrile, and
blood and urine cultures were drawn. Chest x-ray was negative.
His L IJ was pulled on [**3-14**]. His blood cultures grew coag
negative staph in [**1-20**] bottles, but it was not known if these
were the samples drawn from the line or peripherally. The IJ
catheter tip did not grow any bacteria. It was unclear if the
bacteria represented a contaminant, but we decided to manage
conservatively with vancomycin for 7 days. Sensitivies of the
coag negative staph are still pending at the time of discharge,
and he requires 5 more days of treatment with vancomycin.
Follow up blood cultures have been negative, and the patient has
been afebrile for 72 hours. His wbc on the day of discharge was
still mildly elevated at 11.9, but the general trend has been
downward.
.
Endocrine: The pts glucose was initially poorly controlled in
the 200s-300s. His Hgb A1c was 11. He was started on RISS and
NPH. His NPH was titrated up after the pt was started on tube
feeds. At the time of discharge he is getting NPH 35 units in
the morning and 25 units at night, plus sliding scale insulin as
needed.
.
Heme: His hematocrit was stable throughout the admission, and
was 34.7 at the time of discharge. His coags were normal
throughout.
.
FEN/GI:
He was initially tube fed for several days. Once his mental
status improved he had a video swallow study, and was cleared to
take pureed solids and nectar thick liquids, alternating bites
with sips, and using a chin tuck. He self-d/c'd the NG tube and
ate well with assistance for the last two days prior to
discharge.
.
Pulmonary:
He exhibited significant obstructive sleep apnea during his
admission. His roommate [**Hospital1 **] said she occasionally hears him
snoring throughout the night, but she doesn't share his room so
she is not sure if he has apneic episodes at home. On [**3-10**] he
was evaluated by pulmonology and placed on CPAP of 6. This
significantly improved his respiratory status and his level of
alertness. At the time of discharge he was on CPAP of 6 from 9
pm to 6 am. He will need to have a formal sleep study done as
an outpatient, and follow up with a pulmonologist.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Five (35) unit Subcutaneous qAM.
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) units Subcutaneous qPM.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush for 10 days.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q 12H (Every 12 Hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Basal ganglia hemorrhage
Hypertension
Discharge Condition:
Good
Discharge Instructions:
Please take all medications and attend all follow-up
appointments as instructed.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] of [**Hospital 18**] [**Hospital 4038**] Clinic in one
month. Call [**Telephone/Fax (1) 2574**] to do your outpatient registration and
make an appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27555**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-4-5**]
3:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 431, 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4240
} | Medical Text: Admission Date: [**2199-3-13**] Discharge Date: [**2199-3-16**]
Date of Birth: [**2160-9-2**] Sex: M
Service: NEUROSURGERY
Allergies:
furosemide / Keflex
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2199-3-13**] Right Frontal Craniotomy for resection of mass
History of Present Illness:
This is a 38 year old man with metastatic melanoma. He has a
known right frontal lesion with enlargement seen on MRI review
in
MTC, scan from [**2-27**]. The edema was thought to be related to IL2
treatment. He has had daily headaches at home associated with
fatigue and nausea. He was admitted from hem/onc
clinic on [**3-8**]. He denies, change in vision, dizziness, speach
difficulty, weakness, numbness.
He presents on this admission for elective craniotomy for
resection of recurrent tumor.
Past Medical History:
metastatic melanoma to the brain s/p
(1) CyberKnife radiosurgery to a right frontal metastasis to
2200
cGy at 75% isodose line on [**2198-11-8**], and
(2) status post resection of small intestine with metastatic
melanoma by Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**] on [**2198-11-13**].
s/p skin grafting for melanoma
Social History:
Lives with significant other [**Name (NI) **]. [**Name2 (NI) **] does not smoke and
drinks occasional alcohol. He is an electrician.
Family History:
His mother is supposed to have some skin cancer removed 20
years ago. His paternal uncle had esophageal cancer and
paternal grandfather had lung cancer.
Physical Exam:
Vital Signs sheet entries for [**2199-3-5**]:
BP: 124/75. Heart Rate: 84. Weight: 155.3. Height: 69. BMI:
22.9.
Temperature: 98.1. Resp. Rate: 16.
Gen: thin, WD/WN, comfortable, NAD.
HEENT: Pupils: [**4-16**] EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-16**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-18**] throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Handedness Right
PHYSICAL EXAM UPON DISCHARGE: ***
Pertinent Results:
[**2199-3-13**] MRI BRAIN- IMPRESSION:
1. Study for surgical planning redemonstrating the right frontal
heterogeneously enhancing lesion with moderate-to-marked
surrounding edema and mass effect on the right lateral ventricle
and leftward shift of midline structures. No new enhancing
lesions.
[**2199-3-13**]: NCHCT- IMPRESSION: Immediate post-operative changes,
status post resection of right frontal lobe intra-axial mass. No
evidence of acute hemorrhage or infarction.
[**2199-3-14**] MRI BRAIN-1. Post-surgical changes in the right frontal
lobe with blood products. Assessment for any residual tumor is
limited on the present study.
2. Persistent moderate surrounding edema with mild leftward
shift of midline structures and mass effect on the right lateral
ventricle.
Brief Hospital Course:
Mr. [**Known lastname 23239**] presented for an elective right frontal craniotomy
for resection of recurrent tumor. Postoperatively he was
extubated and transferred to the ICU for Q1 hour neuro checks
and systolic blood pressure control less than 140. He remained
neurologically stable overnight but did complain of nausea and
pain which was controlled with IV medications.
On POD#1 he was cleared for transfer to the floor. Arterial line
and foley were removed and he was started on SQH. An MRI was
performed for post operative baseline on [**3-14**]. He [**Last Name (un) 4996**] to
mobilize and advance his diet.
On POD 2 he continued to have moderate headache but refused
narcotic pain medication because of the side effects. He
recieved Toradol 15mg IV and Fioricet. Right eye edema was
slightly worsened.
On POD 3, the day of discharge he was tolerating a regular diet,
ambulating without difficulty, afebrile with stable vital signs.
He will discharge home with close follow-up on [**2199-3-28**].
Medications on Admission:
Acetaminophen 325 to 650 mg q.i.d. p.r.n. pain, Sarna lotion
topically q.i.d. p.r.n. pruritus, ciprofloxacin 250 mg b.i.d.
times 5 days, Benadryl 25 to 50
mg q.i.d. p.r.n. pruritus, Lomotil 1 to 2 tablets q.i.d.
p.r.n. loose stools, iron 325 mg p.o. daily, gabapentin 1 to
200 mg q.6 hours p.r.n. pruritus, lorazepam 0.5 to 1 mg t.i.d.
p.r.n. nausea/vomiting, Compazine 10 mg q.i.d. p.r.n.
nausea/vomiting, ranitidine 150 mg b.i.d. p.r.n. indigestion,
Eucerin cream topically
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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain, fever > 101.4.
3. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for SBP>160.
4. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8hr () for
2 days.
Disp:*6 Tablet(s)* Refills:*0*
5. dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q8hr ()
for 2 days.
Disp:*12 Tablet(s)* Refills:*0*
6. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8hr () for
2 days.
Disp:*6 Tablet(s)* Refills:*0*
7. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q8hr ()
for 2 days.
Disp:*12 Tablet(s)* Refills:*0*
8. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q12hr ()
for 1 days.
Disp:*4 Tablet(s)* Refills:*0*
9. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for pain.
10. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*64 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Melanoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after staples have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please return to the office in [**7-23**] days (from your date of
surgery) for removal of your staples and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**].
?????? You have an appointment in the Brain [**Hospital 341**] Clinic on: [**2199-3-28**]
09:40a [**First Name9 (NamePattern2) 7548**] [**Hospital Ward Name **] SYMPHONY
[**Hospital6 29**], [**Location (un) **]
RADIOLOGY
[**2199-3-28**] 11:00a [**Doctor Last Name **],FONKEM
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
NEUROLOGY UNIT CC8 (SB)
Create Visit Summary
The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**],
in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
?????? You will need an MRI of the brain with and without gadolinium
contrast which is scheduled prior to your appointment.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4241
} | Medical Text: Admission Date: [**2107-3-29**] Discharge Date: [**2107-4-6**]
Date of Birth: [**2037-4-4**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Called by ED to evaluate patient for brain hemorrhage
Major Surgical or Invasive Procedure:
Left arm fasciotomy
Left arm thrombectomy
Left arm debridement
History of Present Illness:
Pt is a 69 yo male w/ PMHx sig for HTN, Afib reportedly on
Coumadin seen healthy by VNA four days ago at his rural [**State 1727**]
cabin and then found down today with blue LUE. Pt medflighted
to [**Hospital1 18**].
Past Medical History:
morbid obesity, HTN, AFib
Social History:
unknown
Family History:
unknown
Physical Exam:
T: 36.9C 152 143/131 26 100/2L
General: lying in bed
HEENT: dry mucous membranes
Neck: supple, no carotid bruit
Pulmonary: CTA b/l
Cardiac: irreg irreg, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: LUE - Blue hand diffusely with marked edema. Cool
extremity distal to elbow.
Neurological Exam:
Mental status: Eyes open, states name, does not respond to other
questions.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: L facial droop
XII: Tongue midline without fasciculations.
Motor/[**Last Name (un) **]: L sided flaccid hemiplegia, does not withdraw to
pain. Antigravity strength in RUE and RLE with withdrawal to
painful stimuli
Reflexes: trace, left toe up, right toe down.
Pertinent Results:
141 109 68
- - - - - - gluc 217
4.2 20 1.5
CK: 5979
Ca: 7.8 Mg: 2.5 P: 4.9
ALT: 66 AP: 58 Tbili: 0.9 Alb: 2.3
AST: 148 LDH: 320
[**Doctor First Name **]: 14 Lip: 17
WBC 19.3 HCT 38.6 PLT 238
PT: 15.5 PTT: 76.8 INR: 1.4
Radiology:
CT head - 1. Moderate to large amount of edema, likely
cytotoxic, involving right frontal and temporal lobes with
areas of high attenuation within the right frontal sulci
representing either subarachnoid hemorrhage or cortical laminar
necrosis in the setting of ischemic disease. The overall
appearance is more suggestive of an MCA distribution infarct
rather than acute trauma. Amyloid angiopathy may also be
considered. Recommend MRI with diffusion- weighted sequences
for better evaluation. 2. Moderate mass effect with compression
of right lateral
ventricle and 7 mm of left [**Hospital1 **] sub falcine herniation.
ELBOW (AP, LAT & OBLIQUE) LEFT [**2107-3-29**] 2:15 PM
HUMERUS (AP & LAT) LEFT; ELBOW (AP, LAT & OBLIQUE) LEFT
1. No definite acute fracture or dislocation in the left arm.
Soft tissue swelling, most prominent in the distal forearm,
wrist, and left hand.
2. Fracture at the IP joint, extending into the joint space, of
uncertain age. Clinical correlation recommended to determine
acuity of this finding.
CT C-spine: 1. No acute fracture or abnormal alignment of
cervical vertebral bodies identified. 2. Multilevel degenerative
changes with areas of foraminal narrowing as described above. 3.
Apical paraseptal emphysema.
Head CT [**2107-3-29**]: 1. Moderately large region of cytotoxic edema,
involving right frontal and temporal lobes with gyriform
high-attenuation foci along the right frontal sulci, likely
representing early cortical laminar necrosis in a subacute right
MCA territorial infarction. The overall appearance is more
suggestive of an ischemic rather than an acute traumatic event.
Amyloid angiopathy with subarachnoid hemorrhage is a more remote
consideration. Recommend MRI with diffusion- weighted and GRE
sequences for more definitive characterization. 2. Moderate
mass effect with compression of right lateral ventricle and 7 mm
of leftward subfalcine, but no uncal or transtentorial,
herniation.
PCXR: No definite congestive heart failure or pneumonia.
Follow-up PA and lateral chest radiographs are recommended if
clinically warranted.
Head CT [**2107-3-30**]: No change in the appearance of the brain with
no change in the amount of mass effect nor change in the area of
possible intraparenchymal hemorrhage. There is no change in the
amount of mass effect or subfalcine herniation. There is no
uncal herniation.
Path [**2107-3-31**]: Muscle, left arm: Necrotic skin and skeletal
muscle.
Unremarkable tendon.
ECHO [**2107-3-31**]: Echocardiographic windows very suboptimal. The left
atrium is moderately dilated. The right atrium is moderately
dilated. Lef ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is grossly
normal (LVEF>70%). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
Head CT [**2107-4-1**]: No significant interval change in right middle
cerebral artery hemorrhagic infarct as described above as well
as mass effect and leftward midline shift.
PCXR [**2107-4-2**]: New right effusion.
EKG [**2107-4-2**]: Atrial fibrillation with a rapid ventricular
response. Diffuse non-specific ST-T wave changes. No previous
tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 0 88 [**Telephone/Fax (2) 71558**]5 -7
PCXR [**2107-4-4**]: No evidence of pneumonia. Bilateral effusions,
increasing on the left, and mild CHF.
CXR [**2107-4-4**]: Right IJ replacement.
Single AP view of the chest is obtained [**2107-4-4**] at 14:10 hours
and is compared with the prior examination performed
approximately two hours previously. No acute change is
demonstrated. The ET tube is approximately 5 cm above the
carina. The right-sided IJ line has its tip projecting over the
distal SVC. Increased opacity is seen in the right hemithorax
consistent with layering right pleural effusion. No large
pneumothorax is seen in this projection.
Brief Hospital Course:
Pt is a 69 yo male w/ PMHx sig for afib and HTN who presents
after being found down at cabin in [**State 1727**]. General exam shows
compartment syndrome of LUE. Neurological exam significant for
minimal verbal output and left sided hemiplegia without sensory
response. INR sub therapeutic. The patient likely had large
cardiac embolus secondary to afib occlude his proximal R MCA.
This resulted in his collapse and subsequent rhabdomyolysis and
ischemia of LUE. Pt to be taken to OR for fasciotomy and then
will transferred to the NeuroICU.
Post-operatively clot found in L brachial artery s/p
thrombectomy. After discussion w/ vascular surgery, likelihood
of additional clot in palmar arch likely. Heparin gtt initiated
with understanding that any change in neuro status heparin
should be shut off and immediate CT head should be obtained.
goal PTT 50.
[**Doctor First Name **]: Patient went to OR for fasciotomy and thrombectomy [**3-29**]
then again on [**3-31**] and [**4-2**] for debridement. Plan was made on [**4-5**]
to proceed with amputation of the left arm. However, family
declined further care.
Neuro: Patient admitted to Neuro ICU. Head of bed was kept at
less than 30 degrees. HOB < 30 degrees
- q 1hr neuro checks, cardiac telemetry
- SBP < 185 and DBP < 105 and keep MAP > 65
- normothermia, normoglycemia
- if change in exam, get stat head CT and consult Nsurg given
possible ICH
- wean sedation when possible
- pain control
Cardiac:
- rate control
- Dc'd heparin IV [**3-31**] and started on coumadin [**3-30**]
- ruled out MI
- 2D ECHO poor study ~70% EF and does not comment on wall motion
abnormality or possible clot
Pulm:
- will discuss w/family ?trach/peg
Renal:
- IVF for Rhabdomyolysis
- follow Cr downtrending
PPX:
- colace/IV PPI
Code: full -> had converstaion with HCP [**Name (NI) **] [**Name (NI) **] on [**2107-4-5**]
where she made patient comfort measures only. Patient was
subsequently extubated and passed away on [**2107-4-6**]. Family
declined autopsy.
Comm: [**Name (NI) 501**] [**Last Name (NamePattern1) 1637**], SW involved. Discussed goals of care with
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 71559**] (HCP)
Medications on Admission:
Coumadin, diltiazem
Discharge Disposition:
Expired
Discharge Diagnosis:
Right middle cerebral artery stroke
Anterior compartment syndrome of the left forearm
Discharge Condition:
Deceased
Completed by:[**2107-4-7**]
ICD9 Codes: 5185, 5849, 4280, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4242
} | Medical Text: Admission Date: [**2110-12-7**] Discharge Date: [**2110-12-9**]
Date of Birth: [**2046-1-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64 yo M s/p MVA. The patient states that he was shopping with
his wife, they got back to the car and then he passed out and
hit a parked car. He denies any chest pain, difficulties
breathing, nausea or vomiting prior to this incident. He denies
any urinary or bowel incontinence and did not have a similar
episode in the past.
+EtOH (237 on admission).
In the ER the patient received 500ml NS, no meds per report or
documented in chart. Of note, the patient states that he was
stung by a bee yesterday for which he took benadryl at home and
then went to ER at OSH where he was observed for 2.5 hours. He
did not get an epinephrine injection.
Past Medical History:
PMH: ?CRI, HTN, HLD, "thyroid dz",?aortic aneurysm
PSH: "gum surgery"
Physical Exam:
99.4 67 110/64 15 96%2L
NAD/AAO
RRR
CTA b/l
SNDNT
no peripheral edema
Pertinent Results:
[**2110-12-7**] 05:18PM BLOOD WBC-7.8 RBC-4.38* Hgb-14.0 Hct-42.4
MCV-97 MCH-32.0 MCHC-33.1 RDW-13.1 Plt Ct-275
[**2110-12-7**] 10:01PM BLOOD WBC-9.4 RBC-4.23* Hgb-13.6* Hct-40.9
MCV-97 MCH-32.1* MCHC-33.2 RDW-13.1 Plt Ct-239
[**2110-12-8**] 06:19AM BLOOD WBC-7.4 RBC-3.80* Hgb-12.2* Hct-37.2*
MCV-98 MCH-32.0 MCHC-32.8 RDW-13.2 Plt Ct-221
[**2110-12-7**] 05:18PM BLOOD UreaN-26* Creat-2.1*
[**2110-12-7**] 10:01PM BLOOD Glucose-126* UreaN-23* Creat-1.5* Na-140
K-3.6 Cl-102 HCO3-25 AnGap-17
[**2110-12-8**] 06:19AM BLOOD Glucose-156* UreaN-19 Creat-1.1 Na-137
K-3.9 Cl-103 HCO3-26 AnGap-12
[**2110-12-7**] 05:18PM BLOOD ASA-NEG Ethanol-237* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
He was admitted to the trauma ICU from the ED for pain control
and respiratory monitoring related to his rib fractures. he was
placed on CIWA protocol given his +blood alcohol level at time
of admission. He remained in the ICU for approximately 24 hours
and once determined that his pain was controlled prn morphine he
was transferred to the regular nursing unit.
Once on the nursing unit he was transitioned to oral narcotics
for which he reported adequate relief. He was given a bowel
regimen as well.
Social work was consulted for assessment re; his +blood alcohol
level.
At time of discharge his pain is adequately controlled, he is
tolerating a regular diet and ambulating independently.
He will follow up in [**1-25**] weeks in [**Hospital 2536**] clinic for repeat chest
xray imaging.
Medications on Admission:
ASA, thyroid medicine, antihypertensive, statin
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Advil 200 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
5. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
6. senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed
for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motor vehicle crash
Bilateral rib fractures [**2-28**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* Your injury caused rib fractures on both sides of your chest
which can cause severe pain and subsequently cause you to take
shallow breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
Follow up in [**1-25**] weeks in [**Hospital 2536**] clinic call [**Telephone/Fax (1) 600**] for an
appointment. You will need a standing end expiraotry chest xray
before this appointment.
Completed by:[**2110-12-9**]
ICD9 Codes: 4019, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4243
} | Medical Text: Admission Date: [**2144-3-18**] Discharge Date: [**2144-3-26**]
Date of Birth: [**2094-5-1**] Sex: M
Service: TRANSPLANT
HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old
male with insulin dependent diabetes and end stage renal
failure. The patient had to be on dialysis for two and a
half years and the patient is status post renal transplant on
[**2144-1-8**], cadaveric. The patient is admitted for
cadaveric pancreatic transplant. Prior to admission the
patient has no nausea, vomiting, fevers or chills, normal
bowel movements and no dialysis since the renal transplant.
PAST SURGICAL HISTORY: Left AV fistula in [**2140**] and status
post cadaveric renal transplant.
PAST MEDICAL HISTORY: Hypertension, insulin dependent
diabetes, end stage renal failure.
ALLERGIES: No known drug allergies except for thyroglobulin.
MEDICATIONS AT HOME: Prograf 4 mg po b.i.d., Prednisone 10
mg po q.d., aspirin 325 mg po q.d., NPH 22 units in the a.m.,
CellCept [**Pager number **] t.i.d., Bactrim one tab q.d., Ganciclovir 500 mg
po t.i.d., Lopressor 50 mg po b.i.d., Paxil 20 mg po q.d. and
Pravachol 20 mg po q.d.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2144-3-19**]. He underwent a pancreatic transplant.
Postoperatively, the patient did well and the patient
remained in the Intensive Care Unit for three days. Because
the patient had increased output from his JP drain and had a
postoperative drop in hematocrit the patient received 6 units
of blood transfusion. On postoperative day number two the
patient stabilized. The hematocrit on the JP was 11 and it
was decided not to take the patient back to the Operating
Room to undergo reexploration. On postoperative day number
four the patient was transferred onto the floor and meanwhile
the patient's finger sticks have been excellent. They have
been ranging between 94 to 140. Also, while the patient was
seen in the unit his blood pressure was somewhat labile. At
first his blood pressure was low and he was on a Dopamine
drip to keep the systolic blood pressure above 120 and then
after the JP output decreased and after his hematocrit
stabilized, blood pressure has been elevated to around 170 to
180.
While on the floor the patient's condition stabilized and
improved. However, on postoperative day number five the
patient's creatinine peaked to 3.5 and the patient was
aggressively hydrated and creatinine has dropped down to 3.2.
At the same time his Prograf level was to be elevated to the
34. At the time the worry of cytomegalovirus reinfection or
reactivation was raised and infectious disease was consulted
and cytomegalovirus PCR test was sent out and cytomegalovirus
antigenemia test was then negative. Hematology was consulted
for his low white count to be at 1.4. They suggested it is
mainly probably due to immunosuppression and drug toxicity.
The patient was deemed ready for discharge on postoperative
day number seven. Prior to discharge the patient was
afebrile and vital signs were stable. Chest was clear.
Abdomen was soft, nontender, nondistended. Incision was
clean, dry and intact. JP has been discontinued. JP output
has been serosanguinous. The patient is tolerating regular
po and having normal bowel movements. He has been
ambulating. Finger stick sugars have been excellent in the
range of 100 to 150s. The patient will be discharged and
told to follow up in clinic on Tuesday.
DISCHARGE MEDICATIONS: Nystatin 5 cc q.i.d., Zantac 150 mg
po b.i.d., Prograf 2 mg po b.i.d., Rapamune 5 mg po q.d.,
Prednisone 20 mg po q.d., Colace 100 mg po b.i.d., Lopressor
50 mg po b.i.d., Norvasc 10 mg po q.d., iron sulfate 325 mg
po q.d., Paxil 20 mg po q.d., aspirin 325 mg po q.d.,
Percocet one to two tabs po q 4 to 6 hours prn.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern1) 28966**]
MEDQUIST36
D: [**2144-3-26**] 13:01
T: [**2144-3-26**] 14:07
JOB#: [**Job Number 28967**]
ICD9 Codes: 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4244
} | Medical Text: Admission Date: [**2158-5-10**] Discharge Date: [**2158-5-11**]
Date of Birth: [**2075-12-6**] Sex: F
Service: MEDICINE
Allergies:
Zithromax / Sorbitol
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82yo female with a history of COPD was admitted from the ED with
dyspnea.
.
She was seen on [**2158-5-5**] with her outpatient pulmonologist Dr.
[**Last Name (STitle) 575**] at which time she complained of persistently increased
shortness of breath. Her O2 requirement increased from 2L to 3L
O2 and was started on prednisone 5mg daily. Then one day prior
to this admission, she developed increased shortness of breath,
persistent cough with changed sputum production. Associated
symptoms include chills, light-headedness, and decreased
appetite. On the morning of admission, she was evaluated by her
home health aide who recommended that she go to the hospital.
She then presented to [**Hospital6 33**]. CXR demonstrated
chronic lung disease with RLL disease suggestive of pneumonia.
While in the OSH ED, she received levofloxacin, lorazepam,
solumedrol, and she was started on BiPap. Since she receives her
medical care from [**Hospital1 18**] primarily, she was transferred to [**Hospital1 18**].
.
Upon arrival to the [**Hospital1 18**] ED, temp 99.5, HR 90, BP 107/52, RR
21, and pulse ox 90% RA. She received ceftriaxone 1 g IV x1,
vancomycin 1g IV x 1, ativan 1mg IV x 1, aspirin 300mg PR x 1.
Past Medical History:
Past Medical History:
-CAD, h/o IMI '[**40**]; dobutamine stress ECHO ([**5-11**]) without
ischemia
-COPD followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**]; FEV1 0.51 (30% predicted)
on last PFTs.
-GERD
-history of gallstones
-biliary colic
- ulcerative colitis followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] states
recently treated with enemas 2-3 months ago.
-depression/anxiety
-osteoporosis w/thoracic compression fx
-Abd ventral hernia. Stable.
-Chronic back pain, currently seen at pain center
-hypothyroidism
Social History:
She is widowed. She lives by herself in [**Location (un) 470**] walk-up apt.
Supportive children. No ETOH or tobacco.
Family History:
n/c
Physical Exam:
Gen: cachectic, fatigued appearing
HEENT: Clear OP, dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: poor effort, crackles at right lower bases, poor air
movement throughout
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. frequently needs redirection to answer questions.
CN 2-12 grossly intact. Preserved sensation throughout. [**4-11**]
strength throughout. [**12-9**]+ reflexes, equal BL. Normal
coordination. Gait assessment deferred
Pertinent Results:
OSH LABS:
[**2158-5-10**]
WBC 26.8 / Hct 35.3 / Plt 280
N 17 / Bands 34 / L 3 / M 3 / Meta 19 / Myelocytes 24
Na 131 / K 3.5 / Cl 83 / CO2 41 / BUN 18 / Cr .5 / BG 82
Ca 8.8 / TP 6.8 / Alb 3.7 / Alk Phos 66
TB .6 / AST 37 / ALT 32
CK 174 / MB 9.8 / Trop T . 1
BNP [**Numeric Identifier 19197**]
.
[**Hospital1 18**] LABS:
[**2158-5-10**] - 7:35pm
Na 130 / K 4.7 / Cl 85 / CO2 35 / BUN 19 / Cr .6 / BG 51
Ck 184 / MB 8 / Trop T . 07
Ca 8.1 / Mg 1.5 / Phos 3.1
ALT 34 / AST 64 / Alk Phos 54 / TB .7 / Alb 3.5 / Lipase 11
WBC 20.4 / Hct 35 / Plt 248
N 33 / Bands 60 / L 3 / E 0 / M 1
INR 1.5 / PTT 31.1
.
OSH STUDIES:
- [**2158-5-10**] CXR - per report - chronic lung disease with right lung
disease suggestive of superimposed pneumonia
.
STUDIES:
- ECG [**2158-5-10**] - sinus rhythm with occasional PBCs, normal axis,
~100bpm, no acute ST change
- Echo [**6-14**] - EF 45-50% - normal LA; mild LV systolic
dysfunction with inferior / inferolateral hypokinesis; mild
global free wall HK; Significant pulmonic regurgitation is seen.
There is no pericardial effusion.
Brief Hospital Course:
She was admitted with hypoxia, hypercarbia, and found to have
pneumonia on CXR superimposed on COPD. She did not tolerate
BiPap and was maintained on high flow mask. She was continued on
broad spectrum antibiotics and unfortunately continued to
desaturate and further decompensate on high flow mask. She
developed bradycardia and asystolic cardiac arrest and died
within 5 minutes. She was DNR/DNI as confirmed with the patient.
Medications on Admission:
HOME MEDICATIONS:
1. Amlodipine 5mg PO daily
2. Aspirin 81mg PO daily
3. Tylenol / Codeine 30/300mg qid prn
4. Spiriva 18mcg inh daily
5. Synthroid 125mcg PO daily
6. Simvastatin 5mg daily
7. Pantoprazole 40mg daily
8. Lorazepam .5mg PO tid prn
9. Lasix 10mg PO daily
10. Advair discus inh [**Hospital1 **]
11. Albuterol 90mcg 1-2 puffs qid prn SOB
12. Lidoderm 5% [**Hospital1 **]
13. Mirapex .125mg qhs prn restless legs
14. Nitrostat .3mg SL NG
15. Hydrocortisone enemas prn
16. Colace 100mg qhs
17. Metamucil PO daily
18. MVI daily
19. Gas-X
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
COPD Exacerbation
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 486, 2761, 4168, 412, 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4245
} | Medical Text: Admission Date: [**2158-10-20**] Discharge Date: [**2158-10-24**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
[**2158-10-20**] Coronary Artery Bypass Graft x1 (saphenous vein graft),
Aortic Valve replacement (21mm CE tissue valve)
History of Present Illness:
86 year old female with known heart murmur, recent dyspnea on
exertion, dizziness, and lightheadedness. Underwent cardiac
workup revealed aortic stenosis and one vessel coronary artery
disease.
Past Medical History:
Aortic stenosis
Hypertension
coronary artery disease
anemia
arthritis
pneumonia [**2145**]
gastrointestinal bleed
AV malformation
Gastric ulcer
Social History:
Retired
Lives alone - support systems brothers
ETOH 1 glass wine/week
Tobacco denies
Family History:
father deceased at 80 from myocardial infarction
Physical Exam:
General NAD
Skin warm dry intact
HEENT EOMI PEERLA
Neck supple full ROM
Chest CTA
Heart RRR 3/6 murmur
Abd soft, NT, ND, +BS
Ext warm well perfused, spider varicosities bilat
Neuro a/o x3, MAE
Discharge
General NAD 98.1, 80 SR, 112/48, 18 RA sat 95%
Skin warm dry intact except sternal inc healing, CDI sternum
stable
HEENT EOMI PEERLA
Neck supple full ROM
Chest CTA
Heart RRR no murmur/rub/gallop
Abd soft, NT, ND, +BS
Ext warm well perfused, spider varicosities bilat
Neuro a/o x3, MAE, face symmetrical, right arm drift with
clumsiness
Pertinent Results:
[**2158-10-23**] 06:35AM BLOOD WBC-11.0 RBC-3.28* Hgb-10.3* Hct-30.9*
MCV-94 MCH-31.5 MCHC-33.4 RDW-14.1 Plt Ct-136*
[**2158-10-20**] 10:50AM BLOOD WBC-11.5*# RBC-2.74*# Hgb-8.5*#
Hct-25.8*# MCV-94 MCH-31.0 MCHC-33.0 RDW-14.2 Plt Ct-124*
[**2158-10-20**] 10:50AM BLOOD Neuts-78.6* Bands-0 Lymphs-17.3*
Monos-2.7 Eos-0.7 Baso-0.8
[**2158-10-23**] 06:35AM BLOOD Plt Ct-136*
[**2158-10-21**] 03:57AM BLOOD PT-12.2 PTT-29.3 INR(PT)-1.0
[**2158-10-20**] 10:50AM BLOOD PT-17.4* PTT-38.5* INR(PT)-1.6*
[**2158-10-20**] 10:50AM BLOOD Fibrino-155
[**2158-10-23**] 06:35AM BLOOD Glucose-89 UreaN-17 Creat-0.9 Na-143
K-4.2 Cl-105 HCO3-31 AnGap-11
[**2158-10-20**] 12:09PM BLOOD UreaN-18 Creat-0.8 Cl-117* HCO3-21*
[**2158-10-23**] 06:35AM BLOOD Calcium-8.9 Phos-1.4* Mg-1.9
[**2158-10-21**] 03:57AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.8*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2158-10-23**] 11:29 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman s/p avr cabg
REASON FOR THIS EXAMINATION:
evaluate effusion
TWO VIEW CHEST OF [**2158-10-23**]
COMPARISON: [**2158-10-22**].
INDICATION: Pleural effusions. Postop.
The patient is status post median sternotomy and aortic valve
replacement. Cardiac and mediastinal contours are stable in the
postoperative period. Bibasilar atelectasis and small pleural
effusions are again demonstrated, with no substantial change
allowing for technical differences between the studies.
Additionally, a hazy area of opacity is present in the right
upper lobe just above the minor fissure, slightly more
conspicuous than on the prior study but not evident on the prior
preoperative study from [**2158-10-17**].
IMPRESSION:
1. Bibasilar atelectasis and small pleural effusions.
2. Subtle right upper lobe opacity. Attention to this area on
short-term followup CXR is recommended to exclude an early focus
of pneumonia.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2158-10-23**] 2:36 PM
Cardiology Report ECHO Study Date of [**2158-10-20**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: avr
Status: Inpatient
Date/Time: [**2158-10-20**] at 09:13
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW-1:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aortic Valve - Peak Gradient: 92 mm Hg
Aortic Valve - Mean Gradient: 62 mm Hg
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal
inferior -
hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo; basal anterolateral - hypo; mid anterolateral - hypo;
anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex -
hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic
valve leaflets. Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
(1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was under
general anesthesia throughout the procedure. The TEE probe was
passed with
assistance from the anesthesioology staff using a laryngoscope.
No TEE related
complications.
Conclusions:
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage.
Right ventricular chamber size and free wall motion are normal.
LV systolic
fxn is globally midlly depressed.There are simple atheroma in
the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve
leaflets are severely thickened/deformed. Trace aortic
regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened.
There is no pericardial effusion.
[**Location (un) **] PHYSICIAN:
Cardiology Report ECG Study Date of [**2158-10-20**] 12:46:20 PM
Normal sinus rhythm. Q waves in leads III and aVF consistent
with old inferior
myocardial infarction. Downward sloping ST segment depressions
and T wave
inversions in leads I, aVL and V4-V6 suggest possible
anterolateral ischemia.
Delayed R wave transition and possible lead reversal in leads
V2-V3. Compared
to the previous tracing of [**2158-10-17**] the prominent Q waves in the
inferior leads
with slight ST segment elevations and downsloping ST segment
depressions in
the lateral precordial leads are new. Clinical correlation is
suggested.
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 138 84 412/415 68 -9 115
Brief Hospital Course:
Ms. [**Known lastname 73286**] was admitted through same day admission and was
brought to the operating room where she underwent a coronary
artery bypass graft x 1 and aortic valve replacement. Please see
operative report for surgical details. She tolerated the
procedure well and was transferred to the CSRU for invasive
monitoring in stable condition. Later on op day she was weaned
from sedation, awoke and was extubated. On post-op day one she
started on beta blockers and diuretics. She was gently diuresed
towards her pre-op weight. She was found to have right arm
clumsiness and neurology was consulted. Head CT scan was done
that ruled out intracranial bleed and no ischemia noted. She
continued to progress and right arm drift and clumsiness
decreased. Physical therapy followed her during entire post-op
course for strength and mobility. She continued to make steady
process and was ready for discharge to rehab on post operative
day 4.
Medications on Admission:
lisinopril
iron
vitamin d
omega 3
tylenol
lecithin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
8. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. medication
please consider starting ACE inhibitor when b/p increased
Discharge Disposition:
Extended Care
Facility:
Radius
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Coronary artery disease s/p CABG
Right sided weakness
Hypertension
Anemia
Arthritis
h/o Gastrointestinal bleed, AV malformation, gastric ulcer
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name (STitle) **] after discharge from rehab ([**Telephone/Fax (1) 23083**]) please call
for appointment
Dr [**Last Name (STitle) **] after discharge from rehab
Completed by:[**2158-10-24**]
ICD9 Codes: 4241, 4280, 4019, 2859, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4246
} | Medical Text: Admission Date: [**2153-9-18**] Discharge Date: [**2153-9-19**]
Date of Birth: [**2116-9-12**] Sex: M
Service: SURGERY
Allergies:
Amoxicillin / Lamictal
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Thyroidectomy
Major Surgical or Invasive Procedure:
Total thyroidectomy involving the substernal resection via
cervical approach
History of Present Illness:
37 yo Male with history of bipolar disorder presented for total
thyroidectomy [**9-18**] for multinodular goiter that was causing
tracheal narrowing, transferred to MICU after thyroidectomy to
monitor his airway. Patient noted to have feel a choking
sensation in neck approximately 3 years ago. His PCP at the time
felt this was due to GERD and was given Prilosec which did not
help. He never felt a mass in his neck, and due to his body
habitus never visualized anything. [**Last Name (un) **] the course of three years
he lost 85 pounds due to his own efforts. He continually felt a
choking sensation when he exercised, layed flat, and even
talked. He had a full pulmonary work up and was told exercise
induced asthma may be the culprit. Given albuterol which had no
effect.
His PCP referred him to ENT ([**8-29**]) recently due to large
tonsils that she noticed. ENT saw no concern with tonsils, but
noticed the large mass in his neck. Within two weeks of this
finding, he was referred for surgery of his thyroid mass. During
his pre-op clearance, a bronchoscopy was done that showed no
endotracheal narrowing. All was external compression from his
goiter.
Past Medical History:
Bipolar Disorder: Stable on current regimen
Gout: Indomethicin PRN. Has not had a flare-up since [**1-8**]
H/O Dermoid Cyst in Brain as a child that has since resolved.
Hemorrhoids
Hernia Repair x2 as child
Social History:
Lives alone in [**Hospital1 **]. Worked as a computer network
administrator, currently unemployed and actively looking for a
job. Has worked in Imaging at [**Hospital1 2025**] in the past. Former smoker,
quit 2 1/2 years ago after 25-30 pack/year history. Social
Drinker.
Family History:
Mother: ?thyroid disease, DMT2;
Father: COPD (smoker)
Maternal GM: CAD s/p CABG; Maternal GF: PCA at age [**Age over 90 **].
Physical Exam:
ON PRESENTATION, Pre-Operatively:
per Surgical team
ON ARRIVAL TO ICU, Post-Operatively:
VITAL SIGNS:
T=96.5 BP=112/62 HR=83 RR=16 O2= 99% 3 Liters
.
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Constricted pupils and PERRLA/EOMI. MMM. OP
clear. Anterior neck C/D/I
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema, 2+ dorsalis pedis/ posterior tibial
pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2153-9-18**] 02:04PM freeCa-1.21
[**2153-9-18**] 02:04PM HGB-14.6 calcHCT-44
[**2153-9-18**] 02:04PM GLUCOSE-103 LACTATE-1.9 NA+-139 K+-4.0
CL--105 TCO2-23
[**2153-9-18**] 02:04PM TYPE-[**Last Name (un) **] PH-7.42 INTUBATED-INTUBATED
[**2153-9-18**] 03:12PM HCT-37.7*
[**2153-9-18**] 03:12PM CALCIUM-9.1 MAGNESIUM-1.8
[**2153-9-18**] 03:12PM POTASSIUM-3.9
Pathology Examination
Thyroid, total thyroidectomy:
a. Follicular carcinoma with angioinvasion, see synoptic
report.
b. Papillary micro-carcinoma (slide C).
Brief Hospital Course:
The patient's operative course was c/b 500-600 cc of blood loss
and no transfusion needed. Patient was extubated after his
surgery with no tracheomalacia or stridor noted. He was
hemodynamically stable post-op and it was noted that he was not
a difficult intubation.
Upon arrival to the ICU, patient was conversing well and stated
he hasn't breathed this well in years. He was hemodynamically
stable.
His diet was slowly advanced, and he tolerated lunch well. He
was started on 200mcg daily of levothryoxine for thyroid hormone
replacement and discharged in stable condition.
Medications on Admission:
Topamax 50 mg [**Hospital1 **]
Azithromcyin 250 mg daily [**1-1**] sinusitis...Last dose was [**9-17**]
Ibuprofen prn (has not had any in 10 days)
Discharge Medications:
1. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day) for 2 weeks.
Disp:*56 Tablet, Chewable(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 2 weeks.
Disp:*30 Capsule(s)* Refills:*0*
5. Morphine 15 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Large substernal goiter with tracheal compression
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 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.
*Avoid driving while taking pain medication.
*Continue taking stool softeners with pain medication to prevent
constipation.
*You may feel tingling around your lips, arms & legs. Take TUMS
(2 tabs four times for a few days until tingling goes away).
emergency room if unable to reach MD.
*You may return to work once you feel comfortable.
*Avoid physical/strenuous activity until you feel comfortable.
*You may shower. Avoid swimming or bath for 5-7 days.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] 4 weeks.
Call [**Telephone/Fax (1) 9**] for an appointment.
ICD9 Codes: 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4247
} | Medical Text: Admission Date: [**2187-8-17**] Discharge Date: [**2187-8-23**]
Service: Orthopedic Surgery
HISTORY OF PRESENT ILLNESS: Mrs. [**Last Name (STitle) **] is a 87-year-old
woman who was transferred to [**Hospital6 2018**] from [**Hospital6 **] with a diagnosis of left
intertrochanteric hip fracture. The patient fell earlier on
the day of admission and subsequent to this was unable to
walk secondary to pain. The patient denied weakness, numbness
or paresthesias in left lower extremity.
PAST MEDICAL HISTORY:
1. Hypertension
2. Cataract
ADMISSION MEDICATIONS:
1. Toprol
2. Calcium
3. Aspirin 81 mg po q day
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
GENERAL: Pleasant 87-year-old woman in no acute distress.
VITAL SIGNS: Temperature 98??????, blood pressure 135/80, heart
rate 80, respiratory 18, O2 saturation 98% on room air.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light. Oropharynx clear.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm, no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended with positive bowel
sounds.
EXTREMITIES: Left lower extremity was shortened and
externally rotated. There was focal tenderness in the great
trochanter area of the left hip. Strength was [**5-13**] in left
toes, ankle and knee. Sensation was intact. Pulses were
normal, including popliteal, DP and PT pulses.
The rest of the physical exam was unremarkable.
X-RAYS revealed a left intertrochanteric fracture. Chest
x-ray was normal. Electrocardiogram was within normal
limits.
LABS: White blood cell count was 6.7, hematocrit was 34,
platelets 187. Sodium, potassium chloride, bicarbonate, BUN,
creatinine and glucose were all within normal limits.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2187-8-19**] and underwent open reduction and internal
fixation of left intertrochanteric fracture. For more
details about the operation, please refer to the operative
note from that date. The patient did not have any
postoperative complications. The operation was under general
anesthesia.
Preoperatively, the patient was started on Coumadin for deep
venous thrombosis prophylaxis. The patient also received 48
hours of Kefzol perioperatively. The patient's diet was
advanced as tolerated. The patient was noted to have some
mild difficulty with swallowing and a swallow study consult
was obtained. It was determined the patient did not have any
significant physiological or mechanical problems and those
difficulties were likely due to anxiety the patient was
experiencing postoperatively. The patient eventually
successfully tolerated a regular diet.
The patient was switched to oral pain medications
successfully. The patient made good progress with physical
therapy and was able to bear weight and walk successfully.
The patient will be discharged to the rehabilitation center.
During the hospital stay, the patient's hematocrit has
remained stable.
DISCHARGE MEDICATIONS are identical to the medications on
admission, plus Coumadin 2.5 mg po q day for target INR of
1.5.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11642**], M.D. [**MD Number(1) 19807**]
Dictated By:[**Name8 (MD) 7892**]
MEDQUIST36
D: [**2187-8-22**] 13:26
T: [**2187-8-22**] 13:33
JOB#: [**Job Number 35270**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4248
} | Medical Text: Admission Date: [**2121-5-21**] Discharge Date: [**2121-5-26**]
Date of Birth: [**2067-12-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Found lethargic on ground of prison; hyponatremia
Major Surgical or Invasive Procedure:
ICU monitoring
History of Present Illness:
This is a 53-year-old male prisoner who was admitted for
hyponatremia. He was found on the ground of his cell lethargic
and only opening his eyes to verbal stimuli. He was noted to
have left eye and left hip hematomas. He was taken to an
outside hospital where he was found to have a sodium of 97. He
was started on hypertonic saline, and his sodium level climbed
to 107. He was transferred to the [**Hospital1 18**] for further management.
In the emergency department, He was found to have a sodium of
108, and he was admitted to the [**Hospital Unit Name 153**] for further management. In
the [**Hospital Unit Name 153**], he denied any ingestion of water or any other
substance. He denied any neurologic symptoms. He did complain
of pain over his left temple.
Past Medical History:
Hyponatremia from primary polydipsia
Depression
Psychosis with violent behavior
Traumatic Brain Injury
Social History:
He is a prisoner at [**Location (un) **]and has a history of
violence. He is married and has two children. Per report, he
was a National Merit Scholar in high school and went on to
become an electrical engineer before he was in a motor vehicle
accident and developed a psychotic disorder.
Family History:
Unknown
Physical Exam:
Vitals: Temperature:95.1 Pulse:64 Blood Pressure:98/59
Respiratory rate:16, Oxygen saturation:97% on room air.
GENERAL: No acute distress.
HEENT: Large hematoma over left temple/cheek with left
conjunctival hemorrhage, moist mucous membranes.
CARDIAC: Regular rate and rhyhtm, s1,s2, without murmurs, rubs,
or gallops.
LUNGS: Clear to auscultation anteriorly.
ABDOMEN: Soft, nontender, nondistended, with normocative bowel
sounds.
EXTREMITIES: Warm and well perfused without cyanosis or edema
NEURO: Alert and oriented x 3. Responds to questions. Moves all
extremities spontaneously. Pupils reactive.
Pertinent Results:
Outside hospital:
--Na+ 97 --> 107
--CT maxillofacial ([**5-23**], prelim read): soft tissue hematoma
superior to L-orbit but no acute fracture; old L-orbital
fracture; DJD in C-spine.
--Urine Osm 62 at admission
.
Admission labs:
WBC-9.4 HCT-38 PLT COUNT-584
NEUTS-83.1 BANDS-0 LYMPHS-11.5 MONOS-4.7 EOS-0.1 BASOS-0.5
.
Sodium: 108
.
PT-12.8 PTT-29.5 INR(PT)-1.1
.
Serum and urine toxocology screen negative.
Brief Hospital Course:
This is a 53 year-old male with history of depression,
psychosis, hyponatremia secondary to primary polydipsia who was
admitted with hyponatremia.
.
1. Hyponatremia: His hyponatremia is secondary to primary
polydipsia (psychogenic polydipsia). His urine was dilute on
admission (osmolarity = 62). His sodium corrected with fluid
restriction. Once his sodium corrected, he had urine
electrolytes and osmolarity checked, and these values were
within normal limits. It is unclear whether he had access to
free water, but presumedly he drank from a sink/toilet. He had
a similar presentation 3 weeks prior. It is unclear if this was
a suicide attempt verse secondary gain from hospitalization. It
is recommended that he have strict monitoring upon discharge to
prevent excessive fluid intake. He could benefit from periodic
electrolyte checks at prison if possible.
.
2. Trauma: He was found on floor in his cell. It is presumed
that he seized or fell secondary to hyponatremia. He had left
eye and left thigh ecchymoses on admission. His neurological
exam was within normal limits. A CT scan at the outside
hospital had a suggestion of a left lateral orbital fracture.
A repeat CT scan here showed no evidence of fracture. Plastic
surgery was consulted and recommended no intervention after
maxillofacial CT was performed and negative for acute fracture.
.
3. Report of melena and guaiac positive stool: His hematocrit
remained stable. He had no further melena or hematochezia. He
had no symptoms of active bleeding other than the old
ecchymoses. His vitals remained stable. He will need an
outpatient colonoscopy at some point to further evaluate.
.
4. Vertigo: On hospital day 3, he complained on vertigo
especially with turning his head to the left. He was evaluated
by neurology who felt that he had peripheral vertigo given his
rotatory nystagmus. It was recommended to try ativan for
symptomatic relief and this did not work for him. He was
educated in Epley's maneuver's to continue until his symptoms
resolved. He still had some vertigo at the time of discharge.
.
5. Psych: He has a history of depression and psychosis. It is
possible that he is seeking secondary gain from
hospitalizations. He was followed by psychiatry while in house.
They recommended starting clozaril; however, his white count
was low. Therefore, this was differed and should be considered
as an outpatient. He was continued on his regular seroquel.
.
6. FEN: He was maintained on fluid restriction up to 2L on the
day of discharge. His hyponatremia was corrected as above.
.
7. Prophylaxis: He was placed on SC heparin & pantoprazole for
prophylaxis throughout hospital stay.
.
8. Code: full.
.
9. Dispo: He was discharged back to prison.
Medications on Admission:
seroquel 50 qAM, 100 qhs
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-23**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for
constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO qAM.
Discharge Disposition:
Home
Discharge Diagnosis:
primary polydipsia with hyponatremia
psychosis
depression
left eye and left thigh hematomas
Discharge Condition:
medically stable
Discharge Instructions:
--Contact MD if you develop chest pain, fever/chills,
seizure-like activity, or other concerning symptoms.
--Do not drink more than 2 liters of fluid per day maximum.
--Take all medications as directed.
--He may benefit for epley's maneuvers (see attached sheet) for
his vertigo.
Pt should be on both medical and suicide watch. The concern in
terms of medical watch is that he was likely drinking water
while not being watched. He will also need to have labs drawn
periodically, particularly sodium. It is also strongly
recommended that he be started on clozaril 12.5mg daily after
his WBC count is normal (was 3.8 here on discharge).
Followup Instructions:
follow-up with medical team and mental health services at prison
within 1 week
It is strongly recommended by our psychiatrists that the pt be
started on clozaril 12.5mg daily. This should be done after
pt's WBC count is checked, as it has decreased while
hospitalized to 3.8.
Pt will also need an outpatient colonoscopy to further evaluate
his guaiac positive stool.
Completed by:[**2121-5-27**]
ICD9 Codes: 2761, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4249
} | Medical Text: Admission Date: [**2128-6-16**] Discharge Date: [**2128-6-21**]
Date of Birth: [**2059-6-23**] Sex: F
Service: TRA
Expired at [**2047**] hours on [**2128-6-21**].
CHIEF COMPLAINT: This is a 69 year-old female who was
brought to the [**Hospital1 69**] from a
referring hospital. The patient had been found at the bottom
of the stairs after a fall. The patient was noted to have [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 2611**] coma score of 3 on arrival of the EMS and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**]
coma score of 3 upon arrival in the [**Hospital1 190**] emergency room. During work the imaging
technique after initial stabilization revealed the following
injuries: Multiple rib fractures. Fractures of the dorsal
vertebra closed. Fracture of the lumbar vertebra closed.
Cerebral contusion with coma. The patient also was noted to
have a significant pulmonary contusion and fractured
clavicle.
HOSPITAL COURSE: The patient was admitted to the trauma
surgical Intensive Care Unit with neurosurgical consultation.
The patient required ventilatory support, arterial
catheterization and hemodynamic monitoring in order to
monitor her resuscitation. During her hospital course the
patient developed a bronchopneumonia and resulting
septicemia. Over the ensuing several days she required an
escalating level of vasopressor support. She essentially
became unresponsive to vasopressor support, sustained a
cardiac arrest from which she was unable to be resuscitated
on [**2128-6-21**]. She was pronounced dead at [**2047**] hours.
[**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 67332**]
Dictated By:[**Last Name (NamePattern1) 67333**]
MEDQUIST36
D: [**2128-9-16**] 17:30:08
T: [**2128-9-16**] 18:09:34
Job#: [**Job Number 67334**]
ICD9 Codes: 486, 0389, 5185, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4250
} | Medical Text: Admission Date: [**2151-11-13**] Discharge Date: [**2151-11-25**]
Date of Birth: [**2072-8-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 9006**] is a 79yo Cantonese man (nonverbal at baseline) with
h/o severe dementia, several aspiration pnas, frequent UTIs who
was recently discharged from our hospital in [**Month (only) 359**] during
which time he was treated for Cdiff, UTI with yeast, and
aspiration pna with Zosyn. He presents today from his nursing
home with shortness of breath and dark urine. According to the
patient's grandson, who saw him yesterday, he looks much worse
today than he did at that time. He just finished treatment for
Cdiff with flagyl and po vanco, which was just stopped and by
report diarrhea worsened after discontinuing. It is also unclear
by his records whether he remains on or has just stopped zosyn
and vanco iv for aspiration pna. Culture data in our computer is
unrevealing except for urine repeatedly positive for yeast.
.
On arrival to our ER he was found to have new hypernatremia to
159 and to be tachycardic between 114-150 (last d/c summary
shows pt was tachycardic from 90s-110s throughout entire last
admission). He had O2 sat 81% on RA and required nonrebreather
mask in the ER for O2 sat 100%. His white count was 20, which is
stable from his last admission. He was given vancomycin 1g iv,
levofloxacin 500mg and flagyl 500mg. He was started on D5 1/2NS
at 150cc/hr. Blood and urine cultures were sent.
.
After a long discussion with his family (by the ER resident, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) they decided to continue his DNR/DNI status but
otherwise want him treated as needed. They will revisit this
after seeing if he stabilizes in a few days (versus possible
change to CMO). He was admitted to the ICU for increased nursing
needs.
Past Medical History:
- severe dementia, nonverbal at baseline
- subdural hematoma
- HTN
- chronic indwelling foley, s/p frequent UTIs
- Gtube, s/p several asp pnas
- BPH
- stage IV sacral decub
- MRSA wound infection
- osteoarthrosis
- dysphagia
- DM2
- PUD
Social History:
lives in nursing home. has 2 sisters, son-in-law, grandson who
are very involved. no etoh or tobacco. wife and several
children, most of whom are Cantonese-speaking only.
Family History:
noncontributory
Physical Exam:
109, 105/80, RR 24, 100% on NRB
gen: minimally responsive, opens eyes to shouting, cachectic
HEENT: PERRL, MM dry, mouth breathing, eyes and cheeks sunken
Neck: JVP 3-4cm, no LAD
Cor: s1s2, tachy, regular rhythm, no r/g/m
Pulm: CTAB, dcreased BS on R compared to L
Abd: soft, cachectic, NT, +bs, Gtube in place
guaiac neg in ER
Ext: no c/c/e, w/w/p
Skin: notable breakdown on medial surfaces of both knees, at top
of R ear, large sacral decub stage 4
Pertinent Results:
CHEST (PORTABLE AP) [**2151-11-13**] 7:13 PM
AP UPRIGHT CHEST: Tip of a right PICC terminates in the distal
SVC. Heart, mediastinal structures are unremarkable and stable.
Nodular density previously noted in the right mid lung not well
appreciated. Basilar consolidations, right greater than left,
improved in comparison to the prior study. There is persistent
prominence of the pulmonary central vasculature representing
volume overload. No pneumothorax is identified.
Improving bibasilar consolidations. Mild pulmonary interstitial
edema.
.
CHEST (PORTABLE AP) [**2151-11-14**] 5:49 AM
There has been improvement in the right-sided aspiration
pneumonia. Changes in the left chest remain unaltered.
IMPRESSION: Some improvement in right lower lobe pneumonia.
.
CHEST (PORTABLE AP) [**2151-11-17**] 12:32 AM
Bilateral pulmonary opacities markedly asymmetric with left
predominance could represent either widespread pneumonia or
asymmetric pulmonary edema. Clinical correlation is needed.
.
CHEST XR: [**2151-11-23**]
There are bilateral effusions with a left lower lobe opacity,
which may represent atelectasis or pneumonia. There are also
similar bilateral diffuse parenchymal opacities, which are
predominantly basilar. There is no cardiac enlargement or upper
zone redistribution of the pulmonary vessels. There is also a
more nodular density seen in the left upper lung zone as well,
perhaps an early consolidation
.
CHEST CT: [**2151-11-24**]
Bilateral smoothly layering fluid density pleural effusions,
without evidence of loculation, but with compressive
atelectasis.
2. Centrilobular emphysema.
3. Low-density lesion within the liver dome, likely represents a
simple cyst. A left well-characterized lesion in the pancreatic
head is also seen. MRI or multiphasic CT is recommended for
further evaluation if indicated
.
EKG: [**11-24**]
Sinus tachycardia. Non-specific ST-T wave changes. Compared to
the previous tracing lateral T wave inversion is new
.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2151-11-25**] 06:48AM 23.9*
[**2151-11-24**] 03:54PM 11.5* 2.32* 7.6* 22.5* 97 32.7* 33.6
18.8* 3851
1 VERIFIED BY SMEAR
SOME LARGE PLATELETS NOTED ON SMEAR
[**2151-11-24**] 05:12AM 23.9*
[**2151-11-24**] 02:11AM 25.0*
[**2151-11-21**] 06:07AM 10.8 2.65* 8.3* 25.6* 97 31.4 32.5 18.4*
539*
[**2151-11-20**] 06:07AM 10.2 2.55* 8.2* 24.5* 96 32.2* 33.5 18.0*
570*
[**2151-11-18**] 05:02AM 9.4 2.39* 7.7* 22.7* 95 32.0 33.8 17.7*
577*
RECEIVED THE SPECIMENS IN THE ROUTINE BAG NOW.
[**2151-11-17**] 08:40AM 9.8 2.59* 8.3* 24.3* 94 32.0 34.1 17.4*
543*
[**2151-11-16**] 02:49AM 9.9 2.51* 7.9* 23.0* 92 31.6 34.3 17.3*
546*
[**2151-11-15**] 03:44PM 22.0*
[**2151-11-15**] 04:27AM 10.9 2.44*# 7.4*# 23.0* 94 30.3 32.1
17.5* 517*
[**2151-11-15**] 02:35AM 21.8*
[**2151-11-14**] 02:04PM 20.8*
[**2151-11-14**] 03:30AM 13.1* 1.73* 5.4* 17.2* 100* 31.0 31.2
17.1* 527*
[**2151-11-13**] 06:35PM 20.3* 2.13* 6.6* 21.2*1 100* 31.0 31.1
17.0* 674*
1 CRITICAL RESULT CALLED TO DR. [**Last Name (STitle) 96**] IN EW AT [**2090**]
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2151-11-17**] 08:40AM 76.6* 20.1 2.4 0.8 0.1
[**2151-11-16**] 02:49AM 86.5* 0 11.3* 1.7* 0.5 0.1
[**2151-11-13**] 06:35PM 76.9* 20.4 1.7* 0.5 0.4
RED CELL MORPHOLOGY Hypochr Anisocy Macrocy
[**2151-11-17**] 08:40AM 1+ 1+
[**2151-11-13**] 06:35PM 3+ 1+ 2+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2151-11-24**] 03:54PM 3851
1 VERIFIED BY SMEAR
SOME LARGE PLATELETS NOTED ON SMEAR
[**2151-11-21**] 06:07AM 539*
[**2151-11-20**] 06:07AM 570*
[**2151-11-18**] 05:02AM 577*
RECEIVED THE SPECIMENS IN THE ROUTINE BAG NOW.
[**2151-11-17**] 08:40AM 543*
[**2151-11-17**] 08:40AM 13.6* 28.5 1.2*
[**2151-11-16**] 02:49AM 546*
[**2151-11-15**] 04:27AM 517*
[**2151-11-14**] 03:30AM 527*
[**2151-11-13**] 06:35PM 674*
[**2151-11-13**] 06:35PM 13.3* 27.0 1.2*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2151-11-25**] 06:48AM 126* 28* 0.8 141 3.9 108 26 11
[**2151-11-24**] 05:12AM 129* 30* 0.8 142 4.0 108 25 13
[**2151-11-23**] 08:59AM 122* 32* 0.9 144 3.7 111* 31 6*
[**2151-11-22**] 07:10AM 123* 30* 0.8 144 3.8 111* 26 11
[**2151-11-21**] 06:07AM 128* 31* 0.9 147* 3.6 113* 25 13
[**2151-11-20**] 06:07AM 123* 30* 0.9 147* 3.7 115* 25 11
[**2151-11-18**] 05:02AM 111* 29* 0.9 144 3.8 112* 24 12
RECEIVED THE SPECIMENS IN THE ROUTINE BAG NOW.
[**2151-11-17**] 08:40AM 114* 29* 0.9 144 4.21 115* 20* 13
SLIGHTLY HEMOLYZED
1 HEMOLYSIS FALSELY ELEVATES K
[**2151-11-16**] 02:49AM 105 33* 0.9 139 3.5 109* 22 12
[**2151-11-15**] 03:44PM 141
[**2151-11-15**] 04:27AM 128* 39* 1.0 146* 4.0 114* 22 14
[**2151-11-15**] 02:35AM 147*
[**2151-11-14**] 02:04PM 115* 48* 0.9 150* 3.7 119* 23 12
[**2151-11-14**] 03:30AM 120* 55* 1.0 157*1 4.0 124*1 24 13
1 VERIFIED BY REPLICATE ANALYSIS
NOTIFIED [**Doctor First Name **] AT 0500 [**2151-11-14**]
[**2151-11-13**] 06:35PM 137* 63* 1.2 159*1 4.8 124*1 27 13
1 VERIFIED BY REPLICATE ANALYSIS
NOTIFIED A.[**Doctor Last Name **],11.18.06,7.45P
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2151-11-23**] 08:59AM Using this1
1 Using this patient's age, gender, and serum creatinine value
of 0.9,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2151-11-23**] 08:59AM 8.0* 3.3 1.9
HEMATOLOGIC calTIBC VitB12 Folate Ferritn TRF
[**2151-11-14**] 03:30AM 68* 698 17.3 1678* 52*
LAB USE ONLY RedHold
[**2151-11-13**] 06:35PM HOLD
Blood Gas
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate
[**2151-11-13**] 06:56PM 1.2
Hematology
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2151-11-23**] 05:30PM Straw Hazy >=1.035
[**2151-11-18**] 07:26PM Yellow Clear 1.012
[**2151-11-13**] 06:55PM Yellow Hazy 1.018
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
[**2151-11-23**] 05:30PM LG NEG NEG NEG NEG NEG NEG 6.5 TR
[**2151-11-18**] 07:26PM LG NEG NEG NEG NEG NEG NEG 5.0 TR
[**2151-11-13**] 06:55PM LG POS 30 NEG TR NEG NEG 5.0 MOD
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2151-11-23**] 05:30PM 21-50*1 0-2 OCC NONE 0
1 CORRECTED RESULT, PREVIOUSLY REPORTED AS 0-2
NOTIFIED [**Name8 (MD) **], RN AND [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] AT 8PM [**2151-11-23**]
[**2151-11-18**] 07:26PM 21-50* [**6-5**]* FEW NONE 0
[**2151-11-13**] 06:55PM [**11-15**]* [**6-5**]* MOD MANY 0-2
URINE CASTS CastGr
[**2151-11-13**] 06:55PM 0-2 COARSE GRANULAR CASTS
Chemistry
URINE CHEMISTRY Hours Creat Na
[**2151-11-13**] 09:00PM RANDOM 41 50
CATHETER
[**2151-11-13**] 09:00PM RANDOM
CATHETER
OTHER URINE CHEMISTRY Osmolal
[**2151-11-13**] 09:00PM 464
CATHETER
LAB USE ONLY, URINE Uhold
[**2151-11-13**] 09:00PM HOLD
.
Urine [**11-13**]: PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
2ND ISOLATE. <10,000 organisms/ml
Urine [**11-25**]: No growth
.
Blood culture [**11-13**] x2: No growth
Blood Culture [**11-23**] x2: Pending
.
Stool culture (C.diff screen) [**11-14**], [**11-15**], [**11-16**]: C.diff toxin
negative
.
MRSA screen [**11-15**]: (+)MRSA, (+)VRE
.
Brief Hospital Course:
79yo man male with recurrent Urinary tract infections,
aspiration pnas to ICU with SOB, hypernatremia and anemia. In
the MICU maintained on vanc zosyn flagyl. urine culture + for
pseudomonas. Loose brown stools. Periodically alert. Sating
well. Transferred to floor, aphasic, cachectic. DNR/DNI, pending
further follow up of infection and placement. To floor on Zosyn,
oral vanc and flagyl for c-diff and UTI.
.
# SOB: unclear etiology. Chronic aspirator, but with no evidence
of pneumonia. Patient put on aspiration precautions. Pt put on
zosyn and flagyl, providing adequate coverage for patient if
aspirating. Continued to monitor for signs of ensuing infection.
Pt tachypneic to 40, unclear etiology but saturating fine.
Repeat CXR with worsening pneumonia vs increasing pulmonary
edema. Chest CT was performed and pulmonary was consulted to r/o
infectious event including empyema. CT showed b/l pleural
effusions w/ underlying atelectasis but felt by medicine and
pulm that not parapneumonic given Pt is afebrile and more
suggestive of some CHF component. Considered ECHO but no
apparent breathing distress and sating at 100%RA and diuresing
but BP borderline. Pt d/c'd sating at 100% on RA with no
apparent dyspnea.
.
# fever: Pt w/ one episode of 101.1 temp. BCX, UCX sent, foley
replaced, PICC line and PEG tube checked w/ no signs of
infection. Sacral decub also checked w/ no clincial signs of
infection. Repeat EKG w/ no new changes. Repeat CXR showing no
acute cardiac issues but ? increase in b/l basilar effusion w/
LLL opacity, ? infectious- see above. (+) rhonchi on exam, no
apparent trouble breathing, mild productive cough. UCX w/ no
growth, BCX pending. Fever resolved w/ tylenol and remained
afebrile for rest of stay
.
# Urinary tract infection: pt was started on fluconazole for
urine with yeast on [**10-25**] for 2 weeks. Pt started on Zosyn for
UTI currently, given pseudomonas in culture and bacteria
sensitive to zosyn. Considered total 10 day course of Abx for
UTI and aspiration pneumonia.
.
# C-diff-pt was diagnosed during last hospitalization in [**Month (only) 359**]
and was treated from [**10-26**] with oral vanco and flagyl for
planned total 3 weeks. Unsure date of stopping medication but as
report diarrhea recurred once stopping. c-diff toxin (-) x 3.
Had been treated with PO vancomycin, but with neg c-diff x 3,
[**11-18**] DC'd po vanc. Continued IV flagyl for aspiration pneumonia
.
# sacral decub: No signs of infection, clinical signs of
infection so will not cover for skin flora at this time.
Attempted to control incontinence to avoid fecal material
contaminating wounds, by placing a rectal bag. Dressed wound
with following wound care recs.
.
# ARF: On admission which appeared pre-renal, baseline 1.5,
currently at 0.9.
Likely hypovolemia for renal failure resolved with hydration,
though also UTI. FENA prerenal picture.
.
# anemia: Crit to 24 on admission to ICU. Iron studies with
anemia of chronic disease. guaiac neg in ER. Transfused 1 unit
in the MICU. Continued to guaiac stools. HCT remaining stable at
23-25 while in house and discharged at 23.9.
.
#hematuria: Foley changed as result of fever 101.1. Soon after
Pt removed w/ balloon inflated resulting in bleeding and
subsequent clots. 3 way foley placed w/ frequent flushing.
Hematuria resolved upon discharge.
.
# FEN: NPO, tube feeds by Gtube (probalance 40cc/hr).
Hypovolemic hypernatremia treated with D5 1/2NS and free water
boluses in Gtube. Free water deficit of 3L on admission to the
ICU. Monitored fluid status. [**11-20**] increased free water bolus to
125 q 4 but net +, [**11-21**] increased free fluid bolus given
hypernatremia to 150 Q4, though appears to be overloaded on CXR,
so considered possible lasix - see above.
.
# contact: grandson [**Name (NI) **] [**Telephone/Fax (1) 9007**]; [**Name2 (NI) **]er (HCP) yuping
[**Telephone/Fax (1) 9008**]; son-in-law [**Doctor Last Name **] [**Telephone/Fax (1) 9009**]
Medications on Admission:
iv vancomycin ?d/ced [**11-4**]
fluconazole
?zosyn
ativan
lansoprazole 30mg gtube qday
keppra 500mg gtube [**Hospital1 **]
zantac
vicodin 2 tabs [**Hospital1 **]
heparin sq
flagyl
PO vancomycin
sertraline
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
2. 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.
3. 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.
4. Piperacillin-Tazobactam 4.5 g Recon Soln [**Hospital1 **]: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 1 days: Please d/c
after one more day to complete day [**10-5**] for UTI.
Disp:*3 Recon Soln(s)* Refills:*0*
5. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback [**Month/Year (2) **]:
One (1) Intravenous Q8H (every 8 hours) for 1 days: Please d/c
after one more day. Flagyl was given as prophylactic while in
other antibiotic.
Disp:*3 qs* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Severe dementia
hypernatremia
urinary tract infection
c-diff colitis
recurrent aspiration pneumonia
Discharge Condition:
at baseline; Patient is non verbal, bed ridden has a PEG and a
PICC line for IV antibiotics. Is afebrile
Pt is very tachycardic at baseline
Discharge Instructions:
You were admitted for dehydration, urinary tract infection, and
aspiration pneumonia. You were treated with antibiotics.
-Please take all medications as prescribed to you
-Please maintain all appointments
Followup Instructions:
Please follow up your primary care doctor
Completed by:[**2151-11-25**]
ICD9 Codes: 5990, 5070, 2760, 4280, 5849, 5859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4251
} | Medical Text: Admission Date: [**2195-7-28**] Discharge Date: [**2195-8-5**]
Date of Birth: [**2112-3-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Nasotracheal Intubation
PEG-tube to J-tube conversion
Placement of a midline in R arm
History of Present Illness:
Patient is a 82 yo M with h/o dementia, seizure disorder and
chronic aspiration events, s/p PEG placement in [**Month (only) 958**] of 08
after mutltiple aspiration events and a failed swallow study,
who was transferred from his rehab facility ([**Hospital3 2558**])
early this morning in respiratory distress. Attempted to give pt
nebs at NH with no relief of SOB or wheezing, 90% on 4L NC. At
that time, nursing staff noted pt to appear diaphoretic,
hypertensive to 169/97 tachycardic.
.
In the [**Name (NI) **], pt was febrile, tachycardic, tachypneic, but
normotensive, satting 98% NRB. V/S Tm: 101.5, HR 118, BP 136/76,
RR 26, O2 98% NRB.
Past Medical History:
Dementia
Recurrent aspiration s/p G tube [**2-28**]
MSSA bactermia
Seizure disorder
Depression
Osteoarthritis
IBS
Vitamin B12 deficiency
chronic hypernatremia
s/p ORIF [**January 2192**]
Social History:
Lives full time at [**Hospital3 2558**]. Brother lives on [**Hospital3 **] and
is POA.
Family History:
Non-contributory
Physical Exam:
Vitals: T:38.3 BP: 101/59 P: 98 RR:16 O2Sat: 99%
Vent settings: 16/600/8/100% on arrival to MICU
Gen: Nasotracheal tube in place, pt opens eyes to voice, not
following commands
HEENT: PERRL, EOMI, sclerae anicteric
NECK: supple
CV: Regular, nl s1/s2
LUNGS: coarse diffuse rhonchi R >L @ the bases, mild expiratory
wheezing bilaterally
ABD: soft, non-tender, non-distended. G-tube site in mid-abdomen
C/D/I with no erythema
EXT: bilateral lower extremity contractures
SKIN: Stage I sacral decubitus ulcer
Pertinent Results:
[**2195-7-28**]: ECG
Baseline artifact. Sinus tachycardia. Left axis deviation.
Persistent S wave to lead V6. Consider pulmonary disease.
Compared to the previous tracing of [**2194-2-12**] the axis is more
leftward and ventricular premature beat is no longer seen. ST-T
wave abnormalities have improved.
[**2195-7-28**] 09:40AM TYPE-ART PEEP-8 O2-70 PO2-229* PCO2-46*
PH-7.35 TOTAL CO2-26 BASE XS-0 INTUBATED-INTUBATED
VENT-SPONTANEOU
[**2195-7-28**] 08:56AM GLUCOSE-213* UREA N-40* CREAT-0.9 SODIUM-139
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
[**2195-7-28**] 08:56AM estGFR-Using this
[**2195-7-28**] 08:56AM CALCIUM-8.6 PHOSPHATE-4.0 MAGNESIUM-2.0
[**2195-7-28**] 08:56AM PT-14.7* PTT-26.7 INR(PT)-1.3*
[**2195-7-28**] 08:11AM POTASSIUM-5.1
[**2195-7-28**] 08:11AM PHENOBARB-16.6
[**2195-7-28**] 06:23AM K+-4.8
[**2195-7-28**] 06:00AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012
[**2195-7-28**] 06:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2195-7-28**] 06:00AM URINE RBC-21-50* WBC->50 BACTERIA-MOD
YEAST-NONE EPI-0
[**2195-7-28**] 05:46AM TYPE-ART PH-7.42
[**2195-7-28**] 05:46AM GLUCOSE-206* LACTATE-5.0* NA+-137 K+-7.5*
CL--97* TCO2-22
[**2195-7-28**] 05:46AM freeCa-0.99*
[**2195-7-28**] 05:40AM WBC-29.2*# RBC-4.13* HGB-13.3* HCT-39.5*
MCV-96 MCH-32.2* MCHC-33.7 RDW-14.2
[**2195-7-28**] 05:40AM NEUTS-82* BANDS-12* LYMPHS-3* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2195-7-28**] 05:40AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2195-7-28**] 05:40AM PLT SMR-NORMAL PLT COUNT-303
[**2195-8-4**] 05:00AM BLOOD WBC-10.3 RBC-3.71* Hgb-11.5* Hct-34.8*
MCV-94 MCH-31.0 MCHC-33.1 RDW-14.0 Plt Ct-291
[**2195-8-4**] 05:00AM BLOOD Plt Ct-291
[**2195-8-4**] 05:00AM BLOOD PT-13.8* PTT-20.9* INR(PT)-1.2*
[**2195-8-4**] 05:00AM BLOOD Glucose-140* UreaN-24* Creat-0.9 Na-143
K-4.1 Cl-105 HCO3-27 AnGap-15
[**2195-7-30**] 06:21AM BLOOD ALT-24 AST-26 LD(LDH)-137 AlkPhos-82
Amylase-40 TotBili-0.1
[**2195-8-4**] 05:00AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.7
[**2195-7-30**] 06:21AM BLOOD Lipase-17
[**2195-8-3**] 03:11AM BLOOD Phenoba-19.6
[**2195-8-4**] CXR:
FINDINGS: In comparison with study of [**8-3**], there is no interval
change.
Cardiomediastinal silhouette is stable in this patient with an
S-shaped
thoracolumbar scoliosis. There are patchy opacities in the upper
zones bilaterally, most likely reflecting summation shadows
rather than focal regions of pneumonia. Pulmonary vascularity is
within normal limits and there is no evidence of pleural
effusion.
IMPRESSION: No change or evidence of acute focal pneumonia.
[**8-3**] Radiology report: PEG to j-tube transition
Successful exchange of a gastrostomy tube for a 14 French [**Doctor Last Name 9835**]
GJ tube with the tip terminating in the proximal jejunum.
Brief Hospital Course:
.
Respiratory Distress / Aspiration PNA:
Upon arrival to the [**Name (NI) **], pt was found to be in extremis with
visible tube feedings in nose and oropharynx. He was febrile,
tachycardic, tachypneic, with leukocytosis and lactate of 5. His
respiratory distress was presumed to be due to aspiration
(chemical pneumonitis v. early aspiration pna) so in the ED he
was given a dose of Vancomycin, Flagyl, Cefepime, and Levaquin.
Pt also had awake nasotracheal intubation in the ED for airway
protection. On arrival to the MICU blood pressure was low
normal, raising concern for developing sepsis. Vancomycin,
Unasyn, & Levaquin were intially continued for MRSA coverage
given long term nursing home residency and dbl coverage for gram
negatives and streptococcus. However after he developed a rash
on [**7-29**], and given the fact that clical presentation and chest
x-ray did not clearly indicate pneumonia, his antibiotics were
changed to Augmentin alone for a 7 day course. On [**7-31**], he was
successfully extubated. However he continued to have labored
breathing due to marked upper airway secretions and insufficient
ability to protect and clear his airway. He received frequent
nebulizer treatments, airway suctioning, and chest PT. On [**8-2**]
it was discovered that his sputum from [**7-28**] grew out pseudomonas
aeruginosa; ceftazidime was started. On [**8-4**] a midline was
placed in his right arm to facilitate completion of the 14 day
course of ceftazidime.
After discussion with the team and the patient's brother, on
[**8-3**] Interventional Radiology converted his PEG tube to a j-tube
in hopes of decreasing long-term risk of aspiration events. His
respiratory status stabilized, with ongoing rhonchi from upper
airway secretions, requiring suctioning every few hours, but no
respiratory distress.
.
Fever:
On the mornings of [**8-18**], and [**7-31**] pt spiked fevers to 101.2,
102, and 100.9. However throughout this period WBC count
declinced, and clinical respiratory status and CXR gradually
improved. He was pan cultured x 2. Labs were drawn to evaluate
for pancreatitis, hepaptis, and cholecystitis, which all came
back normal. He was continued on Augmentin x 6 days then
switched to a 14 day course of ceftazidime (first dose [**2195-8-2**])
after sputum culture showed pseudomonas.
.
UTI:
Pt with history of UTI on prior admission with
MSSA/Enterococcus. Per nursing records, pt with no history of
indwelling foley catheter at NH. Two UAs here showed lg WBCs,
mod leuks, concerning for UTI. Initial antibiotic coverage for
aspiration PNA was appropriate for potential UTI. However urine
cx from [**7-28**] showed no growth and urine culture from [**7-29**] showed
only 10-100,000 yeast/mL.
.
Rash:
On the morning of [**7-29**], new, confluent, erythematous patches were
noted on pt's lower extremities and pelvis to waist, as well as
on his left arm. Rash was thought to represent a drug rash or
environmental allergy. His vancomycin, levaquin, and unasyn were
discontinued, and he was started on Augmentin. He was also
provided Sarna lotion prn for pruritis. By [**7-30**], this rash had
resolved.
.
Seizure Disorder:
Patient is on phenobarbital at home. No report of seizure like
activity at NH, prior to episode of aspiration. Phenobarbital
level on [**7-28**] was therapeutic at 16.6 and on [**8-4**] is 19.2;
patient was continued on his home regimen. No seizure activity
was noted during his hospitalization.
.
Dementia:
Pt on no meds for advanced dementia. Had previously been on
celexa, remeron, zyprexa over a year ago. Plan was to give
remeron if agitation develops however pt never required these
meds.
.
Osteoarthritis:
Patient on APAP at NH for pain control. Oral pain meds were
initially held while on he was sedated w/Fentanyl and Versed on
the ventilator. After pt was extubated, he was written for APAP
prn for pain, but he did not require it.
.
Decubitus Ulcer:
Stage I sacral ulcer with no visible skin breakdown was noted
upon admission. Later a stage II ulcer was noted on his R
lateral ankle, a stage I ulcer was noted on his L medial ankle,
and skin breakdown was seen on his abdomen. These were treated
with an air mattress and frequent repositioning (q1 hr) and
progression of the ulcers was halted.
.
FEN:
Initially, tube feeds were held because of concern for
aspiration. However they were restarted on [**7-29**]. After discussion
with the team and the patient's brother, the decision was made
to consult Interventional Radiology to convert the patient's
PEG-tube (placed by GI) to a J-tube, with the goal of decreasing
regurgitation of tube feeds and aspiration. This was performed
on [**8-3**] and tube feeds were restarted through the j-tube on
[**8-4**]. Probalance 75ml/hour.
.
Prophylaxis:
Pt was placed on ISS for glycemic control. Sugars were well
controlled.
Pt received DVT prophylaxis via SQ Heparin. In addition, his
home PPI was continued for GI prophylaxis, and pt received MOM
as a bowel regimen.
.
Access:
2 20 gage peripheral IVs
Midline placed [**2195-8-4**] Right antecubital
.
Dispo: Full code
Medications on Admission:
APAP
Milk of Magnesia 30cc po daily PRN
Duonebs q4 hrs prn
Prevacid 30mg po daily
Jevity 1.2 @ 95cc/hr
Scopolamine patch 1.5mg q72hr
Phenobarbital 60 mg po BID
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Famotidine 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q12H (every 12
hours).
3. Scopolamine Base 1.5 mg Patch 72 hr [**Month/Day/Year **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for prn increased
secretions.
4. Phenobarbital 30 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2
times a day).
5. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: One Hundred (100) mg
PO BID (2 times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1) ml
Injection TID (3 times a day).
7. Camphor-Menthol 0.5-0.5 % Lotion [**Month/Day/Year **]: One (1) Appl Topical
TID (3 times a day) as needed for itching.
8. Tramadol 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed.
9. Probalance Liquid [**Month/Day/Year **]: Seventy Five (75) cc/hr PO every
four (4) hours: Probalance Full strength;
Starting rate: 35 ml/hr; Advance rate by 10 ml q4h Goal rate: 75
ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml.
10. Insulin Regular Human 100 unit/mL Solution [**Month/Day/Year **]: SLIDING
SCALE Injection ASDIR (AS DIRECTED).
11. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) Nebulizer
Inhalation Q6H (every 6 hours).
12. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Month/Day/Year **]:
One (1) Nebulizer Inhalation Q6H (every 6 hours) as needed.
13. Ceftazidime 2 gram Recon Soln [**Month/Day/Year **]: Two (2) grams Intravenous
every eight (8) hours for 8 days: [**8-5**] = Day 6 / 14.
Total course to end on [**8-13**]. To be delivered through midline in
Right AC fossa.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aspiration pneumonitis with pneumonia.
Discharge Condition:
Stable. No respiratory distress. Chronic upper airway secretions
that patient has difficulty managing due to poor gag and airway
protection.
Discharge Instructions:
You were admitted to the hospital intensive care unit for
difficulty breathing after suffering from an aspiration event. A
tube was put down your nose into your lungs and you were put on
a ventilator to help you breathe while your lungs recovered. You
developed a fever and bacteria was found in your sputum, so you
were started on antibiotics. A line was placed in your arm so
that you can finish a 14-day course of your antibiotics
(ceftazidime) at home. Your respiratory status improved and we
were able to take the tube out of your nose and allow you to
breathe on your own. You continued to have a lot of secretions
in your upper airways, which the nurses helped by suctioning
every few hours.
In order to decrease the chance of another aspiration event
occuring in the future, we advanced your feeding tube from your
stomach into your intestines.
We also continued your regular medicines while you were here.
We communicated with your brother throughout your hospital stay
and he helped us understand your wishes.
Followup Instructions:
Routine follow-up with primary care physician: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],
[**Telephone/Fax (1) 97645**]
Completed by:[**2195-8-5**]
ICD9 Codes: 5070, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4252
} | Medical Text: Admission Date: [**2157-2-24**] Discharge Date: [**2157-3-7**]
Date of Birth: [**2107-7-30**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
49 F with 2 week hx of irregular tongue movements both with
speaking and without speaking. Episodes last a few seconds.
These episodes occured on avergae 2-3 times per day. During
these episodes she had increased salivation and dysarthria. She
has had daily headaches as well althouh she has a history of
less frequent headaches generalized w/o n/v.
Major Surgical or Invasive Procedure:
Right craniotomy x2 through 2 separate incisions for removal of
brain tumors with image guidance. (right parietal and right
frontal)
History of Present Illness:
HPI: Pt initially evaluated by Dr [**Last Name (STitle) **] in the ED; hx was
obtained via interpretor and husband; pt [**Name (NI) 46396**] only.
Pt described a 2 wk hx of tongue movememtns, associated with
salivation. They would last only for a few seconds, about [**2-25**] x
days. There was no clear precipitant and they could occur at any
time of day, whether she was speaking or not. If she was
speaking, her speech would become garbled. Pt denied any
temporal
lobe seizure phenomenon such as [**Last Name (un) 5083**] vu, jamais vu, strange
odors, rising sensation, alteration of consciousness. No
episodes
of LOC. Pt does have h/o what is probably migraines, but did
report that these h/a's had been increasing to occur now daily,
generalized, and varied from mild to severe. Not assoc'd with
tongue movements. Pt otherwise had a (-) ROS. PE normal with nl
MSE, and nl neuro exam. CT and MRI in ER showed R parietal and R
frontal mass, c/w mets.
Past Medical History:
PMH:
1. High cholesterol
2. Osteoporosis
3. h/o spontaneous abortion
4. s/p tubal ligation [**2145**]
Social History:
SH: Lives with husband and 2 kids. Works at [**Company **]. No
tobacco,
EtOH or drugs.
Family History:
FH: No history of headaches, seizures, cancer.
Physical Exam:
ON ADMISSION
PE: T 96.8 BP 138/86 HR 88 RR 16 O2 sat 100% RA
General: Appears stated age, in no acute distress
HEENT: NC/AT Sclera anicteric. OP clear
Neck: Supple
Lungs: Clear to auscultation posteriorly, bilaterally
Back: No spinal tenderness
CV: RRR, nl S1, S2, no murmur. 2+ carotids without bruit
Abd: Soft, nontender, normoactive bowel sounds
Extr: No edema, good dorsalis pedis pulses
Neurologic Examination:
Mental Status: Alert and oriented to person, place and date,
cooperative with exam, normal affect
Attention: Can say months of year backward
Language: Fluent, no dysarthria, no paraphasic errors, naming
intact
Registration: [**3-25**] items, Recall [**3-25**] items at 3 minutes
No apraxia, No neglect. No grasp.
Cranial Nerves: Visual fields are full to finger motion. Optic
fundi show normal discs. Pupils equally round and reactive to
light, 4 to 2 mm bilaterally, brisk. Extraocular movements
intact, no nystagmus. Facial sensation and facial movement
normal
bilaterally. Hearing intact to finger rub bilaterally. Normal
oropharyngeal movement. Tongue midline, no fasciculations.
Trapezius normal bilaterally.
Sensation: Intact to light touch, cold, vibration and
proprioception.
Motor: Normal bulk and tone bilaterally. No fasiculations. No
tremor. No pronator drift. Full strength throughout.
Reflexes: DTRs normal and symmetric. Toes down bilaterally
Coordination: Finger-nose-finger, rapid alternating movements,
heel to shin intact.
Gait: Narrow based and normal, negative Romberg. Stress gaits on
heels and toes as well as tandem gait were normal.
ON DISCHARGE
VSS afebrile
Neuro exam. Awake alert oriented x 3, speech clear, left facial
remains but is much improved, slight left pronator drift
persists, slight left weakness, LUE>LLE. sensation intact.
Incisions to right cranium are clean and dry without erythema.
Pertinent Results:
[**2157-2-24**] 03:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2157-2-24**] 03:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.050*
[**2157-2-24**] 03:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2157-2-24**] 02:20PM GLUCOSE-103 UREA N-20 CREAT-0.7 SODIUM-144
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-27 ANION GAP-14
[**2157-2-24**] 02:20PM CALCIUM-8.8 PHOSPHATE-2.9 MAGNESIUM-2.1
[**2157-2-24**] 02:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2157-2-24**] 02:20PM WBC-5.5 RBC-4.25 HGB-13.1 HCT-37.5 MCV-88
MCH-30.9 MCHC-35.0 RDW-12.9
[**2157-2-24**] 02:20PM NEUTS-65.9 LYMPHS-27.1 MONOS-3.6 EOS-1.7
BASOS-1.6
[**2157-2-24**] 02:20PM PLT COUNT-244
[**2157-2-24**] 02:20PM PT-11.7 PTT-27.1 INR(PT)-1.0
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2157-3-7**] 06:15AM 7.4 4.69 14.1 41.8 89 30.1 33.8 13.4 238
[**2157-3-6**] 09:55AM 6.5 4.39 13.8 39.0 89 31.4 35.3* 13.1 232
[**2157-3-5**] 08:20AM 8.0 4.05* 12.6 35.9* 89 31.0 35.1* 13.0
211
[**2157-3-4**] 03:17AM 13.4* 3.99* 12.4 35.4* 89 31.0 35.0 13.2
220
[**2157-3-3**] 01:36AM 11.7* 4.12* 12.4 35.2* 85 30.0 35.1* 13.1
223
[**2157-3-2**] 07:55PM 15.9* 4.16* 12.5 35.6* 86 30.0 35.1* 13.0
225
[**2157-3-2**] 04:34AM 18.5* 3.75* 11.4* 32.3* 86 30.4 35.3*
13.1 222
[**2157-3-1**] 09:30AM 15.6*# 4.44 13.6 38.5 87 30.6 35.3* 12.9
309
[**2157-2-25**] 06:45AM 6.0 4.27 13.1 37.8 89 30.8 34.7 12.9 228
[**2157-2-24**] 02:20PM 5.5 4.25 13.1 37.5 88 30.9 35.0 12.9 244
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2157-3-7**] 06:15AM 132* 21* 0.7 143 4.2 104 281 15
1 NOTE UPDATED REFERENCE RANGE AS OF [**2156-7-23**]
[**2157-3-6**] 09:55AM 236* 17 0.7 141 3.8 103 251 17
1 NOTE UPDATED REFERENCE RANGE AS OF [**2156-7-23**]
[**2157-3-5**] 08:20AM 151* 18 0.6 139 4.1 105 271 11
NEUROPSYCHIATRIC Phenyto
[**2157-3-7**] 06:15AM 16.2
[**2157-3-6**] 09:55AM 18.1
Brief Hospital Course:
This 49 year-old right-handed, Chinese-speaking woman with a
history of high cholesterol presents with 2 weeks of brief daily
episodes of strange tongue movements. Pt speaks very little
English so most of history via husband as interpreter.
Pt reports that beginning ~2 weeks ago she developed episodes of
strange tongue movements associated with excess salivating.
Episodes last just a few seconds. They can occur any time of the
day, whether she is speaking or not. If she is trying to speak,
she is unable to properly control her tongue and therefore the
words come out slurred. She reports that tongue sensation is
normal. Denies strange odors, tastes, feelings of [**Last Name (un) 5083**] vu,
jamais vu, out-of-body, rising sensation, warmth, or fear.
Episodes occur daily, usually 2-3 times per day, though can be
up to 5 times per day. This has never happened before.
Pt also reports that she has had headaches for years, though
recently they have been bearly daily. They are generalized
throughout her head, and sometimes involve neck as well. Pain
vaires from mild to severe. When more severe, pain is throbbing.
There is no photo- or phonophobia, nausea, or vomiting. She has
no warning. Headaches do not occur withthe episodes of tongue
movements.
After CT scan revealed two seperate locations of intracerebral
lesions (right parietal and right frontal), she underwent a
metestatic workup to look for primary tumor. Her CT of chest
abd and pelvis were negative for malignancy. She did have a
thyroid nodule on the right which was 6mm in size - she
underwent a thyroid US which the results
were:IMPRESSION:Unremarkable thyroid ultrasound with a few
scattered small subcentimeter nodules seen within both lobes of
the gland. In addition she had a bone scan, results:IMPRESSION:
Normal bone scan. She was brought to the OR on [**3-1**] for two
right sided craniotomies under image guidance. The frozen
section on these specimens was consistent with high grade
glioma. The final path was :#1, RIGHT FRONTAL TUMOR BIOPSY
(including intraoperative smear):GLIOBLASTOMA MULTIFORME.
WHO ([**2151**]) grade IV out of IV. #2, RIGHT FRONTAL TUMOR
RESECTION:GLIOBLASTOMA MULTIFORME. WHO ([**2151**]) grade IV out of
IV. #3, RIGHT PARIETAL TUMOR RESECTION:
GLIOBLASTOMA MULTIFORME.WHO ([**2151**]) grade IV out of IV. After
meeting recovery room criteria she was transferred to the floor.
She subsequently developed increased lethargy and the size of
her right pupil had increased in size although it was still
briskly reactive. She was given 10 of decadron and 25 of
mannitol stat. A stat head CT revealed some increased swelling
and some increased MLS as well as effacement of the supracellar
and basilar cysterns. She also had a small amount of hemorrhage
in the right parietal postoperative bed. She continued to do
better through that night and into the next am. She was then
transferred to neuro step down after her exam improved. Per Dr.
[**Known lastname 724**] the pt was placed on dilantin in addition to her Keppra.
Her decadron was increased to 10mg iv q 6 and is currently been
weaned to 4 q 6 hours where Dr. [**Known lastname 724**] wants her to remain at
least until she is seen in brain tumor clinic. Diet was
advanced and foley was d/c'd. She is awake and conversational
with slight left facial droop. Mannitol has been d/c'd.
Medications on Admission:
Meds: Atorvastatin 10 mg DAILY PO [**2157-2-24**] @ 1000
Multivitamins 1 CAP DAILY PO [**2157-2-24**] @ 1000
Levetiracetam 500 mg [**Hospital1 **] PO [**2157-2-24**] @ [**2151**]
Acetaminophen 325-650 mg Q4-6H:PRN PO [**2157-2-24**] @ 2300
Bisacodyl 10 mg DAILY:PRN PO [**2157-2-24**] @ 2300
Lorazepam 0.5-2 mg Q4H:PRN IV [**2157-2-24**] @ 2300
Senna 1 TAB [**Hospital1 **]:PRN PO [**2157-2-24**] @ 2300
Sodium Chloride 0.9% Flush 3 ml DAILY:PRN IV [**2157-2-24**] @ 2300
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
13. Lorazepam 0.5-2 mg IV Q4H:PRN seizure>2min
14. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Multiple Brain Tumors
Discharge Condition:
Neurologically stable.
Discharge Instructions:
Please monitor insicion site for redness, drainage or swelling.
Keep insicion site dry and clean. Can shower without getting
inscion wet.
Call with fever greater tahn 101.5, visual changes, numbness,
weakness, increased headache or any other neurologic problems.
Take your medications as directed. You will be on both keppra
and dilantin take them until discussed by Dr [**Known lastname 724**].
Followup Instructions:
Follow up with Dr [**First Name11 (Name Pattern1) 640**] [**Known lastname 4861**], MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2157-3-14**] 2:00 in Brain tumor clinic located in [**Hospital Ward Name 23**]
building [**Location (un) **]. ****THE PATIENT NEEDS TO ATTEND THIS
APPOINTMENT - IF FOR SOME REASON SHE IS UNABLE TO, THE OFFICE
MUST BE CALLED ********
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2157-3-7**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4253
} | Medical Text: Admission Date: [**2136-1-24**] Discharge Date: [**2136-1-28**]
Date of Birth: [**2078-7-2**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Admit for elective portal venogram/thrombectomy and attempted
TIPS procedure.
Major Surgical or Invasive Procedure:
Transcutaneous Intrahepatic Porto-Systemic Shunt Placement
1) Portal venogram
2) Attempted TIPS procedure
History of Present Illness:
57 y/o M with hx EtOH cirrhosis, portal hypertension and
gastroesophageal varices who presents for evaluation of portal
vein thrombectomy or TIPS placement. The patient has had a 14-15
yr history of liver disease in the setting of heavy drinking
(8-9 beers daily) since teenage. He has been completely
abstinent of EtOH since his diagnosis (14-15 years). He has had
a 5 yr hx of ascites, and reports recent acceleration of ascites
accumulation, with SOB being a prominent symptom of the
accumulated ascites. His SOB resolves upon a therapeutic
paracentesis; most recent paracentesis performed at [**Hospital1 **] [**12-2**] removed 4L fluid. On CT [**2135-12-14**] his known main
portal vein thrombus x 10 years was found to have extended into
L portal and splenic veins. He also has gastroesophageal varices
with hx of bleeding which presented as dehydration and
lightheadedness with no melena/hematochezia/hematemesis; last
major bleed in [**2125**] with ICU admission but no recent bleeding
episodes, last banded by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15532**] ([**Hospital3 **])
summer [**2134**].
ROS: Denies any jaundice, confusion or mental status changes,
myoclonus, melena, hematochezia, hematemesis, dysuria,
hematuria. Reports one episode of emesis and lightheadedness
this morning due to "anxiety" before leaving for the hospital.
Past Medical History:
1. Cirrhosis, EtOH related.
2. Portal hypertension gastropathy with gastroesophageal
varices.
3. Question acute renal failure with previous admission.
4. Borderline diabetes mellitus 2, diet control only.
5. Hypertension, on medication.
6. Silent MI discovered on chemical stress test at [**Hospital1 2519**]
7. Rheumatoid arthritis, previously on Remicade stopped 1 month
ago
8. C. diff enterocolitis.
9. Chronic anemia.
10. Anxiety.
11. Bipolar disorder.
12. Asthma.
Past Surgical History:
1. ORIF, left femur 9/[**2134**].
2. Total hip replacement bilaterally.
3. Total knee replacement bilaterally, [**2118**], [**2120**].
Social History:
Patient states that he quit smoking approximately seven weeks
ago, previously 3ppd hx for 45 years. He denies any alcohol for
the past 14 years. He also denies any recreational drug use.
Physical Exam:
Exam on initial admission post-portal venogram, [**2136-1-24**]:
VS: T 98.9, BP 106/74, HR 79, RR 16, O2 Sat 100% RA.
GEN: Pleasant, talkative middle-aged male lying in bed in NAD
without tachypnea.
NEURO: A+O X 3, appropriate, no asterixis or confusion.
SKIN: Spider angiomata on face, [**12-27**] erythematous scaly lesions
on scalp, no jaundice, no palmar erythema.
HEENT: PERRL (4->3mm bilat), EOMI, sclerae anicteric. MMM, OP
clear, tongue midline.
NECK: Supple, no JVD.
CV: RRR, no M/R/G.
PULM: fine end-inspiratory crackles LLL, otherwise clear.
ABD: distended with caput medusae, somewhat tense, +BS,
+splenomegaly, 3x IR entry sites on R flank clean and dry.
EXT: no edema, poor perfusion in feet but +dopplers bilaterally
in PACU.
Exam on ICU Admission:
GEN: Intubated, sedated
SKIN: Spider angiomata on face, [**12-27**] erythematous scaly lesions
on scalp, no jaundice, no palmar erythema.
HEENT: sclerae anicteric. MMM, OP clear, ET tube inplace
NECK: Supple, no JVD.
CV: RRR, no M/R/G.
PULM: upper airway sounds
ABD: distended with caput medusae, soft +BS, +splenomegaly, 3x
IR entry sites on R flank clean and dry.
EXT: no edema, palp pulses
Pertinent Results:
LABS:
[**2136-1-24**]:
139 | 101 | 28
---------------< 153
3.9 | 34 | 1.3
8.7
4.5 >-----< 83
25.9
PT 14.1, PTT 21.9, INR 2.1
Albumin 3.2, Ca 8.6 Phos 3.6 Mg 2.1
Lab results post TIPS, [**2136-1-26**]:
139 | 106 | 27
---------------< 167
4.1 | 27 | 1.1
10.8
9.1 >-----< 115
30.3
PT 13.6, PTT 22.4, INR 1.2
Retic count 1.6%, Fibrinogen 487
[**2136-1-24**] Portal Venogram Prelim report:
Portal venogram demonstrated the portal vein was completely
occluded with a collateral vein connecting the splenic vein to
the right and the left portal veins. This collateral vein is in
good size and with no pressure gradient drop from the splenic
vein to the collateral and further to the left and right portal
veins. No clots were visualized inside the collateral vein a
highpressure was measured inside the collateral vein, which was
36mmHg. A TIPS procedure should be evaluated for the patient.
[**2136-1-26**] TIPS procedure Preliminary provisional report:
1. Unsuccessful TIPS procedure. The patient's systolic blood
pressure
dropped into the mid 70s and due to two capsular perforations
and this being an elective case, the procedure was terminated.
2. 3 liters of bloody ascites fluid removed.
[**2136-1-26**] Abd/Pelvis CT:
1. Ascites, slightly increased in comparison to [**2135-12-14**], with
contrast layering dependently related to attempted TIPS
placement. 2. No active extravasation seen on post-contrast
imaging. 3. Unchanged cirrhosis and portal hypertension. 4.
Extrahepatic and probable intrahepatic locules of gas associated
with the posterior segment of the right lobe of the liver. 5.
Splenic, superior mesenteric and portal venous thrombosis is
better evaluated on the previous CT.
Brief Hospital Course:
57 y/o M with hx EtOH cirrhosis, portal hypertension and
gastroesophageal varices s/p portal venogram with unsuccessful
thrombectomy [**2136-1-24**], s/p attempted TIPS complicated by bleeding
and hypotension [**2136-1-26**].
.
Patient was initially admitted after elective portal venogram
and evaluation for thrombectomy of portal vein thrombus on [**1-24**].
This was unsuccessful, however, 1.7L ascites was removed.
Patient was then admitted for observation awaiting elective TIPS
eval and procedure on [**1-26**].
.
On [**1-25**], his hematocrit was found to drop from a preop baseline
of 30 to a low of 22; he remained asymptomatic without
lightheadedness, tachycardia or significant hypotension. He then
received 2U PRBCs [**1-25**] pm, which increased his Hct to 29-30 the
next day.
.
On [**1-26**], he was taken by Interventional Radiology for a elective
TIPS eval/placement. For detailed report by IR see Pertinent
Results. Roughly 3 L of bloody ascites was removed prior to the
procedure. Briefly, during the procedure contrast was observed
to extravasate along the track/tract made during the prior
procedure on [**1-25**]; up to 5 passes were made in an attempt to
place TIPS device, but this was complicated by repeated bouts of
hypotension to SBP of 90s and finally 70s. At this point the
procedure was aborted; the patient was started on a low
continuous dose of neosynephrine and transferred to the MICU for
observation and management. Surgery was consulted. CT [**2136-1-26**]
did not show evidence of a active bleed around the liver or in
the abdomen.
.
Per the IR team notes online, contrast injection revealed
extrahepatic pooling lateral to liver likely from transhepatic
access. In addition, the IR team speculates that there is likely
a second capsular perforation inferiorly from one of today's
passes. RA pressure were noted to be 16 mmHg without an IVC
gradient.
MICU Course:
[**2136-1-26**]: The patient developed SBPs to the 70s during failed TIPS
procedure. He was given 2 units of PRBCs prior during the
procedure and in the PACU, intubated, and placed on
neosynephrine. After intubation and on proprofol drip, SBPs were
in 100s on low dose neo. In the ICU, Propofol/neo were weaned.
Antihypertensives and diuretics were held and hematocrit was
monitored closely. His Hct stabilized at 30, and remained stable
throughout HD2. As propofol was weaned, the patient awoke and
self-extubated overnight. His respiratory status was stable
throughout the day post-extubation. His pressures improved
overnight in the ICU and were stable with SBPs 110-120s upon
discharge to the floor. Per IR recommendations, the patient was
given prophylactic ceftriaxone.
On [**2136-1-28**], patient was called out to the floor from the MICU. As
above, BP improved overnight and Hct was stable. On the floor,
his BP was stable (100s - 120s) although lower than his usual
baseline (130s) hence his BP meds were held. He was instructed
not to restart his diltiazem and metoprolol until he speaks to
his PCP. [**Name10 (NameIs) **] Hct continued to be stable at 29-30 with no sign or
symptom of cardiovascular instability or GI bleed; he was
discharged with instructions for followup in the next 2 weeks
with Dr. [**Last Name (STitle) **] and his PCP.
Medications on Admission:
1. Advair 1 puff daily
2. Spironolactone 50mg daily
3. Colace 100mg daily
4. Diltiazem 180mg daily
5. Folate
6. Lasix 40mg [**11-25**] daily
7. Metoprolol XL 25mg daily
8. Prednisone 5mg [**Hospital1 **]
9. Pantoprazole 40mg [**Hospital1 **]
10. Trazodone 100mg QHS
11. Vicodin 5/500 Q6H PRN
12. Lithium 300mg daily
13. Vitamin D2 50,000U qFriday
14. Lexapro 20mg daily
15. "IV iron" likely ferrelecit
* Remicade for RA stopped 1 month ago for liver intervention.
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**11-25**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
5. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 6 days: Please continue to take this medication until it is
finished.
Disp:*12 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QFRIDAY ().
8. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO once a
day.
9. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
10. Lasix 40 mg Tablet Sig: 1-2 Tablets PO once a day.
11. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H:PRN as
needed for pain.
13. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO
once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1) Liver cirrhosis secondary to alcohol.
2) Portal gastropathy
3) Portal hypertension
Discharge Condition:
Afebrile, ambulating, blood pressures stable, no
lightheadedness, dizziness, tachycardia, no abdominal pain at
rest.
Discharge Instructions:
You were admitted for an evaluation for a procedure called TIPS,
which was aimed at reducing the likelihood of bleeding from the
distended veins in your stomach and esophagus, as well as
reducing the fluid in your abdomen. However, the procedure could
not be successfully performed due to intraoperative
complications where there was a small amount of bleeding around
your liver with a drop in your blood pressure. You were given 4
units of blood during your stay due to low blood counts.
IMPORTANT: Due to your current low blood pressure, we have
stopped the following medications. PLEASE DO NOT TAKE THESE
MEDICATIONS:
1) Diltiazem (Cardizem)
2) Metoprolol (Toprol)
You should see your PCP or other doctor in [**12-27**] days after
discharge for an evaluation before restarting both these
medications.
Please continue to take all your other medications as prescribed
previously. We have also added a new medication called
cefpodoxime which is an antibiotic that you have to take twice a
day for 6 days. Please finish the entire course of this
medication.
If you experience any dizziness, lightheadedness, fainting
spells, increase in your abdominal pain, nausea/vomiting or find
blood in your stool, urine or vomit, notice black tarry stools
or feel unwell, please seek medical help as soon as possible.
Please call the liver center for an appointment with Dr. [**Last Name (STitle) **]
(see below)
Followup Instructions:
It is very important that you follow up with these providers:
1) Dr. [**First Name (STitle) **] [**Name (STitle) **], your liver doctor here at [**Hospital1 18**] within 2
weeks. Call ([**Telephone/Fax (1) 1582**] to schedule an appointment.
2) Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18323**] during the next
week about your blood pressure medications.
3) Please follow up with your liver doctors [**First Name (Titles) **] [**Hospital3 4107**]
as soon as possible.
Completed by:[**2136-1-28**]
ICD9 Codes: 2859, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4254
} | Medical Text: Admission Date: [**2162-9-29**] Discharge Date: [**2162-10-6**]
Date of Birth: [**2091-2-18**] Sex: M
Service: MEDICINE
Allergies:
Nsaids/Anti-Inflammatory Classifier / Vancomycin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
CC:[**CC Contact Info 103544**]
Major Surgical or Invasive Procedure:
Mesenteric angiograpm w/ coil embolization of bleeding vessel.
Sigmoidoscopy.
Colonoscopy.
History of Present Illness:
HPI: Pt is a 71 y/o male with h/o dm2, cad s/p cabg, DVT/PE on
long term anti-coagulation, ulcerative colitis on Asacol
presents with brbpr starting at 9am of the morning of admission.
He'd been having lower abdominal pain for approximately the past
week, a symptom for which he's been admitted in the past. His
PCP had recently started ciprofloxacin for a UTI. At 9am the
morning of admission he passed a large, bloody bowel movement
and came to the ED. There, his vitals were intially stable with
a hct of 36.7, though he was felt to be hypovolemic and this
hemoconcentrated; his previous hct was 39 about five months ago.
He refused an NG lavage. Although an initial DRE showed only
clot, he later passed a large, bloody bowel movement, and his bp
nadired to the low 90's but rested there only transiently and
easily rebounded to the 130's-140's with fluid; he then went to
angiography for a tagged RBC scan where they found and embolized
two vessels to the sigmoid colon. His HCT had dropped from 36.7
to 30.8 despite 2U PRBC and 3 U FFP.
.
Is called out of the [**Hospital Unit Name 153**] as has been been HD and stable HCT.
Currently denies CP, SOB, abd pain or continued BRBPR.
Past Medical History:
PMH:
1.)DM-2
2.)CAD s/p 3v-CABG [**2152**] and subsequent stenting of SVG and LIMA
3.)CHF with EF 30-35% on [**6-8**] echo
4.)Right parietal intracranial bleeding following [**2152**] cardiac
cath
5.)LBBB
6.)Sinus node dysfunction s/p pacemaker
7.)H/O DVT (right sided) and subsequent PE, put onto lifetime
warfarin
8.)Ulcerative colitis
PSH:
1.)C4-7 anterior discectomies
2.)CABG [**2152**]
3.)R intracerebral hemorrhage drainage
Social History:
SocHx: Mr [**Known lastname 103545**] generally lives with his wife but has spent a
great deal of time recently at rehab. He has no h/o ETOH/IVDA
but quit tob 15 years ago.
Family History:
Noncontributory.
Physical Exam:
VS 98.4, 62, 103/37, 15 97%2L
gen- lying in bed, NAD
heent- anicteric sclera, op clear with mmm
neck- jvd flat
cv- rrr, s1s2, no m/r/g
pul- CTAB without rales
abd- soft, minimally distended, nt, no rebound/guarding, nabs
extrm- trace edema at ankles, no cyanosis, warm/dry
Pertinent Results:
[**2162-9-29**] 05:47PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2162-9-29**] 05:47PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2162-9-29**] 05:47PM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-<1
[**2162-9-29**] 02:32PM LACTATE-1.8
[**2162-9-29**] 12:20PM GLUCOSE-197* UREA N-25* CREAT-0.8 SODIUM-141
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-22 ANION GAP-18
[**2162-9-29**] 12:20PM WBC-5.6 RBC-4.35* HGB-12.6* HCT-36.7* MCV-84
MCH-28.9 MCHC-34.3 RDW-15.7*
[**2162-9-29**] 12:20PM NEUTS-80.5* LYMPHS-13.1* MONOS-3.5 EOS-2.5
BASOS-0.4
[**2162-9-29**] 12:20PM POIKILOCY-1+ MICROCYT-1+
[**2162-9-29**] 12:20PM PLT COUNT-102*
[**2162-9-29**] 12:20PM PT-20.5* PTT-29.4 INR(PT)-3.0
GI BLEEDING STUDY [**2162-9-29**]
IMPRESSION: Increased tracer activity demonstrated within the
left lower
quadrant, most likely sigmoid colonic loops of bowel, consistent
with active
bleeding.
CT ABDOMEN W/CONTRAST [**2162-9-29**] 3:27 PM
IMPRESSION:
1. No evidence of colitis or other bowel pathology present to
explain the patient's bright red blood per rectum.
2. Stable appearance of left adrenal fat-containing lesion
consistent with a myelolipoma.
3. Stable appearance of hypodense lesion within the caudate lobe
of the liver, too small to fully characterize.
4. Subcentimeter attenuation lesion within the lower pole of the
right kidney, too small to characterize.
5. 3-mm noncalcified pulmonary nodule within the right lower
lobe. If the patient does not have a history of a primary
malignancy, followup CT of the chest in 1 year is recommended to
evaluate for stability of this finding.
Brief Hospital Course:
Initial A/P:
71 y/o male with dm2, cad, chf, uc presents with one week of
lower abdominal pain and 2 episodes of brpbr on the day of
admission.
.
#BRBPR -- The patient was in the intensive care unit given his
lower GI bleed. An angiography showed bleeding in two vessels
off of the [**Female First Name (un) 899**] supplying the sigmoid that were succesfully
embolized. The patient was transfused from a Hct 29 to 34 on the
day of discharge. His coumadin was held during his stay given
his acute bleed but restarted per his PCP with the guidance of
GI on the day of discharge.
- The patient underwent a flex sigmoidoscopy on Friday, [**10-1**],
which showed old blood in the rectal vault but no active source
of bleeding. Given this, it was advised that the patient have a
colonoscopy to rule out further bleeding.
- The patient had a colonoscopy on Monday [**10-4**] but
unfortunately, was unable to complete the study as his bowel
prep was inadequate. Therefore, he had a repeat colonoscopy on
[**10-5**] which showed expected mucosal signs of moderate ulcerative
colitis, no polyps, w/ 8 mm ulcer at junction of distal
descending colon and sigmoid colon.
.
- Biopsies were obtained during his colonoscopy and he should
follow up with gastroenterology for the results.
#Ulcerative colitis -- The patient's Asacol was originally held
but restarted the day prior to discharge per GI.
.
#CAD/CHF - The patient was restarted on his home regimen prior
to discharge as it was held temporarily given his acute GI
bleed. The exception is that per his PCP, [**Name10 (NameIs) **] aspirin will be
held for 2 weeks given that he was restarted on coumadin with
his risk of bleeding.
.
#DM-2 -- The patient was maintained on his home insulin regimen.
#h/o DVT/PE: Coumadin was initially held. It was unclear at
first as to why the patient required life-long anticoagulation.
After discussing this with his PCP, [**Name10 (NameIs) **] was clear that the
patient had had recurrent DVTs and ultimately a PE and his PCP
felt strongly that he required long-term anticoagulation. His
goal INR should be 1.6-2.0. If bleeding continues to occur,
consider [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter.
.
#Access -- 2 large bore PIV's
.
#Code -- full
Medications on Admission:
Meds on Admission:
1.)Spironolactone/hctz 25/25 daily
2.)Atenolol 12.5mg daily
3.)Insulin 45N/8R qAM and 33N qPM
4.)Furosemide 10mg every other day
5.)Aspirin 81mg daily
6.)Zoloft 40mg qAM
7.)Flomax
8.)Atorvastatin 40mg daily
9.)Ritalin 20mg daily
10.)Ramipril 2.5mg daily
11.)Asacol 400mg 3, TID
12.)Carafate 1gm [**Hospital1 **]
13.)Actos 15mg daily
14.)Folate 1mg daily
15.)Warfarin 2mg daily
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for DM.
11. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day) as
needed for ulcerative colitis w/o recent severe flares.
12. Insulin
45 NPH in am with 33 NPH at bedtime
Continue Sliding scale insulin as needed.
13. Sertraline 20 mg/mL Concentrate Sig: Two (2) PO at bedtime.
14. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Rectal bleeding from inferior mesenteric artery tributaries
supplying sigmoid colon.
Discharge Condition:
Good.
Discharge Instructions:
Please call physician if you develop shortness of breath,
weakness in your legs or arms, sudden blurry vision or slurred
speech, chest pain, faintness, or significant unexplained weight
loss.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2162-11-26**] 2:30
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2162-12-10**]
1:30
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2162-12-10**] 2:00
Please call [**Last Name (LF) **],[**First Name3 (LF) **] L. at [**Telephone/Fax (1) 2660**] to schedule an
appointment with him in 1 week.
Please call your gastroenterologist to schedule a follow up
appointment in 2 weeks.
ICD9 Codes: 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4255
} | Medical Text: Admission Date: [**2113-3-2**] Discharge Date: [**2113-3-8**]
Service:
ADMITTING DIAGNOSIS:
1. Non Q wave MI.
2. Pneumonia.
CHIEF COMPLAINT: The patient was an 81-year-old woman
admitted to the CCU service with a chief complaint of
ischemia, transient left bundle branch block, status post
cardiac catheterization.
HISTORY OF PRESENT ILLNESS: This is an 81-year-old woman
with a past medical history significant for dementia,
depression, coronary artery disease of three vessels, status
post non Q wave MI in [**2110**]. The patient refused further
work-up at that time. The patient was transferred from
[**Hospital3 2558**] the morning of admission for the evaluation of
respiratory distress. On [**3-1**] at 10 p.m. the patient started
to complain of chest pain. At that time she had vital signs
done which were significant for temperature of 100.4, heart
rate 88, respiratory rate 28 and blood pressure 160/80, no
oxygen saturation was recorded. She received Nitroglycerin
.4 mg sublingual, Ativan 0.5 mg and Lasix 40 mg po. She was
started on oxygen at that time. She felt better after these
interventions. At 3:30 a.m. the day of admission she again
experienced chest pain and was given Nitroglycerin sublingual
times two. At 7:30 a.m. she was noted to be hypoxic with an
oxygen saturation of 70% on three liters and she complained
of chest pain again. Initially she refused to go to the
hospital and then she acquiesced and she was transferred to
[**Hospital1 69**] for further care. On
her way, the paramedics gave her Lasix 80 mg IV times one and
three Nitroglycerin sublingual. In the Emergency Room she
had a systolic blood pressure in the 100's, she was
tachycardic to 110 and tachypneic to respiratory rate of 34.
She had an EKG that showed a heart rate of 120 with a new
left bundle branch block, increased left axis deviation and
ST depression in V4 through V6 on the initial EKG.
Subsequent EKGs showed progressive diffuse ST depression and
3-4 mm depressions in V3 through V6, 2-3 mm in V2, V3 and AVF
and [**Street Address(2) 4793**] depression in 1, and [**Street Address(2) 4793**] elevation in AVL.
Oxygen saturation was in the 60's in the Emergency Room. She
was intubated nasally for hypoxia. Her O2 sat increased to
80% and the ABG following intubation was 7.32, PCO2 50, PO2
74. Following intubation and sedation, she dropped her blood
pressure to 50/30 and was started on Dopamine drip or
hypertension. The patient then progressed to emergent
cardiac catheterization with a new left bundle branch block
and these ischemic changes with the presumption of
cardiogenic shock. When she arrived in the cath lab, she had
a borderline systolic blood pressure in the low 100's on 20
mcg per minute of Dopamine and she had an intra-aortic
balloon pump placed. She was started on Heparin and
Integrilin. The RCA was noted to be diffusely diseased as
was the LAD and the circumflex. The OM1 had a lesion that
looked acutely ruptured and occluding. It was a small
vessel, it was intervened on by PTCA but it was not stented.
During the cath, they noted her filling pressures to be quite
low. She was given bolus of normal saline and the cath lab
team was able to wean off the Dopamine and the balloon pump
was also removed post catheterization as her pressure came up
with aggressive fluid resuscitation. She was then
transferred to the CCU for further care. Upon arrival in the
CCU the Heparin and Integrilin had also been discontinued.
Prior to transfer to the CCU, a transthoracic echocardiogram
was done to evaluate for wide open mitral regurgitation. It
showed ejection fraction 35-40% on the intra-aortic balloon
pump, 2+ TR, moderate regional LV dysfunction and hypokinesis
of the anterior septal and apical wall, 1+ MR and mild
pulmonary artery hypertension.
PAST MEDICAL HISTORY: 1) Dementia, Alzheimer's vs multi
infarct dementia and head CT has shown periventricular small
vessel ischemic changes. 2) Failure to thrive at home with
placement in a nursing home in the past year. 3) Depression.
4) Anxiety disorder presenting as stridor. 5) Hypertension.
6) Hypercholesterolemia. 7) History of CAD, status post non
Q wave MI in [**2110-2-24**]. She refused further work-up and
left AMA. 8) Hypothyroidism. 9) Peptic ulcer disease. 10)
Degenerative joint disease.
MEDICATIONS: Aspirin 81 mg po q d, Risperdal .25 mg po q
a.m., 25 mg po q h.s., Buspirone 5 mg po bid, Depakote 125 mg
po bid, Colace 100 mg po bid, Ultram 50 mg po bid, Vasocidin
1 drop tid, Atenolol 25 mg po q d, Celexa 40 mg po q d, Lasix
40 mg po q d, Levoxyl 112 mcg po q d, Multivitamin one tablet
po q d, KCL 20 mEq po q d, Prevacid 15 mg po q d, Prinivil 10
mg po q d, Dulcolax as needed and Milk of Magnesia as needed,
Tylenol as needed and Trazodone 25 mg po q h.s. prn for sleep
as needed.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives at [**Hospital3 2558**] with a
baseline dementia. She does not use tobacco or alcohol. Her
son, [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 100610**] is the next of [**Doctor First Name **].
PHYSICAL EXAMINATION: On arrival in the CCU, physical exam
revealed the patient was awake, she opened her eyes to voice,
she was nasotracheally intubated. Temperature was 99.8.
Heart rate 88, blood pressure 111/43, respiratory rate 24.
Oxygen saturation 100%. Ventilation settings were IMV 500
total volume, respiratory rate set at 10, PEEP 5, pressure
support of 5, FIO2 70%. This was changed to C-Pap pressure
support 10 and 5 with FIO2 of 50%. ABG was 7.38, 45, 95.
HEENT: She was nasotracheally intubated through the right
nare. Pupils are equal, round, and reactive to light and
accommodation. Neck exam, patient had no JVD. Chest,
bilateral rhonchi. Heart sounds, regular rate and rhythm, S1
and S2 were normal, no murmurs, gallops or rubs. Abdominal
exam was soft, nontender, non distended, positive bowel
sounds. Extremities were cool with palpable pulses in all
four extremities. Neuro, she moved all four extremities
spontaneously.
LABORATORY DATA: White count 13.9, hemoglobin 13.8,
hematocrit 39.2, platelet count 231,000. Differential on the
white count, 83 neutrophils, 3 bands, 10 lymphs, 4 monos. PT
12.7, PTT 36.0, INR 1.1. SMA 7 was 142, 4.1, 99, 29, 22, 1.0
and glucose 151. CK #1 in the Emergency Room was 129 with MB
of 3, CK #2 drawn on arrival at the CCU was 285, MB 32, MB
index 11.2. Troponin 1.4. Chest x-ray showed slightly
hyperinflated lungs with pulmonary infiltrates consistent
with pulmonary edema, right greater than left without any
obvious infiltrates. EKG #1 done in the Emergency Room as
above, normal sinus rhythm at 120, left bundle branch block,
left axis deviation, ST depression 3-4 mm in V4 through V6,
ST depression 1 mm in 2. Compared with prior EKG from [**2112-5-24**], left bundle branch block is new. EKG #2, normal sinus
rhythm at 100, 3-[**Street Address(2) 5366**] depressions in V3 through V6, 2-[**Street Address(2) 11741**] depressions in 2, 3, and F.
ASSESSMENT: This is an 81-year-old woman with past medical
history of coronary artery disease of three vessels, status
post non Q MI in [**2110**], hypothyroidism, depression, dementia,
admitted following an episode of acute pulmonary edema but
still unclear [**Name2 (NI) 100611**] etiology. Several scenarios are
still possible at the time of admission including: 1)
Respiratory distress from some other etiology, possibly
pneumonia leading to overdiuresis and ischemia. 2) Diastolic
dysfunction, it is unknown why the patient would have become
ischemic but is it possible she became ischemic which then
led to pulmonary edema. The patient also seems to be ruling
in for non Q wave MI. This certainly could be the primary
lesion. Patient became ischemic and went into pulmonary
edema.
PLAN:
1. Cardiac: CKs will be cycled until trending down. EKGs
will be checked. The patient will be placed on Aspirin,
Lipitor and a beta blocker as the blood pressure tolerates.
The patient will also be started on an ACE inhibitor as the
blood pressure tolerates. She will be given IV fluids and
Lasix as needed to balance her volume status.
2. Pulmonary: From a pulmonary perspective the patient has
a possible pneumonia. She will be started on Levaquin 500 mg
per day. We will try to aggressively wean off the patient's
sedation and extubate her as quickly as possible.
3. Infectious Disease: Blood cultures were sent from the
Emergency Room and from the cath lab. These will be followed
up. We will also check a urinalysis and urine culture and
send sputum if the patient is producing it.
HOSPITAL COURSE: The day of admission the patient was
quickly weaned off her sedation and was placed on vent
settings of 10 and 5. A pressure support wean was initiated.
The patient was placed on [**5-28**] pressure support and did well.
She was then extubated later that evening around 6 p.m.
Post extubation the patient did well for a few hours. She
had no issues with hypoxia or hypercarbia, however, she had
copious secretions and the patient could not clear her own
secretions. The secretions could be cleared by suctioning,
however, suctioning provided such stimulus to the patient
that her heart rate increased into the 120's and she became
hypertensive to the 180's/100's. Given the patient's recent
non Q wave MI, these values were unacceptable and the patient
was electively reintubated for inability to protect her
airway. This allowed us to suction her secretions without
causing tachycardia and hypertension as the patient was
sedated. CKs were cycled and peaked at 842 at midnight the
day of admission. EKGs were checked and revealed that the
left bundle branch block was either rate related or ischemia
related as it resolved. The patient's heart rate and blood
pressure were controlled with beta blocker and ACE
inhibitors. For the next two days the patient became
hypotensive while she was intubated and on sedation. She
required aggressive fluid resuscitation and transiently
required Dopamine as a pressor on and off with maximum dose
being approximately 10 mcg per minute. Further chest x-rays
were obtained that revealed the patient had a pneumonia. She
had worsening bilateral pulmonary infiltrates consistent with
either ARDS or cardiogenic pulmonary edema, however, as the
hospital course progressed and the patient was maintained on
antibiotics, her bilateral pulmonary infiltrates slowly
resolved. The patient's secretions which were copious and
purulent at first, also decreased. On [**3-6**] a family meeting
was held with the son, the daughter-in-law, the attending,
social worker and the house staff. We all discussed the
patient's course and prognosis and wishes. Her son expressed
that she would not want to be kept alive on a respirator.
The team expressed their opinion that the patient was close
to extubation. The son thought that once patient was
extubated she would not want to be reintubated. The team
thought this was a reasonable course of action as if the
patient could not be extubated in the next 48 hours it would
entail a long recovery; likely including a tracheostomy and
month long vent weaning process that the patient would not
want. The course of action was then decided to extubate the
patient in the next 24-48 hours as medically indicated and
when she was extubated to now reintubate the patient. She
was made DNR on the 11th, after that family discussion. On
[**3-7**] the patient's secretions had decreased. She was placed
on a spontaneous C-pap trial of pressure support 5 and 5.
The patient did well with a rapid trial of breathing index in
the 70's to 80's. Her sedation had been turned off the night
before and she was alert and able to follow commands. The
team thought it was medically indicated to attempt to
extubate the patient on the 12th. This was done. The
patient did well for approximately 4-5 hours. After that
time, however, the patient slowly began to tire. Her initial
respiratory rate was at 26 and she declined to breathing
around 15-20 after the first hour. Her blood pressure was
controlled with Labetalol drip during this time. As the
hours progressed, the patient's respiratory rate slowed. An
ABG was checked that showed a PH of 7.17, PCO2 77 and PO2 of
143. The patient was becoming more somnolent, the team
believed this was due to the hypercarbia. The son was
[**Name (NI) 653**] and at that point he said the patient should be
kept comfortable above all. The team shifted their goals to
meet this requirement as well as to give the patient the best
chance to recover. Over the course of the night her
respirations maintained in the low teens, between [**11-6**]. The
patient was kept comfortable during this time with Morphine.
On [**3-8**] the patient slowly became less and less responsive
and more and more somnolent as her respiratory rate declined
and at 6:30 p.m. on the evening of [**3-8**] the patient's
respirations and heart rate stopped and she was pronounced
dead at that time. The son was with her when she passed. An
autopsy was performed. The patient died of cardiopulmonary
arrest that was due to a pneumonia and a non Q wave MI on
this admission.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Last Name (NamePattern1) 8228**]
MEDQUIST36
D: [**2113-3-15**] 11:07
T: [**2113-3-16**] 16:18
JOB#: [**Job Number 100612**]
ICD9 Codes: 4280, 5070, 0389, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4256
} | Medical Text: Admission Date: [**2108-10-7**] Discharge Date: [**2108-10-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Mental status changes/hypotension
Major Surgical or Invasive Procedure:
Central line placement.
Pressors in the intensive care unit.
History of Present Illness:
HPI: [**Age over 90 **] y/o M w/ DM and recent admission for hypotensive TIA who
presents from rehab with lethargy, hypotension and mild
abdominal pain. HCP [**Name (NI) **] [**Name (NI) **] noticed pt to be lethargic at
rehab, and VS revealed hypotension with sbp in 70s. Pt was c/o
mild abd pain; otherwise, denying any complaints.
.
VS on arrival to ED: T 99.7 BP 68/45 HR 53 RR 14 Sats 96% on
NRB.
Pt received 4L of IVF. After fluid resuscitation, SVO2 was
69-80, CVP 12-13, BP in 90/60s without pressors adn a subclavian
CVL was placed. Blood and urine Cx sent. UA was positive for
many WBCs. CT abdomen revealed left perinephric stranding.
Empiric Vanc/Zosyn was started. Mental status improved slightly
and pt was transferred to ICU for further care. On arrival to
the ICU, BP was 77/47 and CVP 12. Pt remained asymptomatic of
chest pain, shortness of breath or abd pain. He was responsive
and oriented to hospital & person, denying lightheadedness. Pt
received 500cc bolus and was started on Levophed gtt.
.
Past Medical History:
Diabetes Type II
Hypertension
Partial gastric resection with bilroth II anastomosis for
bleeding peptic ulcer ([**2056**])
Multiple prior episodes of SBO
Atrial tachycardia: recent hypotensive event from atrial
tachycardia causing TIA like symptoms, no evidence of CVA on
MRI.
Peripheral Neuropathy
Remote EtOH
Circumcision ([**2106**])
L ankle fracture
L DVT s/p filter [**2100**], GIB on coumadin
Pernicious anemia
GERD
Osteoarthritis
Right leg bakers cyst
Social History:
Widowed. No children. Active in church, sings in choir. Lives
with friend from church [**Name (NI) **].
Pt has remote former EtOH and tobacco history, recently
discharged to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] but had been living with adopted son
prior to recent admission.
*** DNR/DNI per HC [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (h) [**Telephone/Fax (1) 79368**] and (c)
[**Telephone/Fax (1) 79369**]
Physical function: Independent at baseline with dressing,
toileting, and walking wtih rooling walker. [**Doctor Last Name **] assists with
meal preparantion, housekeeping, laundry, errands. No home
services.
Family History:
Unknown--pt is reported by friend to be the last living member
of his family.
Physical Exam:
Physical Exam:
Vitals: T 98.4 HR 78 BP 77/47 RR 17 Sats 98% on 2L
GEN: Appears younger than stated age, no acute distress,
oriented to hospital & person only
HEENT: EOMI, no epistaxis or rhinorrhea, dry MM, OP Clear
NECK: No JVD, no cervical lymphadenopathy
COR: quiet heart sounds, no m/r/g apprec
PULM: Lungs CTA anteriorly, no W/R apprec
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: +[**2-15**] bilateral foot edema, no c/c
NEURO:oriented to person, hospital. CN II ?????? XII grossly intact.
Moves all 4 extremities. Strength 5/5 in upper and lower
extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2108-10-7**]:
139 107 35 172 AGap=17
------------
4.8 20 2.1 (baseline creatinine 1.1)
.
Ca: 8.2 Mg: 2.1 P: 3.2
.
WBC 8.1 Hgb 9.1 Hct 26.1 Plts 177
.
N:87 Band:9 L:4 M:0 E:0 Bas:0
.
Lactate 2.9
.
ECG: NSR, no acute ST-T wave changes, essentially unchanged from
prior tracings.
.
CXR [**2108-10-7**] Markedly abnormal but stable radiograph as detailed
above. As best can be determined, no definite gross acute
pulmonary process.
.
CT Abd/Pelvis: Limited [**3-17**] lack of IV and oral contrast. no
intrabdominal fluid collections or abscess; mediastinal
asymmetry due to chronically elevated left hemidiaphragm.
stranding in the left perinephric region, raises the
possibility of pyelonephritis.
.
ECHO [**2108-9-25**]: dilated left atrium. LVEF >55%. moderately dilated
aortic root, ascending aorta. mildly thickened aortic valve
leaflets. mildly thickened mitral valve leaflets. Trivial mitral
regurgitation. Borderline pulmonary artery systolic
hypertension.
[**2108-10-8**]:
143 114 39 40 AGap=14
-------------<
4.4 19 2.2
Ca: 7.1 Mg: 1.8 P: 4.1
CBC 17.9 / 26/ 140
PT: 15.7 PTT: 42.7 INR: 1.4
ALT: 568 AP: 254 Tbili: 1.0 AST: 705 LDH: 737 [**Doctor First Name **]: 34 Lip: 9
Fe panel: Iron: 10 calTIBC: 259 Ferritn: 499 TRF: 199
ABG: pH 7.34 pCO2 38 pO2 80 HCO3 21 lactate 2.5
RUQ U/S: [**10-8**]
IMPRESSION:
1. Distended gallbladder with wall thickness at the upper limits
of normal
and slightly greater than expected for the level of gallbladder
distention. No definite edema within the wall of the
gallbladder. Patient could not be assessed for son[**Name (NI) 493**]
[**Name2 (NI) 515**] sign but was tender over the gallbladder. Close
clinical followup is recommended as this could represent early
presentation of acalculous cholecystitis.
2. Normal intra-hepatic and extra-hepatic bile ducts.
3. Patent hepatic vasculature and grossly normal liver on
limited exam.
[**10-9**] CT Abdomen/pelvis without contrast
IMPRESSION:
1. Unremarkable appearance of bowel in absence of IV contrast.
No secondary sign of mesenteric ischemia, including no
pneumatosis or portal venous gas.
2. Unable to assess patency mesenteric vessels due to the
absence of IV
contrast.
3. Right-sided renal low-attenuation lesions previously
characterized as
simple cysts.
4. Redemonstration of chronically elevated left hemidiaphragm,
causing
rightward mediastinal shift.
HIDA scan [**10-9**]
IMPRESSION:
No evidence of acute cholecystitis.
URINE CULTURE (Final [**2108-10-10**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.
______________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
Assessment/Plan: [**Age over 90 **] y/o M with PMHx of DM & hypotensive TIA
presents from rehab with hypotension and UTI/pyelonephritis.
.
Sepsis: Patient presented with hypotension, ARF, elevated LFTs
and bandemia. Secondary to urosepsis. Patient was on Levophed,
and weaned off. Transfused 2 U for early goal directed therapy
and stools guiac negative. Positive UA and CT showed
perinephric stranding. UCx with Ecoli, improving on Meropenem.
Changed to cipro [**10-12**] after 4 doses of meropenem given stable BP
and absence of fever. He will need six more days of
ciprofloxacin to complete his course.
.
Abdominal pain: Dilated colon on CXR and Abd CT. Patient has a
history of small bowel obstructions. CT scan did not show
evidence of obstruction, and was only remarkable for perinephric
stranding. He had a gallbladder ultrasound which was followed by
a HIDA which was unremarkable. He was seen by the surgical
consult service for evaluation for bowel ischemia, and was felt
not to have ischemic bowel. Flagyl started for possible C diff,
but discontinued given negative C diff cultures. Patient was
kept on bowel regimen, and had NG tube placed for decompression.
Pain resolved with decompression, most likely secondary to
constipation, and NG tube was removed. Agressive bowel regimen
initiated with some improvement in his symptoms.
.
Altered mental status: Most likely toxic/metabolic
encephalopathy or septic encephalopathy in setting of acute
infection. Resolved prior to discharge.
.
Hypotension: resolved, with end organ damage (kidney, liver)
Shock liver with elevated enzymes which have since resolved. His
metoprolol and lisinpril were held. The metoprolol was restarted
once his blood pressures improved. The lisinopril should be held
until a repeat creatinine is checked, and continued to trend
downward.
.
ARF likely related to sepsis and hypoperfusion [**3-17**] hypovolemia:
baseline creatinine of 1.1, currently elevated at 2.0 but
trending downward. He has been diuresing briskly, with some
lasix. He was not restarted on his lisinopril given his labile
creatinine, but this should be restarted once his creatinine is
rechecked in one week, and is back to baseline.
.
Hypoglycemia: Patient had blood sugars intermittently as low as
23 on admission. Started on D10 drip. Thought to be secondary
to glyburide, which was given for first few days of admission.
Given ARF, probably the cause of hypoglycemia. Of note, home
dose of Glyburide was 2.5mg daily. This was increased to 10mg
twice daily during previous hospitalization in [**Month (only) 216**], despite
%A1C of 6.4. He was restarted on glyburide 2.5 mg [**Hospital1 **] at time of
discharge. His blood sugars will need to be monitored closely.
He needs assistance with meals; otherwise he eats minimally due
to deconditioning and weakness.
.
Thrombocytopenia: Platelets trended down from admit to nadir of
76. HIT antibody sent off and is negative. Heparin was
discontinued initially, but then restarted once his platelet
count returned to [**Location 213**].
.
Anemia: Baseline HCt is ~30; [**3-17**] apparent Fe deficiency anemia
given Fe panel.
Transfused 2 U for early goal directed therapy - guaiacs
negative. Also has pernicious anemia. Last B12 injection was
1000mcg [**9-11**]. Given dose 8/29.
.
Toe blister, poor nail hygeine. Patient will need outpatient
Podiatry follow up.
.
Total body edema: He was noted to be edematous, likely from
aggressive fluid resuscitation in the initial setting. He was
diuresed with 40 IV lasix, with good response. He will most
likely autodiurese with improvement of his renal function, but
may require intermittent doses of po Lasix to help with
resolution of edema.
Medications on Admission:
Medications on Admission from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]:
Methylphenidate 5 mg tablet qam
Omeprazole 20 mg daily
Metoprolol Tartrate 12.5mg [**Hospital1 **]
Atorvastatin 10 mg Tablet Daily
Lisinopril 5 mg Tablet daily
Heparin 5000u sc TID
Glipizide 10 mg 1-2 tabs [**Hospital1 **]
Aspirin 81 mg Tablet daily
Medication list from VA:
Lisinopril 5mg daily
Glyburide 2.5mg daily
Plavix 75mg daily
Omeprazole 20mg daily
Monthly B12 injections
Metamucil
Ritalin was discontinued [**2108-8-8**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection three times a day.
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
11. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
12. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding
scale Injection ASDIR (AS DIRECTED).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Pyelonephritis
Sepsis from urinary tract infection
Constipation
Abdominal pain
Hypertension
Hypoglycemia
Acute renal failure
Anemia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital with an infection in your
kidney and your blood. You were very sick needing intensive
care unit treatments with medications to treat low blood
pressure and antibiotics. You will need to take antibiotics for
several days by mouth following discharge from the hospital.
Please call your primary care doctor if you develop fevers,
chills, or nausea or vomiting.
Followup Instructions:
Please contact your primary care [**First Name8 (NamePattern2) **] [**Name (NI) **] [**Last Name (NamePattern1) 79370**] from
[**Hospital 86**] [**Hospital6 **] for a follow up appointment within 2
weeks from discharge from the hospital. Phone: [**Telephone/Fax (1) 41354**]
5415
You will need to have a repeat creatinine checked in 7 days to
ensure that the number is improving.
ICD9 Codes: 5849, 3572, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4257
} | Medical Text: Admission Date: [**2184-8-26**] Discharge Date: [**2184-9-5**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2184-8-31**] Three Vessel Coronary Artery Bypass Grafting utilizing
left internal mammary to left anterior descending, and vein
grafts to obtuse marginal and posterior descending artery
[**2184-8-26**] Cardiac Catheterization
History of Present Illness:
This 83 year old man with hypertension and dyslipidemia was
recently seen in consultation for progressive dyspnea on
exertion. He is normally quite active and up until a few months
ago was able to walk [**3-17**] miles per day without difficulty.
Several months ago he began to notice progressive dyspnea. It is
now occurring with walking about a half a block. He denies any
past or current history of chest discomfort. Stress testing on
[**2184-8-9**] showed 2mm ST depression in the inferolateral leads.
Imaging revealed mild to moderate reversible defects in the LAD
and PDA territories. His LVEF was estimated at 36% with diffuse
hypokinesis. Based on the above results, he was admitted for
elective cardiac catheterization. Of note, prior to
catheterization, he received several days of Plavix in
anticipation of PCI.
Past Medical History:
Hypertension
Dyslipidemia
Prostate cancer, diagnosed approximately 10 years ago, s/p
radiation
Radiation Proctitis with mild scarring (mild bleeding about 6
years ago)
Left eye cataract
Surgery for a right undescended testicle as a child
Remote right knee injury
Social History:
Patient is married with adult children that live out of state.
His wife [**Name (NI) **] will bring him to the procedure. Patient is a
retired chemist for the EPA who previously worked with mass
spectroscopy. Denies tobacco use.
Family History:
Father with CAD and an MI, first diagnosed in his 60's. He died
from a CVA at age 85.
Physical Exam:
Height 5'7", weight 144 pounds
Vitals T 97.3, BP 138/79, HR , RR 18 with O2 sats 100% on RA
Gen Pleasant elderly gentleman in no acute distress.
HEENT Normocephalic. PERRL. EOMI. MMM, OP clear.
Neck No carotid bruits. No thyromegaly or lymphadenopathy.
Chest Clear to auscultation bilaterally.
CV RRR, distant heart sounds. No murmur appreciated.
Abd Soft, positive bowel sounds. No tenderness to palpation or
organomegaly.
Ext No peripheral edema. Cath site c/d/i with overlying bandage.
No bruit. No hematoma. DP pulses 2+ bilaterally.
Skin Hypopigmented macules covering both arms bilaterally.
Neuro A&O X 3. Speaking clearly and in full sentences.
Occasionally stutters. Moving all extremities. Face symmetric.
Pertinent Results:
[**2184-8-26**] 09:35AM BLOOD WBC-7.0 RBC-3.43* Hgb-10.6* Hct-31.5*
MCV-92 MCH-30.9 MCHC-33.6 RDW-16.1* Plt Ct-286
[**2184-8-26**] 09:35AM BLOOD PT-13.2* PTT-29.7 INR(PT)-1.2*
[**2184-8-26**] 09:35AM BLOOD Glucose-155* UreaN-24* Creat-1.0 Na-136
K-4.6 Cl-105 HCO3-22 AnGap-14
[**2184-8-26**] 09:35AM BLOOD ALT-28 AST-36 AlkPhos-115 TotBili-0.3
[**2184-8-27**] 07:35AM BLOOD Triglyc-90 HDL-33 CHOL/HD-4.6 LDLcalc-100
Brief Hospital Course:
Mr. [**Known lastname 68726**] was admitted and underwent cardiac catheterization.
Left ventriculography revealed [**1-16**]+ mitral regurgitation and an
LVEF of 38% with severe inferior and anterior hypokinesis, and
apical dyskinesis. Coronary angiography showed a right dominant
system with 80% left main stenosis, 30% proximal LAD lesion, 30%
obtuse marginal stenosis and a totally occluded proximal right
coronary artery with excellent left to right collaterals. Given
coronary anatomy and possiblity of mitral intervention, cardiac
surgery was consulted and further preoperative evaluation was
performed. Plavix was discontinued. An echocardiogram showed
only mild to moderate mitral regurgitation and mild aortic
insufficiency. The aortic valve leaflets were mildly thickened
and no aortic stenosis was present. The mitral valve leaflets
were mildly thickened and there was no mitral valve prolapse.
The aortic root and ascending aorta were mildly dilated,
measuring 4.0 - 4.1 centimeters. The left ventricular cavity
size was normal and the overall left ventricular systolic
function was moderately depressed with global hypokinesis and
akinesis of the inferior wall. Right ventricular systolic
function was borderline normal. To further evaluate his
ascending aorta, a chest CT scan was obtained. This was notable
for the ascending aorta at upper limits of normal in size
measuring 3.7 centimeters. It also showed mild emphysema.
Further evaluation included dental consultation, pulmonary
function tests and carotid non-invasive studies which found no
significant disease of his internal carotid arteries. After
thorough evaluation and allowing the effect of Plavix to wear
off, he was eventually cleared for surgery. He remained pain
free on medical therapy which included intravenous Heparin for
his dyskinetic left ventricle.
On [**8-31**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass
grafting. Mitral intervention was not performed at time of
surgery as an intraoperative TEE showed only mild mitral
regurgitation. Surgery was otherwise uncomplicated. Following
surgery, he was brought to the CSRU for invasive monitoring. For
further surgical details, please see separate dictated operative
note. Within 24 hours, he awoke neurologically intact and was
extubated. He maintained good hemodynamics and remained in a
normal sinus rhythm. His CSRU course was uneventful and he
transferred to the SDU on postoperative day one. ACE inhibitor
added for low ejection fraction and beta blockade titrated. He
went into AFib and was treated with amiodarone.Pacing wires
removed on POD #3.His QTc was prolonged and repeat EKG done.
Cleared for discharge to home with VNA on POD #5. Pt. is to make
all follow up appts. as per discharge instructions.
Medications on Admission:
Norvasc 10mg daily every morning
Lisinopril 10mg daily every morning
Aspirin 81mg daily every morning
Plavix 75mg daily every morning (for 4-5 days prior to cath)
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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 6-8 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease - s/p CABG, Mitral Regurgitation, Mildly
Dilated Ascending Aorta, Hypertension, Hypercholesterolemia,
Prostate Cancer - s/p radiation therapy, Radiation Proctitis,
Left Eye Cataract, Prior Knee Surgery, Prior Tonsillectomy
AFib
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in [**3-17**] weeks - call for appt
Dr. [**Last Name (STitle) **] in [**1-16**] weeks - call for appt
Dr. [**Last Name (STitle) **] in [**1-16**] weeks - call for appt
Completed by:[**2184-9-7**]
ICD9 Codes: 4280, 4240, 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4258
} | Medical Text: Admission Date: [**2152-6-14**] Discharge Date: [**2152-8-23**]
Date of Birth: [**2101-2-27**] Sex: M
Service: SURGERY
Allergies:
Nafcillin / Zosyn / Sulfa (Sulfonamide Antibiotics) / meropenem
/ tacrolimus
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2152-6-21**] ex lap, LOA
[**6-28**]//12 transjugular liver biopsy
[**2152-6-30**] IR drain placement of right and left fluid collection
[**2152-7-5**] left abdominal drain removed
[**2152-7-6**] Left abdominal drain placed
[**2152-7-12**] LUQ drain placed
History of Present Illness:
51M s/p 51M s/p ABOI liver transplant on [**2152-1-15**] c/b postop
abdominal abscesses and hepatic artery stenosis on coumadin
presents with 1 day history of worsening abdominal pain and
decreased ostomy output. The patient reports he was feeling
fine
until this morning when he began to have chills at 2:30 am. He
subsequently had 3 episodes of non-bilious emesis. He also
reports that his abdomen has become progressively more distended
from yesterday. He endorses recurrent hicups since this AM. He
reports that he has not had any ostomy output since yesterday
evening. He has been recording his drain output which have
consistently been 30cc per day. His drain output has changed in
appearence from dark tea color to dark yellow in the past few
days.
ROS:
(+) per HPI
(-) Denies fevers, night sweats, unexplained weight loss,
changes
in appetite, trouble with sleep, pruritis, jaundice, rashes,
bleeding, easy bruising, headache, dizziness, vertigo, syncope,
weakness, paresthesias, nausea, vomiting, hematemesis, bloating,
cramping, melena, BRBPR, dysphagia, chest pain, shortness of
breath, cough, edema, urinary frequency, urgency
Past Medical History:
HCV/EtOH Cirrhosis c/b Jaundice, Ascites
3 cords of grade I varices were seen starting at 30 cm ([**2151-6-3**])
ABO incompatible OLT on [**2152-1-15**]
postop abdominal abscesses, Ecoli
Heterozygous for H63D MUTATION
Hyponatremia
MSSA osteomyelitis of the L foot s/p debridement [**5-/2151**]
GERD
HTN
Gout
CAD - pt does not recall h/o MI or stents
Cervical laminectomy
Social History:
Lives w/ wife, walks w/ a cane and is independent w/ ADLs. He
quit ETOH in [**2151-5-14**].
Family History:
No h/o liver disease
Physical Exam:
On admission:
Vitals: 98.8 92 140/97 16 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender to palpation bilateral upper
quadrants, incision clean, dry and intact, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused
On discharge:
Patient expired
Pertinent Results:
On Admission: [**2152-6-14**]
WBC-11.8* RBC-4.26* Hgb-11.0* Hct-37.2* MCV-87 MCH-25.7*
MCHC-29.5* RDW-20.5* Plt Ct-363
PT-19.6* PTT-56.8* INR(PT)-1.9*
Glucose-116* UreaN-27* Creat-1.4* Na-135 K-4.4 Cl-107 HCO3-17*
AnGap-15
ALT-14 AST-48* AlkPhos-134* TotBili-1.9* Albumin-3.6
Calcium-9.3 Phos-3.9 Mg-1.5*
Cyclspr-88*
Lactate-0.9
Brief Hospital Course:
51 y/o male with liver transplant and post op course complicated
by fluid collections, mental status changes requiring medication
adjustments and prolonged hospitalizations who now presents a
few days after clinic visit with increasing abdominal pain. One
drain remains in place to drain a known fluid collection.
On admission, an NGT was placed, and on KUB to assess placement
there was noted to be paucity of bowel gas, with some gaseous
distention of right lower quadrant
small bowel loops: cannot exclude obstruction. An abdominal CT
was obtained showing
multiple loops of dilated bowel with transition point within the
right lower quadrant approximately 10-15 cm upstream from the
end-ileostomy.
Decrease in size of multiloculated intra-abdominal fluid
collections with
interval removal of catheter in the anterior pelvic fluid
collection and
appropriate position of catheter in the perihepatic fluid
collection.
Findings were concerning for early or partial small bowel
obstruction. The NG tube was kept in place, and medications were
converted to IV admisnistration and he received IV fluids.
Upon admission there was minimal stool output or gas in the
ostomy bag, however over the course of the next 24 hours, stool
output increased significantly, and NGT drainage dropped off. NG
tube was removed in am of [**6-16**]. He was allowed sips of clears,
but developed significant abdominal pain. NG was replaced with
immediate drainage of 900 cc of bilious fluid. He was kept NPO
with the NG tube in place for 3 more days. NG was then removed,
but he had increased abdominal pain with more bloating. Ostomy
output decreased to 200 cc for the day, and the NG tube was
replaced.
On [**6-21**], he was taken to the OR by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for ex lap and
lysis of adhesions. There was concern for spillage of bowel
contents as enterotomies were performed. EBL was approximately
1L. In PACU, he was tachycardic (130s), hypotensive (SBP 70s),
and oliguric. PRBC,FFP, albumiun, and 8L crystalloid were
administered. He was transferred to the SICU for management. ID
was consulted. Tigecycline continued and and Micafungin was
started per ID's recommendations.
TTE was done to evaluate fluid status (decreased urine output)
as he did not have central access. EF was >75 and LV was
hyperdynamic. He received IV fluid with improved urine output.
Hct remained stable after blood products. A red rubber catheter
was placed into the ostomy for stenting. Dark fluid was noted in
the ostomy pouch. VS and labs were stable. He transferred out of
the SICU.
NG was removed after 2 days and sips were started. Dilaudid was
initially given for pain. This was switched to Morphine.
However, he was still confused and paranoid. Pain meds were
minimized. UA was nl, urine culture was pending. Blood cultures
were sent. LFTs were notable for increase of t.bili up to 7.3
from 4. The bilirubin continued to rise and peaked at 9.6 on
[**7-1**].
In response to the worsening LFTs, on [**6-28**] a transjugular liver
biopsy was performed. He tolerated the procedure without
incident, liver biopsy results showed Bile ductular
proliferation with associated neutrophils and mild to moderate
intrahepatocytic and canalicular cholestasis, there was no
evidence of acute rejection. Early Hepatitis C recurrence cannot
be ruled out. An HCV Viral load was sent showing a result of
743,239 IU/mL. (The viral load in [**2152-2-13**] was 1,170,000
IU/mL).
On [**6-30**], as follow-up to CT done a day earlier, the patient
underwent placement of two new drains, which were in response to
new areas of fluid concerning for abscess. He underwent
placement of an 8 French [**Last Name (un) 2823**] pigtail catheter to the
right multilobulated fluid collection, which yielded malodorous
altered blood
in keeping with an infected hematoma and which Micro isolated E
coli and Vanco resistant enterococcus. He also had an 8 French
[**Last Name (un) 2823**] pigtail catheter into the
left flank fluid which appeared dark and serous, but was not
overtly infected and was negative on culture. Daptomycin was
added. Give high MIC, Daptomycin was changed to Linezolid. The
left sided drain was removed on [**7-5**] for very low output.
Patients energy level and mood were depressed. Blood cultures
and repeat CT scan [**7-5**] was done. Blood culture were negative.
CT demonstrated smaller right sided abdominal fluid collections.
There was a new fluid collection in the left abdomen which
communicated superiorly and inferiorly with additional fluid
collections which measured 9.7 x 6.2 x >11.3 cm.The LUQ drain
was removed. On 5/34, a 10 French drainage catheter was placed
into the left intra-abdominal fluid collection with drainage of
200mL dark, brown fluid. This fluid collection appeared to
communicate with the more inferiorly located collection
extending into the pelvis and a more superiorly located
collection inferior and anterior to the pancreatic tail. Gram
stain and culture isolated 1 colony of Enterococcus.
Anticoagulation was resumed for h/o splenic vein thrombus. TPN
was started for poor po/kcal intake. On [**7-11**], CT demonstrated a
new LUQ collection. On [**7-12**], a drain was placed in this
collection and fluid from this collection culture was negative.
Tigecycline was stopped on [**7-14**] and Linezolid on [**7-16**]. On [**7-17**], he
was made NPO as LUQ drain (#3)amylase and bilirubin were 6174
and 8.4 which was consistent with a bowel leak. TPN continued.
He was allowed sips with restriction of no more than 400ml po
fluid per day. Pigtail drain outputs averaged 25-85ml/day.
Daily forward flushes were done.
Transferred into SICU on [**2152-8-9**] for respiratory distress,
tachypneic to the 30s. By [**2152-8-10**] he was intubated had
thoracentesis for pleural effusion getting 1300cc out. He was
started on pressors at this point. Over the next few days he was
noted to desturate on the vent and required high PEEP as well as
suctioning. He was placed on CRRT on [**2152-8-13**], was still on
pressors, and continued on broad spectrum antibiotics. On [**2152-8-14**]
he had his four abdominal drians inspected by IR and two fo them
were upsized. Fluid was taken off by CRRT and he was placed on
CPAP by the vent. He did have mucous plug episode that he was
bronched for. By this point he was on and off levofed to
maintain MAP above 60. On [**2152-8-18**], after being on CPAP all day at
40/5/5 on [**8-17**], he was extubated and CRRT was stopped. By [**2152-8-19**]
he was re-intubated and placed back on pressors. On [**2152-8-20**] his
repsiratory requirements on the vent were increasing and he was
on 100% FiO2 with 14 PEEP. He developed an increased pressor
requirement that same day and was found to have cardiac
tamponade and had a pericardial drain placed. Despite getting
the fluid out of his pericardial sac he continued to have
increased pressor requirement and poor function on the vent. On
[**2152-8-22**] a family meeting was held. By [**2152-8-23**] he was made CMO
and once pressors were removed he expired shortly thereafter on
[**2152-8-23**].
Medications on Admission:
mycophenolate mofetil 500'', levothyroxine
50', aspirin 81', omeprazole 20', thiamine HCl 100',
cyanocobalamin (vitamin B-12) 100', folic acid 1', ferrous
sulfate 300'', metoprolol tartrate 25''', enoxaparin 100 mg/mL
DAILY (Daily) for 2 weeks, warfarin 12', cyclosporine 100'',
pentamidine 300 mg once a month, Kayexalate prn
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Small bowel obstruction
Abdominal fluid collections/abscesses
vre bacteremia
Intestinal leak
UTI
Depression
Malnutrition
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
None-patient expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2152-8-25**]
ICD9 Codes: 0389, 5119, 5849, 2875, 5990, 4019, 2749, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4259
} | Medical Text: Admission Date: [**2193-7-3**] [**Month/Day/Year **] Date: [**2193-7-7**]
Service: MEDICINE
Allergies:
Aleve / Ace Inhibitors / Florinef
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Nausea/vomitting
Major Surgical or Invasive Procedure:
ERCP [**2193-7-5**] with stent placement
History of Present Illness:
[**Age over 90 **]yo M PMHx lymphoma p/w N/V x several hours. Patient reports
that shortly after eating dinner on day of admission, he
developed acute onset nausea and vomitting. He had 3 episodes
of NB/NB emesis. Patient denied
.
Found by ems rigoring. no cp, sob, abd pain, flank pain. fever
to 100.2 at home.
Of note, patient reports eating a hamburger for dinner and is
concerned that it may have been undercooked; no one else eating
the dinner got sick; patient denies any other sick contacts,
recent travel.
.
In the ED, initial vital signs were 100.4 (oral) 104.0 (rectal)
123 137/80 18 95%RA. Labs were significant for WBC 3.1, Hct 28,
Platelet 54, Cr 1.6, ALT/AST 168/226, AP456, Tbili 1.2, lactate
2.7 (repeat lactate 3.2). CXR was unremarkable. Patient was
given IV vanco/cefepime. Vital signs prior to transfer were
113/49 102 23 97.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- recurrent malignant melanoma (including local recurrences),
last [**2191**] that was pT1b
- [**Doctor Last Name **] 3+3 prostate adenocarcinoma (diagnosed [**2183**]) followed
by surveillance with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 79**]
- benign prostatic hypertrophy
- cholecystectomy
- chronic intestinal pneumatosis
- Type 2 DM
- HTN
- asthma
- hyperlipidemia
- GERD
- Subarachnoid Hemorrhage
- Orthostatic Hypotension
- Anemia attributed to MDS
- Thrombocytopenia
- Acute renal failure
Social History:
Retired 11 years ago after working as a travel [**Doctor Last Name 360**]
for 50+ years; also worked conducting a band. Lives at home with
his 78yo wife. Smoked 6-7 years as a young adult, none since.
Denies etoh, illicits
Family History:
NC
Physical Exam:
ADMISSION
Vitals: T: 99.8 rectal BP: 97/42 P: 88 R: 18 O2: 97%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: markedly distended and tympanic to percussion;
non-tender, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
[**Doctor Last Name 894**]
Pertinent Results:
Admission Labs: [**2193-7-2**] 10:30PM
WBC-3.1* RBC-3.02* Hgb-9.6* Hct-28.0* MCV-93 Plt Ct-54*
Glucose-145* UreaN-66* Creat-1.7* Na-140 K-6.0* Cl-107 HCO3-25
AnGap-14
ALT-172* AST-271* AlkPhos-540* TotBili-1.4
Lactate-2.7*
TTE:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The aortic valve is not well seen. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen.
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. The right
ventricle is not well seen. No pathologic valvular abnormality
seen. Pulmonary artery systolic pressure could not be
determined.
Compared with the prior study dated [**2193-1-11**] (images reviewed),
image quality is worse.
CT Abd/Pelvis:
1. Opacities at the lung bases, right greater than left,
concerning for
aspiration pneumonia as seen on the recent chest x-ray.
2. No evidence of bowel obstruction. Persistent mild gaseous
distention of
the colon which tapers to normal caliber at the sigmoid colon.
3. Mild central intrahepatic biliary dilation and inflammatory
changes
surrounding the common bile duct, unchanged since [**2192-10-5**]. Again, this is likely related to sequela of chronic
cholangitis with no evidence of an active process.
RUQ U/S :
This is a very limited study due to overlying gas, showing mild
central common hepatic duct dilatation. The etiology for this is
not apparent and most of the common duct cannot be imaged
successfully. This could be further evaluated with MRCP or ERCP
if clinically appropriate.
ERCP [**7-5**]:
Impression: A plastic stent placed in the biliary duct was found
in the major papilla. The stent appeared occluded without
noticeable drainage - this was successfully removed. Upon
removal, extensive sludge and debris extruded from the biliary
orifice. Three stones and debris ranging in size from 5 mm to 10
mm that were causing partial obstruction were seen at the common
bile duct. The CBD was dilated to 12 mm. Given recent MI and low
platelets, decision was made not to proceed with sphincterotomy.
A 7cm by 10FR biliary stent was placed successfully. Good
drainage of bile was noted from the stent after placement.
Microbiology: [**Month/Year (2) **] cultures no growth to date at the time of
[**Month/Year (2) **].
[**Month/Year (2) **] Labs: [**2193-7-7**] 05:26AM
WBC-2.2* RBC-2.71* Hgb-8.4* Hct-25.6* MCV-95 Plt Ct-36*
Glucose-121* UreaN-43* Creat-1.5* Na-140 K-4.3 Cl-110* HCO3-22
AnGap-12
ALT-52* AST-27 LD(LDH)-238 AlkPhos-305* Amylase-21 TotBili-1.6*
Brief Hospital Course:
HOSPITAL COURSE
[**Age over 90 **]yo M PMHx CLL, recent SAH, a/w fever, vomitting, elevated
LFTs, thought to have infection of biliary source, course
complicated by NSTEMI.
Active Diagnoses:
# Fever: Patient was admitted with fever, rigors, labs
significant for transaminitis and elevated alk phos suggesting
billiary source; u/s abd demonstrated mild CBD dilatation, CT
abd demonstrated intrahepatic biliary dilation and inflammatory
changes surrounding the common bile duct, without significant
change from prior imaging performed at time of recent CBD
stenting. Review of records demonstrated prior ERCP performed
[**9-/2193**] at which time biliary stent was placed w recommendation
for removal in 2 months, however this was never done. ERCP was
performed which showed sludge and debris from biliary orifice
upon removal of an occluded stent. Stones were found to be
obstructing the CBD and there was biliary dilation. No
spincterotomy was performed in the setting of recent NSTEMI and
low platelets. Patient remained afebrile on Unasyn, and was
transitioned to Augmentin on [**2193-7-6**]. He is being discharged
with a prescription for ten additional days of antibiotics.
# NSTEMI: Pt reported a brief episode of chest pain on admission
accompanied by non-specific ST depressions that resolved w/o
intervention, followed by troponins peaking at 1.17 before
trending downward. He was seen in consultation by cardiology who
felt this was an NSTEMI. Aspirin was started, along with a
beta-blocker. He remained chest pain free on the general
medicine service and in the ICU. He will need to be seen in
follow-up for a [**Date Range **] pressure check and consideration of
further risk stratification.
#Myelodysplasia: Oncology (Dr.[**Last Name (STitle) **] and Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**])
following. Neulasta and Epo held while patient hospitalized. He
was transfused 2u pRBC's and 1u platelets on [**2193-7-4**] in
anticipation of his ERCP. He developed a dry cough and 1-2L
oxygen requirement following his second unit of pRBC's, and was
given one dose of Lasix 5mg IV overnight and 20mg IV the morning
of [**2193-7-5**] with resolution of his respiratory symptoms. He will
resume his outpatient Neulasta and Epo schedule, with his next
nursing visit scheduled for [**7-11**].
#DM: Patient had intermittent episodes of hypoglycemia while in
the ICU. His home insulin was held and the patient was placed on
D51/2NS while NPO. As his diet was advanced his sugars improved,
and his home NPH 70/30 was re-started at 7u rather than his
prior dose of 15u. He was instructed to check his finger sticks
at home and follow-up with his PCP to have his insulin increased
as needed.
#GERD: Continued omeprazole
#Glaucoma: Continued timolol and bimatoprost
#BPH: Continued finasteride
TRANSITIONAL ISSUES
- Patient needs Repeat ERCP in 2 months for stent removal and
stone extraction. The [**Hospital **] [**Hospital **] will call him to schedule that
appointment.
- Follow-up final results of [**Hospital **] cultures
- Check [**Hospital **] pressure on Toprol 50mg (new medication for
patient)
- Uptitrate NPH as needed
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
3. bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic daily ().
4. magnesium oxide 140mg Sig: Two (2) twice a day.
5. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Insulin NPH 70/30 Sig: 15 units qAM.
[**Hospital1 **] Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
[**Hospital **] Diagnosis:
Cholangitis
NSTEMI (damage to your heart)
Pancytopenia (low [**Hospital **] counts)
[**Hospital **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
[**Hospital **] Instructions:
You were admitted to the hospital with fevers that were thought
to be due to an infection of your biliary system. You were given
IV antibiotics and underwent an ERCP during which your previous
stent was removed and a new stent was placed. You will need to
follow-up with the ERCP team in eight weeks to have that stent
removed; their office will call you to schedule that
appointment.
In the setting of your fever and infection you had evidence of
damage to your heart. For this reason you were started on a new
medication called Toprol. You will need to follow-up closely
with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] to have your [**Last Name (Titles) **]
pressure checked while on this medication.
While in the hospital you received transfusions of [**Last Name (Titles) **] and
platelets; you were not given Neulasta or Epo. You should resume
your usual schedule when you are discharged, and will receive
your next doses on [**7-11**]. You will follow-up with
Dr.[**First Name (STitle) 4587**] again on [**7-25**].
While in the hospital you were not able to eat for several days.
In this setting, your [**Month (only) **] sugars dropped down very low, and
your home insulin was stopped. When you started eating again
your [**Month (only) **] sugars began to improve and your insulin was
re-started at a lower dose (7 units instead of the 15 units you
normally take at home). You should check your [**Month (only) **] sugars at
home and follow-up with your PCP so that they can help you
increase your insulin dose back up to an appropriate level as
your appetite improves.
Followup Instructions:
Please call to schedule an appointment with your primary care
doctor within 3 to 5 days of [**Month (only) **], and keep the following
previously scheduled appointments:
Department: NEUROSURGERY
When: THURSDAY [**2193-7-11**] at 10:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-7-11**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-7-25**] at 2:30 PM
With: DR. [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 0389, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4260
} | Medical Text: Admission Date: [**2200-1-17**] Discharge Date: [**2200-1-19**]
Service: MICU/MEDICINE
HISTORY OF PRESENT ILLNESS: This is an 86 year-old male with
a past medical history significant for type 2 diabetes
mellitus, invasive squamous cell carcinoma status post Mohs
surgery of left lower extremity who presents to the Emergency
Department following two black stools the day prior to
admission. Per VNA the patient stopped his aspirin [**1-16**].
At home he was tachy to 138 with a blood pressure of 140/80.
He was referred to the Emergency Department by VNA. The
patient states he has been feeling tired for the last few
days. He denies any chest pain, shortness of breath, heart
racing. He would feel a little lightheaded after walking one
block. He denies any new bruising, bleeding, no nausea,
vomiting or abdominal pain, heartburn is present 15 years
ago, but none recently. He has had back pain a few days ago
and took two Tylenol.
In the Emergency Department he was given intravenous fluids
at 150 an hour, 2 units of packed red blood cells and
intravenous Protonix. He had an nasogastric lavage, which
produced coffee ground emesis. No fresh blood. No clots per
Emergency Department note. Did not clear after 500 cc.
MEDICATIONS:
1. Aspirin 81 stopped [**1-16**].
2. Glucophage 1000 mg q.a.m., 500 q.h.s.
3. Zocor 10 po q.d.
PAST MEDICAL HISTORY:
1. Invasive squamous cell carcinoma of the left lower
extremity status post Mohs surgery [**11-1**].
2. Type 2 diabetes mellitus.
3. Hypercholesterolemia.
4. Right cataract surgery.
6. Colonoscopy in [**8-1**].
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives alone, has VNA. He is widowed. No
history of tobacco, alcohol or drug use. No pets. He has
two sons.
FAMILY HISTORY: Colon cancer in his brother. [**Name (NI) **] [**Name2 (NI) **] or
gastric cancer.
PHYSICAL EXAMINATION: Temperature 97.3. Blood pressure
142/69. Heart rate 119. Respirations 16. In generally
lying in bed. Neck supple. No left anterior descending
coronary artery. HEENT pupils are equal, round and reactive
to light. Nasogastric tube in place. Extraocular movements
intact. Arcus senilis bilaterally. Right cataract.
Oropharynx without lesions. Cardiovascular tachy, no rubs or
murmurs appreciated. Respirations fine crackle at the bases
bilaterally. Abdomen soft, nontender, nondistended.
Normoactive bowel sounds. Extremities no edema. 1+ dorsalis
pedis pulses. Left lower extremity with ulcerations. No
erythema surrounding. Rectal guaiac positive per Emergency
Department.
LABORATORY: Significant for a white blood cell county of
16.3 with 92% neutrophils, 0 bands, 3 lymphocytes, 5
monocytes, hematocrit of 29.2, in [**Month (only) **] it was 47 and in
[**Month (only) **] it was 34. Platelets 346, MCV 105 with an RDW of
13.9. Creatinine 1.1. A1C was 7.8. Electrocardiogram
showed sinus tachycardia at 115, normal axis. CT chest
[**2199-11-30**] showed some abnormal thickening of the
esophageal walls, large hiatal hernia.
HOSPITAL COURSE:
1. Gastrointestinal bleed: The patient was admitted to the
MICU for upper gastrointestinal bleed. Two large bore IVs
were placed. Intravenous fluids were given. Intravenous
Protonix was given. The patient had an
esophagogastroduodenoscopy the following day and during that
time his hematocrit was followed closely. The patient was
transfused 2 units initially in the Emergency Room and when
his hematocrit did not bump he received a third unit. His
esophagogastroduodenoscopy on [**2200-1-18**] showed normal stomach,
normal duodenum, large hiatal hernia, esophageal ulcer. No
anomalies of the esophageal mucosa, although there is a
single ulcer in the hiatal hernia seen, therefore the
esophagus was not biopsied. The patient's hematocrit
stabilized and he was called out to the floor. He did not
require further blood and his hematocrit remained stable.
His gastrointestinal plan was for him to follow up in eight
weeks for a repeat esophagogastroduodenoscopy to ensure the
ulcer was healing and to continue on his Protonix b.i.d.
2. Diabetes: The patient was continued on his sliding
scale, but once out of the unit was restarted on his oral
medications.
3. History of cellulitis to his leg: The patient had
cellulitis to his leg. He was continued with dressing
changes. No antibiotics were given.
4. Hematology: In addition to the packed red blood cells
secondary to the patient's high MCV a B-12 level was checked
and it was slightly low, therefore the patient was started on
B-12 repletion.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Gastric ulcer.
2. Barrett's esophagus.
DISCHARGE STATUS: To home with services.
DISCHARGE MEDICATIONS:
1. Simvastatin 20 po q.d.
2. Protonix 40 one b.i.d. and then after eight weeks one po
q.d.
3. Metformin 1000 one q.a.m.
4. Metformin 500 one q.p.m.
5. Vitamin B-12 one microgram tablet one po q day.
DISCHARGE FOLLOW UP PLANS:
1. The patient will follow up with Dr. [**Last Name (STitle) 21140**] in eight weeks
for repeat esophagogastroduodenoscopy.
2. The patient will follow up with Dr. [**Last Name (STitle) **] in Dermatology
[**2200-1-31**].
3. The patient will follow up with Dr. [**Last Name (STitle) 14069**] [**2200-2-7**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 8141**]
MEDQUIST36
D: [**2200-6-3**] 03:15
T: [**2200-6-5**] 09:29
JOB#: [**Job Number 93581**]
ICD9 Codes: 2859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4261
} | Medical Text: Admission Date: [**2127-7-14**] Discharge Date: [**2127-7-19**]
Date of Birth: [**2089-12-13**] Sex: F
Service: CSU
CHIEF COMPLAINT: Atrial mass.
HISTORY OF PRESENT ILLNESS: The patient is a 37-year old
female with a right atrial mass that was found on
echocardiogram. The patient was hospitalized in [**Month (only) 958**] of
this year for an asthma exacerbation. The patient underwent
an echocardiogram to follow up for a high-dose steroid use.
The echocardiogram revealed a right atrial mass. The patient
had reported six to seven weeks of a low-grade fever with a
temperature of 99 to 100. The patient was placed on Ceftin
for a positive urinary tract infection, and since then she
has had no fevers. The patient reportedly had received 125
mg of Solu-Medrol two days prior to admission for an asthma
exacerbation. The patient's Perm-A-Cath (through which she
was receiving gamma globulin) was discontinued under local
anesthetic on Friday - three days prior to admission. She
complained of no pain since that time.
The patient had an echocardiogram in [**Month (only) 958**] of this year with
an ejection fraction of 65 percent and a right atrial mass of
2 cm x 2 cm.
PAST MEDICAL HISTORY: The patient has a significant history
of asthma, chronic obstructive pulmonary disease,
hypertension, morbid obesity, degenerative disc disease,
systemic lupus erythematosus, sleep apnea, hypoglycemia, skin
cancer, renal calculi, steroid-induced myopathy of the spine,
and rheumatoid arthritis.
PAST SURGICAL HISTORY: The patient is status post
laparoscopic cholecystectomy, bilateral temporal artery
biopsy, and right subclavian Port-A-Cath placement.
ALLERGIES: She is allergic to BETADINE, ERYTHROMYCIN, SULFA,
AMOXICILLIN, AUGMENTIN, CIPROFLOXACIN, VASOTEC, BIAXIN,
TETRACYCLINE, XOLAIR, OXYCONTIN, ETODOLAC, PSEUDOEPHEDRINE,
and GUAIFENESIN.
MEDICATIONS AT HOME:
1. Albuterol nebulizer twice per day.
2. Atacand 8 mg by mouth once per day.
3. Celexa 10 mg by mouth once per day.
4. Pulmicort nebulizers three times per day.
5. Zantac 150 mg by mouth twice per day.
6. Singulair 10 mg by mouth once per day.
7. Gamma globulin infusion 84 grams every three weeks.
8. Ambien 2.5 mg by mouth as needed.
9. Nasonex 2 squirts as needed.
10. Verapamil 280 mg by mouth once per day.
11. Topamax 50 mg by mouth once per day.
12. Uniphyl 400 mg by mouth twice per day.
13. Weekly intramuscular allergy injections.
14. Ceftin 500 mg by mouth twice per day (for the past
two weeks).
FAMILY HISTORY: Mother is alive at the age of 67. Father
died at the age of 51 - killed in a motor vehicle accident.
SOCIAL HISTORY: The patient denies smoking or the use of
alcohol. The patient is disabled and lives with her husband.
The denies the use of cocaine or marijuana.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's
temperature was 99.3, her pulse was 86, her blood pressure
was 138/78, respiratory rate was 18, and she was saturating
96 percent on room air. The patient was generally obese,
alert, and oriented. The patient had no obvious lesions on
the skin. The patient's pupils equal, round and reactive to
light. The extraocular movements were intact. The sclerae
were anicteric. The eyes were not injected. There were no
bruits heard. There was no jugular venous distention on the
neck. There was no lymphadenopathy. The patient's lungs
were clear to auscultation bilaterally. The patient had a
well-healed right Port-A-Cath site. Cardiovascular
examination revealed first heart sounds and second heart
sounds heard. A regular rate and rhythm. There were no
murmurs. The patient's abdomen was obese and healed. The
extremities were warm and well perfused. There was no
clubbing, cyanosis, or edema. The patient's neurologic
examination was grossly intact. The patient had good 2 plus
dorsalis pedis pulses bilaterally and 1 plus posterior tibial
pulses bilaterally.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
hospital and underwent a repeat urinalysis and complete blood
count.
The patient was admitted to the Cardiac Surgery Service and
an evaluation for low-grade fever prior to her surgery. The
patient had a repeat urinalysis and straight catheter
urinalysis recommended by Infectious Disease. We obtained a
consultation from them, who felt that the patient did not
have a urinary tract infection and that there was no need for
her to continue antibiotic coverage. Thus, from that
standpoint, was able to go to the operating room. The repeat
urinalysis was negative with the straight catheterization.
The patient's white blood cell count was 13.5 preoperatively;
however, the patient had Solu-Medrol three days prior. Thus,
this was not a concern. Infectious Disease recommended that
the patient may go to the operating room without antibiotics.
The patient underwent a right atrial removal. On
postoperative day one, the patient was extubated. She
remained neurologically intact and remained in a sinus rhythm
with good pressure without any clips. The patient was
saturating 97 percent on 2 liters. She was able to take
clears without any difficulties. She had a low-grade
temperature of 100.1, but this temperature defervesced. The
patient's creatinine was 0.6. Otherwise, she was doing well.
The patient's chest tubes were removed due to low chest tube
output, and she was advanced to a cardiac diet.
On postoperative day two, the patient was doing well. The
patient was on the floor. She was afebrile with stable vital
signs. The patient was put on Toradol for pain management.
There were no major issues.
On postoperative day three, the patient remained afebrile
with stable vital signs. The patient was put back on her
home medication and was given Dilaudid and Motrin for pain
management and was discharged home.
MEDICATIONS ON DISCHARGE:
1. Verapamil 280 mg by mouth once per day.
2. Celexa 10 mg by mouth once per day.
3. Zantac 150 mg by mouth twice per day.
4. Theophylline 400 mg by mouth twice per day.
5. Atacand 8 mg by mouth once per day.
6. Pulmicort nebulizer three times per day.
7. Colace 100 mg by mouth twice per day.
8. Dilaudid 2 mg to 4 mg by mouth once per day.
9. Motrin 600 mg by mouth three times per day (for three
days).
10. Tylenol as needed.
11. Albuterol as needed.
DISCHARGE FOLLOWUP: The patient was instructed to follow up
with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in four weeks.
The patient was instructed to follow up with Dr. [**First Name (STitle) **] in
one to two weeks.
DISCHARGE STATUS: Discharged home with Visiting Nurses
Association.
CONDITION ON DISCHARGE: Good.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Doctor Last Name 6052**]
MEDQUIST36
D: [**2127-7-19**] 12:21:58
T: [**2127-7-19**] 14:06:55
Job#: [**Job Number **]
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4262
} | Medical Text: Admission Date: [**2145-4-21**] Discharge Date: [**2145-5-22**]
Date of Birth: [**2090-12-8**] Sex: M
Service: Transplant Surgery
CHIEF COMPLAINT: End stage renal disease.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male with diabetes mellitus type 2 diagnosed in [**2141**], on
hemodialysis since [**2142-6-17**]. In addition, the patient has a
questionable diagnosis of hepatitis C, hypertension. The
patient has no surgical history.
MEDICATIONS ON ADMISSION:
1. Actos 30 mg po q a.m.
2. Ambien 10 mg po q hs prn.
3. Cozaar 50 mg po q day.
4. Nephrocaps po q hs.
5. PhosLo 667 mg po tid with meals.
6. Renagel 800 mg before each meal.
7. Toprol 50 mg po q day.
8. Procrit [**2140**] units q weekly.
9. TUMS 500 mg 3 with meals.
10. Vasotec 20 mg po once daily.
11. Viagra 50 mg po prn.
PHYSICAL EXAMINATION: The patient was afebrile with stable
vital signs. Weight of 195.
HEAD, EARS, EYES, NOSE AND THROAT: Normal. Neck supple.
Trachea midline. OP clear.
LUNGS: Clear bilaterally.
HEART: Regular rate and rhythm. No CVA tenderness.
ABDOMEN: Soft and nontender. Non-distended.
RECTAL: Minimally enlarged prostate. No masses. Guaiac
negative.
EXTREMITIES: Within normal limits.
NEUROLOGICAL: Grossly intact.
HOSPITAL COURSE: At this time the patient was admitted to
Renal Transplant Unit on [**2145-4-21**]. His postoperative
course was remarkable for a postoperative ileus. This was
managed with an NG tube decompression and NPO status. This
resolved unremarkably. The patient also started dialysis on
postoperative day 1 for volume overload. Urology consult was
called secondary to penile and scrotal swelling which caused
multiple small ulcers which were well healed at the time of
discharge. Postoperative course was also remarkable for a
drop in hematocrit requiring a take back for evacuation of
hematoma on [**2145-4-30**] and [**2145-5-12**]. At this time, the
patient was transferred to the Intensive Care Unit and was
difficult to extubate. The patient was extubated and failed
this trial and had to be reintubated.
The patient had another postoperative ileus after the third
time to the Operating Room at which time he was placed on TPN
and was treated with NG tube decompression. With time, the
ileus resolved and the patient's TPN was weaned and diet was
advanced without problems. The patient continued to require
hemodialysis throughout the hospital course. Physical
therapy and occupational therapy were working with the
patient throughout the hospital course as well. [**Last Name (un) **] was
consulted for management of diabetes throughout the hospital
course and made multiple recommendations regarding diabetic
regimen, NPO and while tolerating diet.
Upon discharge the patient was afebrile with stable vital
signs, doing clinically well. The patient was finishing up
treatment with Zosyn for postoperative pneumonia and switched
to Augmentin on discharge for 10 days. As mentioned upon
discharge the patient was afebrile with stable vital signs,
tolerating regular diet and voiding without problems. The
patient was ambulating with a walker and help with physical
therapy without problems as well. The patient's white count
was 16 and stable. Hematocrit was 29.4 and stable. Platelets
were 392 and stable. Potassium was 34 and BUN 45 and
creatinine was 6.8 which was stable. Liver function tests
were also stable and hepatitis viral load was pending at the
time of dictation.
On examination the patient had minimal serosanguinous
drainage from the wound site and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain in
place draining minimal serosanguinous fluid. Otherwise
physical examination was unremarkable. The patient was
discharged to a rehabilitation center with plans for dialysis
on Monday at his previous dialysis place at [**Location 30672**],
[**Location (un) **].
DISCHARGE DIAGNOSIS: End stage renal disease status post
Cadaveric renal transplant 55 and status post evacuation of
perinephric hematoma on [**4-30**] and [**5-12**]. Co morbidities are
diabetes mellitus type 2, hypertension, history of hepatitis
C and OSA.
DISCHARGE CONDITION: Stable. The patient was instructed to
call of fever, chills, nausea, vomiting, or increased
redness, drainage from the wound site. Laboratory values
were re-drawn 3 times a week by transplant team including the
oral levels twice weekly.
Immunosuppressive drug levels were followed throughout the
hospital course and dosed appropriately.
DISCHARGE MEDICATIONS:
1. Nystatin swish and swallow qid
2. Bactrim 1 tab po qid
3. Bacitracin applied topically qid.
4. Prednisone 20 mg po qid
5. Lopressor 50 mg po bid
6. Reglan 5 mg po qid with meals
7. Protonix 40 mg po qd
8. Percocet 1 to 2 tabs for q 4 to 6 hours prn
9. CellCept [**Pager number **] mg po bid.
10. Hydralazine 25 mg po q 6 hours
11. Valganciclovir 450 mg po q od
12. Insulin as [**First Name8 (NamePattern2) **] [**Last Name (un) **] and sliding scale/flow sheet.
13. Augmentin 1 tab po q 24 hours x 10 days
14. Cyclosporin 100 mg tonight and in the a.m.
Labs are to be drawn and transplant team is to follow levels.
DISPOSITION: To rehab.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]
Dictated By:[**Last Name (NamePattern1) 4881**]
MEDQUIST36
D: [**2145-5-21**] 21:11:32
T: [**2145-5-22**] 04:55:40
Job#: [**Job Number 30673**]
ICD9 Codes: 5070, 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4263
} | Medical Text: Admission Date: [**2200-4-29**] Discharge Date: [**2200-5-6**]
Date of Birth: [**2200-4-29**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **], twin number one,
was admitted to the NICU for issues of prematurity, born at
35 and 6/7 weeks gestation. This infant was born to a 32 year-
old, G3, P1 mother, with prenatal screens as follows: Blood
type 0 positive, antibody negative, RPR nonreactive, HBSAG
negative, Rubella immune. EDC was [**2200-5-28**]. There was a
benign prenatal course. This infant was born after
spontaneous preterm labor by Cesarean section. The infant
emerged with Apgars of 8 and 9. There were no sepsis risk
factors except for an unknown group beta strep status. The
infant was brought to the NICU for further care due to
prematurity.
PHYSICAL EXAMINATION: On admission, birth weight was [**2132**]
grams, which is 10th percentile. Length of 42 cm which is
slightly less than the 10th percentile. Head circumference of
31.75 cm which is 10 to 25th percentile. Active infant.
Anterior fontanel open and flat. Normal S1 and S2 with no
murmur. Palate intact. Breath sounds clear and equal.
Abdomen soft and nontender, nondistended. Extremities well
perfused. Tone appropriate for gestational age. Hips stable.
Anus patent. Spine intact. No rash.
HOSPITAL COURSE:
1. Respiratory: The infant has remained on room air since
admission to the NICU and has had no symptoms of
respiratory distress. She has required no methylxanthine
therapy and has had no apnea or bradycardia episodes.
2. Cardiovascular: The infant has maintained a
cardiovascularly stable status, has had no signs of a
murmur; normal heart rates and blood pressures and well
perfused.
3. Fluids, electrolytes and nutrition: The infant was
started on enteral feedings on the newborn day; has never
received IV fluids nor has she had any electrolytes
measured. She has been mostly p.o. feeding with some p.g.
feedings initially and has been all p.o. feeding for the
past 48 hours. She is taking approximately 120 ml/kg per
day of breast milk or Similac 20 with iron. Her most
recent weight is 1890 grams which is up 5 grams from the
prior day.
4. Gastrointestinal: She has developed mild
hyperbilirubinemia, not requiring phototherapy, with a
peak bilirubin level on [**2200-5-2**] of 9.7 over 0.3. The
subsequent bilirubins have slowly been declining without
use of phototherapy. Most recent bilirubin was 8.5 over
0.3 on [**2200-5-4**].
5. Hematology: No blood typing has been done on this
infant. No CBC has been done on admission. Therefore,
there is no hematocrit or platelets to measure.
6. Infectious disease: There have been no infectious disease
issues.
7. Neurology: The infant has maintained a normal neurologic
exam for gestational age.
8. Sensory: Audiology: A hearing screen was performed with
automated auditory brain stem responses on [**2200-5-5**] and the
infant passed in both ears.
9. Development: The infant did require thermoregulatory support
in an isolette, but by the time of discharge, had a stable
temperature in a crib for over 48 hours.
10. Psychosocial: Twin number 2 had been discharged with the
mother prior to the discharge of this infant. That infant
is doing well at home.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr.[**Name (NI) 72807**] from [**Hospital 246**]
Pediatrics, telephone number [**Telephone/Fax (1) 37501**].
CARE RECOMMENDATIONS:
1. Ad lib p.o. feedings by breast with supplementation as
needed of [**Doctor Last Name **]-20 with iron.
2. Medications: Infant is on no medications at this time.
3. Car seat position screening was done and the infant passed.
4. State newborn screen was sent on [**2200-5-1**]. Results are
pending.
5. Immunizations received: The infant has received
hepatitis B vaccine on [**2200-5-4**].
FOLLOWUP: Follow-up appointment should be scheduled with the
pediatrician within 48 hours of discharge from the NICU.
DISCHARGE DIAGNOSES:
1. Prematurity born at 35 and 6/7 weeks gestation.
2. Mild hyperbilirubinemia, resolving without treatment.
3. Feeding immaturity
4. Thermoregulatory instability
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2200-5-5**] 22:20:57
T: [**2200-5-6**] 05:17:59
Job#: [**Job Number 72808**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4264
} | Medical Text: Admission Date: [**2102-5-20**] Discharge Date: [**2102-6-14**]
Date of Birth: [**2020-2-24**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5341**]
Chief Complaint:
Recurrent falls
Major Surgical or Invasive Procedure:
Transbronchial nodal biopsy
History of Present Illness:
Ms. [**Known lastname **] is an 82 yo female with PMH significant for HTN and
HLD who initially presented from OSH on [**5-20**] with 3 week history
of multiple falls, approximately once per week. She had an MRI
which showed 4 enhancing cerebellar lesions, thought to be
consistent with metastatic cancer. She was transferred to the
oncology service for further work-up.
She underwent a CT scan chest at OSH (read by our
radiologists)which showed a RUL lung mass with mediastinal
lymphadenopathy. She was started on Decadron and Keppra. She was
transferred to the IP service for further work-up. on [**5-24**] and
underwent a transbronchial nodal biopsy. She acutely became
hypertensive and tachycardic causing her to go into flash
pulmonary edema. Initial EKG showed ST depressions inferiorly
and laterally. She received Nitropaste, Lasix, and was started
on a Labetalol gtt. She was taken to SICU and placed on BIPAP
with little improvement in her respiratory status. Repeat ECG
showed ST elevations in V2 and V3 and post-procedure cxray
showed moderate R sided pneumothorax. Chest tube was placed and
she was intubated. During her stay in the MICU her hypoxia
slowly improved with diuresis. Cardiology was consulted and did
not feel that she was having an ACS. ST elevations resolved and
she was transferred back to the oncology service.
Past Medical History:
1)Hypertension
2)COPD
3)Hyperlipidemia
Social History:
Patient has daughter and son. Lives at [**Hospital1 1501**]. No tobacco, alcohol,
or IVDA.
Family History:
NC
Physical Exam:
vitals T 98.1 BP 110/50 AR 74 RR 22 O2 sat 97% on 5L
Gen: Patient lying in bed, does not appear distressed
HEENT: dry MM
Heart: nl s1/s2, no s3/s4, no m,r,g
Lungs: +bibasilar crackles
Abdomen: soft, NT/ND, +BS
Extremities: 1+ bilateral edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
Laboratory results:
[**2102-5-20**] 11:55PM BLOOD WBC-8.5 RBC-3.60* Hgb-10.7* Hct-29.7*
MCV-83 MCH-29.8 MCHC-36.1* RDW-14.0 Plt Ct-339
[**2102-6-14**] 02:11AM BLOOD WBC-12.3* RBC-3.69* Hgb-10.3* Hct-30.2*
MCV-82 MCH-28.0 MCHC-34.2 RDW-15.8* Plt Ct-290
[**2102-5-24**] 01:30PM BLOOD Neuts-61.8 Lymphs-34.5 Monos-3.1 Eos-0.3
Baso-0.2
[**2102-5-20**] 11:55PM BLOOD PT-13.1 PTT-25.5 INR(PT)-1.1
[**2102-5-20**] 11:55PM BLOOD Glucose-111* UreaN-14 Creat-0.7 Na-134
K-5.0 Cl-103 HCO3-21* AnGap-15
[**2102-6-14**] 02:11AM BLOOD Glucose-133* UreaN-11 Creat-0.6 Na-129*
K-3.9 Cl-101 HCO3-20* AnGap-12
[**2102-5-20**] 11:55PM BLOOD ALT-102* AST-66* LD(LDH)-399* AlkPhos-99
TotBili-0.5
[**2102-5-22**] 06:40AM BLOOD proBNP-1344*
[**2102-5-24**] 01:30PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2102-5-20**] 11:55PM BLOOD Albumin-3.3* Calcium-8.9 Phos-3.1 Mg-2.2
[**2102-5-22**] 06:40AM BLOOD calTIBC-352 Ferritn-116 TRF-271
[**2102-5-22**] 06:40AM BLOOD TSH-0.86
[**2102-5-22**] 06:40AM BLOOD Free T4-1.4
Relevant Imaging:
1)LE doppler ([**5-23**]): 1. No deep vein thrombosis in the lower
extremities.
2)ECHO ([**5-23**]): No obvious vegetations visualized. Mild focal
hypertrophy of the basal septum with normal biventricular
systolic function. Mild pulmonary artery systolic hypertension.
No pathologic structural valve disease. If clinically
indicated, a TEE may better assess for evidence of endocarditis.
3)ECHO ([**5-24**]): There is symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. LV systolic function
appears depressed with spetal akinesis/hypokinesis and anterior
hypokinesis (views are suboptimal). Overall LV ejection fraction
estimate is ?45%? Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
4)CT Head ([**6-5**]): Bilateral cerebellar masses with no evidence
of hydrocephalus or herniation.
5)CT Chest ([**6-5**]): 1. Multifocal pneumonia/aspiration, greater
in the left lower lobe than the right lower lobe. Right lower
lobe opacities are more rounded in configuration and underlying
nodules are not excluded. There is no dominant lung mass
visualized. 2. Small peripheral centrilobular nodular opacities,
sub-5-mm in size. These may be inflammatory, but it is unclear
if these preceded the current pneumonia as no prior CT exams are
available for comparison. 3. Several small mediastinal lymph
nodes, and more infiltrative opacity of the left hilum. While no
single node meets CT size criteria for pathologic enlargement,
metastasis may be resonsible.
4. Right adrenal mass, not characterized on this study. 5. Lytic
lesion of the left T10 pedicle. Bone scan could be obtained if
indicated for further evaluation. 6. Fracture of the right
posterior eighth, ninth, and tenth ribs.
Brief Hospital Course:
Ms. [**Known lastname **] is a 82yo female who presented with multiple falls,
found to have multiple brain lesions now s/p transbronchial
biopsy complicated by respiratory failure, pneumothorax, and
STEMI.
1)Respiratory distress: Occurred in the setting of malignant
hypertension during the bronchoscopy causing her to go into
pulmonary edema. In addition, she was found to have a R sided
pneumothorax secondary to bronchoscopy but she did not require a
chest tube. As a result of her hypoxemia, she was found to have
ST depressions and then elevations, likely demand ischemia.
Patient was intubated and then extubated successfully. Upon
transfer to the oncology service, she was diuresed further but
given mild improvement in her respiratory status a CT scan chest
was done. CT revealed multifocal opacities. She was started on
Vancomycin & Zosyn for presumed hospital aquired pneumonia and
the pulmonary service was consulted. The pulmonary team agree
with our plan and further diuresis was held. During the
remainder of her hospital stay her respiratory status
significantly improved, only requiring 2-3L supplemental oxygen
at time of discharge. Repeat cxray confirms this as well. PICC
line was placed and she will need 2 week course of Vancomycin &
Zosyn (last day [**2102-6-19**]). Patient was also started on Bactrim DS
for PCP [**Name Initial (PRE) 1102**]. PICC line should be removed once
antibiotics are completed.
2)Brain lesions: Patient initially presented with multiple falls
and found to have multiple lesions on imaging. Likely metastatic
cancer but no primary found thus far. Tissues obtained during
bronchoscopy was nondiagnostic. Patient and family are still
unsure about brain biopsy and further work-up will be deferred
as outpatient once her respiratory status improves. She was
started on Keppra on admission which was titrated up to 1000mg
[**Hospital1 **]. She was also placed on Decadron. Both medications should be
continued as an outpatient, as per her oncologist.
3)Hypertension: Patient found to have extremely elevated SBPs
s/p bronchoscopy. This likely caused her to flash causing her
respiratory decline. She remained hypertensive throughout her
stay in the MICU and required her to be on a nitro gtt for
better blood pressure control. She had been on an extensive
regimen in the MICU which was changed upon transfer to the
oncology service since she had not been able to take PO. She was
placed on Lopressor 5mg IV which was changed to PO prior to
discharge. Low dose Lisinopril 5mg was also started.
4)SIADH: Throughout the first part of her admission patient
maintained normal sodium. After her return from the MICU she was
hypernatremia and her free water deficit was appropriately
corrected. For the remainder of her stay she has remained
hyponatremic. The etiology was thought to be hypovolemic given
poor oral intake. As a result, she was hydrated with IVFs. Urine
electrolytes and osmolality were checked and confirm diagnosis
of SIADH. She was started on Demeclocycline on day of discharge.
Electrolytes should be followed every 2-3 days.
5)UTI: Patient found to be growing enterococcus in urine
cultures. She was already on Vancomycin for her pneumonia, which
was also appropriate coverage for her UTI. Cultures were
rechecked and showed resolution.
6)STEMI: Patient found to have ST depressions/elevations on EKG
after bronchoscopy which have normalized since then. She has
remained chest pain free. Cardiology was consulted in the ICU
and did not feel that her presentation was consistent with acute
coronary syndrome. Decision was made to medically manage her
with aspirin, beta-blocker, ace-inhibitor, and statin.
7)Depression: Patient extremely depressed in context of her
husband's suicide while she was in the hospital. Patient at this
point is not aware of this, however it was discussed with the
family who is in agreement with this plan. The patient was told
that her husband passed away in his sleep from heart attack.
This confidentiality should be maintained, but should be
addressed with the family once the patient is more clinically
stable. Patient was started on Paxil for her depression and
should titrated up appropriately.
8)FEN: After patient returned from the ICU, patient's oral
intake remained poor. There was concern for vocal cord
dysfunction given her recent intubation and resultant
aspiration. ENT was consulted and felt that there was no vocal
cord dysfunction. Speech and swallow worked with patient several
times and she underwent few video swallow studies. At time of
discharge, patient's diet was advanced to thin liquids, pureed
consistency. Patient has dentures and once the family brings in
Polydent or an equivalent and her dentures appropriately fit,
her diet may be advanced ground consistency. She should continue
to be followed by speech and swallow once discharged to the
facility.
8)Prophylaxis: Patient on heparin SQ for DVT prophylaxis. This
should be stopped once patient is ambulatory. Also on PPI since
patient on steroids.
9)Code: DNR/DNI; pt does not want ICU level of care
Medications on Admission:
Ipratropium Bromide Neb 1 NEB IH Q4H
Lactulose 30 ml PO Q6H:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Lansoprazole Oral Disintegrating Tab 30mg PO DAILY
Amlodipine 5 mg PO DAILY
Levetiracetam 1000 mg IV Q12H
Aspirin 325 mg PO DAILY
Atorvastatin 40 mg PO DAILY
Metoprolol 125 mg PO Q 8H
Bisacodyl 10 mg PO/PR DAILY
Nystatin Oral Suspension 5 ml PO QID
Captopril 100 mg PO TID
Olanzapine (Disintegrating Tablet) 2.5 mg PO QHS:PRN
Dexamethasone 4 mg PO Q12H
OxycoDONE 5 mg PO Q4-6H:PRN
Docusate Sodium 100 mg PO BID
Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
Heparin 5000 UNIT SC TID
Xopenex *NF* 0.63 mg IH Q6-8H:PRN
HydrALAzine 10 mg IV Q6H
Discharge Medications:
1. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Demeclocycline 150 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
4. Dexamethasone 2 mg Tablet [**Hospital1 **]: 1.5 Tablets PO Q12H (every 12
hours).
5. Heparin Flush Port (10units/ml) 5 ml IV DAILY:PRN
10 ml NS followed by 5 ml of 10 Units/ml heparin (50 units
heparin) each lumen Daily and PRN. Inspect site every shift.
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q6H (every
6 hours) as needed.
8. Levetiracetam 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: 0.5 Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed.
12. Paroxetine HCl 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
14. Vancomycin in Dextrose 1 g/250 mL Solution [**Last Name (STitle) **]: 1000 (1000)
milligrams Intravenous once a day: Last Day is [**2102-6-19**].
15. Lisinopril 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
16. Piperacillin-Tazobactam 2.25 g Recon Soln [**Month/Day/Year **]: 2.25 grams
Intravenous Q6H (every 6 hours): Last day [**2102-6-19**].
17. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) neb
Inhalation Q4H (every 4 hours).
18. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID
(2 times a day).
19. Miconazole Nitrate 2 % Powder [**Month/Day/Year **]: One (1) Appl Topical QID
(4 times a day) as needed.
20. Levalbuterol HCl 0.63 mg/3 mL Solution [**Month/Day/Year **]: 0.63 mg
Inhalation Q6-8H (every 6 to 8 hours) as needed for shortness of
breath or wheezing.
21. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: 5000 (5000)
units Injection TID (3 times a day): please stop once patient is
ambulatory.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Pneumonia
Pneumothorax
Urinary tract infection
Brain masses
Hypertension
Cardiovascular disease
Discharge Condition:
Stable
Discharge Instructions:
1)Please take all medications as listed in the discharge
instructions.
2)You are being discharged on 2 antibiotics (Vancomycin and
Zosyn)to treat your pneumonia. You must be on these medications
until [**2102-6-19**]. At that time your PICC line may be removed.
3)Please attend all appointments as listed below. You have an
appointment with Dr. [**Last Name (STitle) 4253**] on [**Last Name (LF) 766**], [**6-19**] at 1pm in
the [**Hospital Ward Name 23**] Building, [**Location (un) **].
4)If you experience any fevers, chills, chest pain, shortness of
breath or any other concerning symptoms please return to the
emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2102-6-19**] 1:00
ICD9 Codes: 9971, 4280, 5990, 496, 5070, 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4265
} | Medical Text: Admission Date: [**2121-1-4**] Discharge Date: [**2121-1-7**]
Date of Birth: [**2055-6-29**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Niacin / Flonase
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65 y/o female with metastatic breast cancer who was admitted to
the oncology service with cough, SOB, and hypoxia. Hypoxic to
80% on RA at NH -> in ambulance improved to 100% on NRB. She had
been c/o weakness for the past several weeks along with
worsening back pain. She has had a nonproductive cough 3 days
PTA. She has had intermittent nausea and some abdominal pain,
but no vomiting. She denies any burning when she urinates but
does note that her R nephrostomy tube has been painful and the
urine in it has been bloodier. She denies any swelling in her
legs, PND, or orthopnea. She denies any recent bruising,
bleeding, or skin changes.
In the ED, VS on arrival were T 102.2, BP 142/86, HR 113, and
sats were 80% on RA, improving to 95% on 5LNC. CXR was initially
read as pneumonia of the RML and she was given cefepime 2gm IV
x1 and levofloxacin 750mg IV x1. However, [**First Name3 (LF) **] said her CXR
did not show evidence of pneumonia so she was sent for CTA which
was concerning for atypical pneumonia. Given her ongoing
dexamethasone taper, she was given bactrim 350 mg IV x 1 for
PCP.
On the floor, she was treated for PCP pneumonia vs. HAP. She was
given cefepime, ciprofloxacin, vancomycin, and bactrim +
steroids. ID was consulted and agreed with the above
management.
On the floor, in the PM [**2121-1-5**], the patient triggered for
hypoxia with an oxygen saturation of 90% on a NRB. She was also
SOB. She is currently being treated for pneumonia, possible PCP
pneumonia vs. HAP. She is on broad-spectrum ABx including
Bactrim + steroids for PCP. [**Name10 (NameIs) **] was also found to be hypotensive
earlier in the evening with SBPs in the 80s which also resulted
in a trigger. She was given a 500 mL IVF bolus and her SBP
improved to the 100s. Her code status was confirmed with the
patient and her family, DNR/DNI. She was transferred to the [**Hospital Unit Name 153**]
for possible non-invasive ventilation and closer hemodynamic
monitoring.
Past Medical History:
1. Breast cancer - dx [**2112**] by chest MRI, s/p left mastectomy -
ER+, her2/neu +, [**7-29**] LN +, treated initially w/ adriamycin,
cytoxan, developed bone mets in [**2114**], treated w/ xeloda, then
herceptin + gemcitabine, then herceptin + paclitaxel, brain mets
dx [**4-26**] -> s/p WBXRT, 2000cGy, completed in [**5-26**], also underwent
XRT to thoracic and lumbar mets, XRT to pelvic mets in [**8-26**],
pelvic involvement -> hydronehprosis -> [**Date Range **] nephrostomy
tubes, had also been receiving herceptin, vinblastine, and
[**Last Name (LF) **], [**First Name3 (LF) **] mets recurred in [**10-27**] -> s/p 5 treatments w/
Cyberknife in [**11-26**] for recurrence; also on seizure medication
currently, chemotherapy changed to Tykerb and Xeloda [**2120-12-25**]
2. HTN
3. GERD
4. Cataracts s/p surgery
5. Breast reduction surgery [**2112**]
6. Left hip replacement [**2111**]
7. Tendon releases and carpal tunnel release
ALL:
codeine, niacin, flonase
Social History:
Retired, former administrative assistant. Has recently been at
rehab, but prior to that lived in an apartment with family in
adjacent apartments. Divorced. Quit smoking many years ago, occ
EtOH use.
Family History:
NC - + for CAD, prostate problems
Physical Exam:
VITALS: T 99.8 BP 103/57 HR 81 RR 22 97%NRB
GENERAL: Pale, older female.
HEENT: Sclera anicteric, PERRL (3->2mm), EOMI, MMM, OP clear w/
no oral lesions. No LAD.
NECK: Supple. No appreciable JVD.
CHEST: PAC in R chest, nontender. L mastectomy.
CV: Regular, tachycardic, normal S1, S2. No m/r/g.
RESP: Crackles at L base, decreased breath sounds in LUL and
LML. No wheezing, no rhonchi.
ABD: Soft, ND, + tender along midline, no rebound or guarding. +
BS throughout. No appreciable organomegaly.
EXT: Warm, no c/c/e, 2+ DP and radial pulses bilaterally.
BACK: No focal spinal tenderness. Some tenderness to palpation
over R nephrostomy tube.
SKIN: No rashes. Rose tattoo on posterior L shoulder.
NEURO: CN II-XII intact. [**3-24**] bicep/tricep/deltoid/hand grip
bilat, 4-/5 hip flexor bilaterally, [**3-24**] dorsiflexion
bilaterally, [**1-22**] plantarflexion bilaterally. Sensation to LT
grossly intact. No further neuro exam testing able to be
performed as pt stated "I just want to go to sleep!"
Pertinent Results:
[**2121-1-4**] 07:00PM BLOOD WBC-7.1# RBC-2.99* Hgb-10.0* Hct-28.7*
MCV-96 MCH-33.3* MCHC-34.7 RDW-20.0* Plt Ct-122*
[**2121-1-6**] 05:26AM BLOOD WBC-5.0 RBC-2.40* Hgb-7.9* Hct-24.1*
MCV-100* MCH-32.8* MCHC-32.8 RDW-20.7* Plt Ct-90*
[**2121-1-6**] 05:26AM BLOOD PT-12.0 PTT-26.9 INR(PT)-1.0
[**2121-1-4**] 07:00PM BLOOD Glucose-100 UreaN-22* Creat-0.5 Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
[**2121-1-6**] 05:26AM BLOOD Glucose-85 UreaN-14 Creat-0.4 Na-142
K-4.6 Cl-114* HCO3-21* AnGap-12
[**2121-1-4**] 07:00PM BLOOD ALT-116* AST-47* LD(LDH)-855*
AlkPhos-122* TotBili-0.4 DirBili-0.2 IndBili-0.2
[**2121-1-6**] 05:26AM BLOOD Calcium-7.2* Phos-2.7 Mg-2.1
[**2121-1-4**] 07:00PM BLOOD calTIBC-247* VitB12-615 Folate-13.1
Hapto-186 Ferritn-502* TRF-190*
[**2121-1-5**] 08:40AM BLOOD CEA-7.0*
[**2121-1-4**] 07:24PM BLOOD Lactate-1.9
EKG [**2121-1-4**]: sinus tach, rate 113, normal axis, normal
intervals, Q wave in III, flattened T waves in III, aVF, but no
other ST or TW changes (unchanged from priors)
CXR [**2121-1-4**]: Cardiomediastinal silhouette is unchanged.
Pulmonary
vascularity is unremarkable. Linear atelectasis is noted at the
mid-to-lower lung zones bilaterally. Multiple sclerotic lesions
involving the ribs and vertebral bodies are consistent with
known osseous metastases. Pigtail catheters again overlies the
left and right upper quadrants. IMPRESSION: Aside from
atelectasis, no evidence of an acute cardiopulmonary process.
CTA [**2121-1-4**]:
1. Multiple scattered nodular and linear ground-glass opacities
within a predominantly peripheral distribution, new compared to
study performed less than one month prior. Diagnostic
considerations include an atypical infection; however, other
etiologies such as drug reaction, eosinophilic pneumonia, or
cryptogenic organizing pneumonia (COP) should also be
considered.
2. No evidence of pulmonary embolism
Brief Hospital Course:
65yo F w/ widely metastatic breast cancer, on dexamethasone
taper for brain metastases, and w/ bilat nephrostomy p/w SOB and
fever w/ likely PNA +/- UTI.
Given symptoms of fever, nonproductive cough, hypoxia, and CTA
findings of new nodular and linear ground glass opacities,
initially treated for pneumonia. Given her recent history of
long hospitalizations and recent NH stay, will treat for
health-care acquired pneumonia with cefepime, levaquin, and
vancomycin. She was also presumably started on IV bactrim in the
ER for ? of PCP (given that she was on dexamethasone) and new
ground-glass opacities on CT, LDH elevated from baseline.
Upon transfer to the ICU, the patient refused positive pressure
ventilation, stating that she just wanted to be comfortable.
After discussing the matter with her and the health care team,
the patient was made comfort measures only.
Antibiotics were discontinued and she was put on a morphine gtt
to treat her sense of dyspnea. She expired at 4:50am on [**1-7**]
with her family at the bedside.
COMM: with patient and her son/HCP [**Name (NI) **] [**Name (NI) 102820**] ([**Telephone/Fax (1) 102822**])
and other son [**Name (NI) 4468**] [**Telephone/Fax (1) 102823**]
Medications on Admission:
Amlodipine 10 mg PO daily
Compazine 10 mg PO Q6 prn
Dexamethasone 4mg PO TID
Keppra 750 mg PO TID
Protonix 40mg PO BID
Toprol XL 50 mg PO daily
Tykerb 1250 mg PO daily
Xeloda 1000 mg PO BID - 2weeks on, 2 weeks off
Zonisamide 100 mg PO BID
Valtrex 1000mg PO BID x 10 days (started [**2120-12-25**])
.
NH meds:
Zonisamide 100 mg PO BID
Jeparin SC BID
keppra 750mg PO TID
amlodipine 10mg PO QD
metoprolol ER 50mg PO QD
tylenol prn
MOM prn
dulcolax prn
Fleet's prn
valacylcovir 1gm PO BID x10d - completed [**2121-1-3**]
protonix 40mg PO BID
trazadone 25mg PO QHS prn sleep
celexa 10mg PO QD
imodium prn loose stool
dexamethasone - tapered down to 2mg daily starting [**1-4**] x4d,
then plan to 2mg QOD x4d
? methadone 1.25mg PO Q8 + prn (was not started yet)
nystatin
MVI
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2121-1-7**]
ICD9 Codes: 486, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4266
} | Medical Text: Admission Date: [**2178-11-12**] Discharge Date: [**2178-12-3**]
Date of Birth: [**2106-1-8**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
72 yo Portugese speaking F with hx of HTN, ? CHF, hyperchol
presents with acute onset of upper back pain starting approx 12
hours prior to transfer. Pt states that she has never had pain
like this before and did have associated nausea and vomiting. No
CP or SOB. No Lightheadedness or dizziness. Pt does report that
she was admitted to an outside hospital for "heart problems". By
report from the OSH pt has a hx of a chronic thoracic aortic
aneurysm. Pt presented to OSH ED with pain and vomiting. Found
to have BP 240/120. Pt received Labetolol and Nipride and BP
improved to 140's, HR 60's. CTA suggestive of acute on chronic
thoracic aortic disection. Pt transfered for further management
and surgical consult.
Past Medical History:
HTN
CHF: necessitating hosp in [**Month (only) 958**]
Hypercholesterol
Hx thoracic aortic aneurysm
Social History:
denies smoking, drinking of IV drug use. Born in [**Last Name (un) **],
lived in [**Country 6171**] adn [**Country 480**] approx 30yr ago. Retired; used to
work in factories. No hx of blood transfusions. 3 children
from 3 men, now currently married
Family History:
DM
CVA
hx of aneurysms in sister and [**Name2 (NI) 12232**]
Physical Exam:
Admission exam by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]:
VS T:96.6 P:75 BP: 107/54 RR: 20 O2Sat:100%
GENERAL: Awake and alert, responding to questions.
HEENT: Pupils equal. MM dry. Op clear.
NECK: supple, JVD flat
CARDIOVASCULAR: RRR, faint 2/6 systolic murmur, left PMI.
LUNGS: rales at b/l bases.
ABDOMEN: NDNT, no palpapble pulse, no bruit, non-tender,
hyperactive BS.
EXTREMITIES: warm and well perfused.
NEURO: non focal.
GUIAC positive
Pertinent Results:
Admission labs:
pH 7.44 pCO2 29 pO2 111 HCO3 20
Lactate:1.6
.
135 I 102 I 13
--------------< 204
3.2 I 20 I 0.6
.
Trop <0.01 x3
Ca: 9.0 Mg: 1.3 P: 4.7
ALT: 6 AP: 54 Tbili: 0.4 Alb: 3.6
AST: 17
[**Doctor First Name **]: 108 Lip: 17
.
9.7
6.2 >---< 240
28.1
PT: 12.2 PTT: 28.3 INR: 1.0
.
ECG: NSR, prolonged QT, TWI V1-V3, no St changes.
.
ESR: 150
CRP: 78 to 36
anti-CCP positive
RF: 342
[**Doctor First Name **] positive
.
Q-Fever, Histo, Bartonella, Brucella negative.
Lyme negative
Crypto negative
HIV negative
RPR negative
CSF ([**2178-11-18**]): WBC 1, RBC 22, negative cultures
.
Total chol 158, trig 124, HDL 41, LDL 92
.
Cortisol stim: adequate.
.
Imaging:
MRI Chest ([**2178-12-2**]): Extensive type B intramural hematoma
extending from the takeoff of the left subclavian artery through
the entire visualized thoracic and upper abdominal aorta.
Additionally noted on the current exam is marked delayed
crescentic enhancement of the entire aortic wall in the region
affected by the intramural hematoma, compatible with associated
engorgement of the vaso vasorum. Lack of circumferential
enhancement argues strongly against aortitis.
.
AP Wrist Hand ([**2178-11-28**]): Generalized osteopenia. No definite
fracture or other traumatic injury. The erosion of the right
triquetrum and the ulnar styloid process may be early indicators
of rheumatoid arthritis disease. However, no further findings
to corroborate such a diagnosis are noted.
.
Shoulder Xray ([**2178-11-28**]): Severe diffuse osteopenia, likely
secondary to osteoporosis. Given the severity of the osteopenia,
the sensitivity is decreased for detecting subtle nondisplaced
fracture.
.
CTA Chest, Abdomen, Pelvis with and without contrast
([**2178-11-23**]):1. Stable appearance of the chest, abdomen and pelvis
with type B intramural hematoma and associated penetrating
ulcer. 2. Improving ground-glass opacities. 3. Stable 4-cm
infrarenal abdominal aortic aneurysm. 4. Stable left common
iliac artery aneurysm.
.
WHITE BLOOD CELL STUDY ([**2178-11-23**]): No definite evidence for
acute peri-aortic infection.
.
CXR ([**2178-11-18**]): Borderline interstitial pulmonary edema is new.
Large heart is stable. There is no change in the mediastinal
contour of the generalized thoracic aorta. Small bilateral
pleural effusion, stable. No pneumothorax.
.
HEAD CT ([**2178-11-17**]): There is no intracranial hemorrhage. There
is no midline shift, mass effect or hydrocephalus. There is a
lacune within the left thalamus. There are multiple foci of low
attenuation within the periventricular and subcortical white
matter of both cerebral hemispheres most consistent with chronic
microvascular ischemic changes. There is atherosclerotic disease
within the anterior and posterior circulations.
.
CTA Chest, Abdomen, Pelvis ([**2178-11-17**]): 1. Unchanged appearance
of extensive Type B intramural hematoma from the subclavian
artery origin to the upper abdominal aorta. The associated
posterior penetrating ulcer at the diaphragmatic hiatus is
stable. No new
dissection. 2. Findings suggestive of congestive failure/volume
overload with bilateral pleural effusions and septal thickening.
3. Four-cm infrarenal abdominal aortic aneurysm. 4. Mild
aneurysmal dilation of the left common iliac artery. 5. Dense
coronary vascular calcifications.
.
Renal Ultrasound ([**2178-11-16**]): Normal arterial and venous waveforms
seen within the main renal arteries and veins bilaterally. Good
flow demonstrated within parenchymal branches of the mid and
lower poles bilaterally, upper pole is not well visualized
secondary to patient respiration.
.
CTA Chest ([**2178-11-14**]): 1) Extensive acute tupe B intramural
hematoma extending from the origin of the subclavian artery
throughout the entire thoracic and upper abdominal aorta.
Assessment of the distal abdominal aorta and iliacs is
suboptimal on this study. 2) Prominent posterior penetrating
ulcer at the level of the hiatus. 3) 3.7cm distal AAA. 4)
Evidence of volume overload with bilateral pleural effusions. 5)
Prominent subcarinal nodes, likely reactive.
.
ECHO ([**2178-11-13**]): 1. The left atrium is normal in size. The left
atrium is elongated. The interatrial septum is aneurysmal.
2.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%).
3.Right ventricular chamber size is normal. Right ventricular
systolic function is normal. 4.The aortic root is moderately
dilated. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. The descending thoracic aorta is mildly
dilated. 5.The aortic valve leaflets (3) are mildly thickened.
No aortic regurgitation is seen. 6.The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
7.The pulmonary artery systolic pressure could not be
determined. 8.There is no pericardial effusion.
.
EKG: Sinus rhythm. A-V conduction delay and A-V nodal
Wenckebach. Diffuse non-specific ST-T wave flattening.
.
CXR ([**2178-11-12**]): 1. Tortuous aorta dilated up to 4.9 cm to the
level of the thoracic aortic arch. This exam cannot prove or
rule out the possibility of aortic dissection or aneurysmatic
rupture. If clinically suspected further evaluation with chest
CTA is recommended. 2. Small bilateral pleural effusions.
.
Brief Hospital Course:
72 yo F with intramural hematoma of thoracic aorta. Hospital
course by problem:
.
1. Chronic TAA:
Initially, surgical intervention was not felt to be indicated as
it was a type B hematoma. Her BP was managed initially with
labetolol and Nipride for goal SBP<140 and >100 given likely hx
of chronic elevated BP and risk for hypoperfusion. She was
ruled out for an acute MI. Her Hct dropped to 23.9 on [**11-14**] and
developed acute abdominal pain radiating to her back, so a CTA
was repeated and showed possible large intramural hematoma in
descending thoracic aneurysm. Vascular Surgery was notified and
upon review of the scans w/ Radiology, felt the aneurysm was not
significantly changed. We changed her antihypertensives and had
good BP control with labetalol (changed to Toprol XL upon
dispo), amlodipine, and valsartan.
.
2. Intramural hematoma with penetrating ulcer: The etiology was
unclear. Initially, the ulcer was thought [**3-12**] atherosclerotic
disease. However, the patient became febrile during her stay
and rheum and ID were consulted. She had a negative workup for
infectious cause. Her rheum workup was above and notable for
positive [**Doctor First Name **], anti-CCP, and RF in the setting of an elevated ESR
and CRP. An MRI was obtained and revealed a pattern which was
not consistent with aortitis. Thus, her fever and inflammatory
response was thought to be [**3-12**] rheumatoid arthritis and the
patient did not have an underlying aortitis. The patient was
discharged with good blood pressure control and plans to return
on [**12-18**] for surgical intervention of her penetrating aortic
ulcer. Additionally, we started atorvastatin for goal LDL<70
and for it's anti-inflammatory activity. She has VNA to assist
with medication compliance as well as frequent blood pressure
checks.
.
3. Fevers: As above. The patient had intermittent fevers and
confusions for approx 6 days in the middle of her stay. CSF
analysis and head CT showed no pathology. ID workup was
negative. The fever was thought [**3-12**] inflammatory state. The
mental status change was thought [**3-12**] ICU delirium and it
improved rapidly after she was transferred to the floor.
.
4. CHF: EF>55% by ECHO. No evidence of heart failure on chest
Xray. No shortness of breath and oxygen saturation in high
90's. We continued lasix low salt diet
.
5. Hyponatremia: Labs were consistent with SIADH. The patient
had resolution of her hyponatremia prior to discharge.
.
6. Osteoporosis: All of her bone films mentioned severe
osteopenia. We started the patient on alendronate, calcium, and
vitamin D during her admission and continued it upon discharge.
Medications on Admission:
( pt does not know, report from OSH ED)
Calcium
Kcl
Sucralfate 1mg
Isosorbide 30mg
Metoprolol 50
Felodipine 5
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
Disp:*4 Tablet(s)* Refills:*2*
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. 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*
9. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
- atherosclerotic aortic disease with hematoma, dissection,
ulceration
- rheumatoid arthritis
- hypertension
- AAA
- osteoporosis
Secondary:
- CHF
- hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with upper back pain. You had
a thoracic aortic anuerysm and elevated blood pressure. We
controlled your blood pressure. You were evaluated by the
surgeons, infectious disease specialists, and rheumatologists
and we determined that you will need surgical correction of your
aorta in a few weeks. You also likely have rheumatoid arthritis
and will need to see rheumatology as an outpatient.
.
Please take your medications as instructed. It is very
important for you to take your blood pressure meds. Please keep
your followup appointments as directed. Please adhere to a
cardiac healthy diet.
.
If you develop severe chest or back pain, have difficulty
breathing, or become severely nauseated please contact your
doctor and return promptly to the emergency department.
Followup Instructions:
Please bring your daughter to all of your appointments.
.
You are scheduled to have an operation on [**2178-12-18**] at 10:30am.
Please arrive at the hospital no later than 8:30 am. Please
have nothing to eat for 12h prior to your surgery.
.
Please followup with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 69075**] on Monday, [**12-7**] at 11:15. The office phone number is [**Telephone/Fax (1) **] and fax
[**Telephone/Fax (1) 69076**]
.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 2206**] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2178-12-16**]
11:30
ICD9 Codes: 4280, 2762, 4019, 2724, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4267
} | Medical Text: Admission Date: [**2178-8-7**] Discharge Date: [**2178-8-11**]
Date of Birth: [**2127-6-24**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Vioxx / Codeine
Attending:[**Last Name (NamePattern1) 9662**]
Chief Complaint:
LE edema and dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51M with T2DM, unclear diastolic CHF, HTN and chronic pain on
narcotics who presents with worsening LE edema and SOB at rehab.
The patient states that over the past week, he has been having
more LE edema and shortness of breath. Prior to 1 week ago, he
was on Lasix 120mg qAM and 80mg qPM and was still c/o worsening
LE edema and weight gain. He states that he has gained 19 pounds
in the past 3 days. He was switched to torsemide 80mg [**Hospital1 **] 7 days
ago by his PCP [**Name Initial (PRE) **] 3 days ago was admitted to [**Hospital 4310**] rehab for
diuresis and because of falls at home. He states he has been
falling more because of his LE edema and neuropathy in his feet,
he denies lightheadedness or dizziness prior to the falls.
During this time, he also endorses worsening DOE, although he
denies orthopnea or PND (however, he states that he doesn't lay
flat because of his size and not his breathing). States he is
able to walk [**3-13**] blocks before feeling SOB now, previously not
limited by his breathing. He has a chronic dry cough from his
smoking but denies any change in his cough or productive
coughing. He also reports having a fever to 103F at rehab,
however speaking to his rehab they report no documented fevers.
He denies chills or subjective fevers.
He also states that he has been urinating much less than usual
lately and that his urine has appeared darker in color. This
change has been over the past few days. Denies dizziness when
standing or lightheadedness. Prior notes mention that his dry
weight is 385 lbs, he is currently 444 lbs in the ED.
In the ED, initial VS were: 98.2 82 74/50 24 91% RA. He was
initially placed on BiPAP 5/5 for hypoxia and was able to be
weaned to a facemask. He was not able to tolerate nasal cannula
as he was desatting to the mid 80s at rest. Labs were notable
for a Cr of 4.0 (baseline l-1.5), BUN of 63, WBC of 13 and
proBNP of 100. He was given levofloxacin 750mg IV and 500cc NS.
He triggered for hypotension to 70/50s, however this was likely
[**3-12**] using an inappropriately small BP cuff, SBP in 90-100s on
repeat with large cuff.
On arrival to the MICU, he is satting high 90s on 50% Venturi
mask and complaining of only mild SOB at rest. Reports pain over
his buttocks from lying on his back in the ED this evening and
chronic pain in his shoulders and knees which is similar to his
usual pain.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
1. Restrictive lung disease.
2. LVH but no known history of systolic CHF, on lasix for venous
insufficiency.
3. DM, type II, poorly controlled. Last A1c:12.9 on [**2176-3-8**].
4. Morbid Obesity: undergoing screening for gastric bypass
surgery.
5. Depression/Anxiety.
6. History of Alcoholism and polysubstance abuse: reports being
sober
now.
7. History of PUD: seen on EGD [**1-16**]. + for H. pylori, s/p
treatment.
Repeat EGD [**2-/2176**] normal.
8. History of rectal fissures, on stool softeners.
9. Status post multiple orthopedic procdures, most recently left
shoulder arthroscopic biceps tenotomy, subacromial
decompression,
and open biceps tenodesis on [**2176-5-16**].
10. History of pyelonephritis.
11. History of cellulitis.
12. Status post 6 abdominal hernia repairs with mesh.
Social History:
Lives alone at home prior to going to [**Hospital 4310**] rehab 3 days ago.
He is retired.
- Tobacco: 1ppd for 35 years
- Alcohol: None
- Illicits: None
Family History:
-Father - CAD and CABG
-Mother - healthy
Physical Exam:
Admit exam:
Vitals: T: 97.9 BP:97/70 P: 84 R: 18 O2: 96% on 50% venti mask
General: Morbidly obese gentleman, awake but sleepy, speaking in
full sentences, uncomfortable from pain
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, unable to assess JVP 2/2 habitus
CV: Distant heart sounds, RRR, no m/r/g appreciated
Lungs: Quiet breath sounds, scattered exp wheezing more
prominent at the bases
Abdomen: obese with mupltiple well-healed incisions, quiet BS,
mild TTP in RLQ, soft.
GU: no foley
Ext: 3+ edema and mild erythema of the calves bilaterally. PT/DP
pulses dopplerable bilaterally. Sensation grossly intact to
touch in the feet.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Skin: multiple telangectasias on chest and back
Discharge Exam:
VS:T 97.7 BP 99/57 P 80 RR16 O295 RA
General: Morbidly obese gentleman, speaking in full sentences,
sitting in chair
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: difficult to assess JVD given body habitus, no cervical
LAD
CV: Distant heart sounds, RRR, no murmurs appreciated
Lungs: Quiet breath sounds
Abdomen: obese with mupltiple well-healed incisions, mildly
hypoactive BS, soft, NT
Ext: calves bandaged tightly, 4+ edema of feet bilaterally.
Neuro: grossly normal sensation, A+Ox3
Pertinent Results:
[**2178-8-7**] 11:10PM TYPE-ART TEMP-36.7 PO2-101 PCO2-55* PH-7.29*
TOTAL CO2-28 BASE XS-0 VENT-SPONTANEOU
[**2178-8-7**] 11:10PM TYPE-ART TEMP-36.7 PO2-101 PCO2-55* PH-7.29*
TOTAL CO2-28 BASE XS-0 VENT-SPONTANEOU
[**2178-8-7**] 11:10PM HGB-12.2* calcHCT-37
[**2178-8-7**] 11:10PM freeCa-1.10*
[**2178-8-7**] 06:38PM VoidSpec-SPECIMEN C
[**2178-8-7**] 04:15PM GLUCOSE-112* UREA N-63* CREAT-4.0*#
SODIUM-138 POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-25 ANION GAP-23*
[**2178-8-7**] 04:15PM estGFR-Using this
[**2178-8-7**] 04:15PM CK(CPK)-580*
[**2178-8-7**] 04:15PM cTropnT-0.02*
[**2178-8-7**] 04:15PM CK-MB-6 proBNP-107
[**2178-8-7**] 04:15PM WBC-13.2* RBC-4.22* HGB-12.9* HCT-39.2*
MCV-93 MCH-30.4 MCHC-32.8 RDW-15.6*
[**2178-8-7**] 04:15PM NEUTS-82.3* LYMPHS-13.1* MONOS-3.5 EOS-0.7
BASOS-0.5
[**2178-8-7**] 04:15PM PLT COUNT-301
DISCHAREGE LABS:
[**2178-8-11**] 06:35AM BLOOD WBC-7.1 RBC-3.59* Hgb-11.0* Hct-33.3*
MCV-93 MCH-30.5 MCHC-33.0 RDW-15.4 Plt Ct-243
[**2178-8-11**] 06:35AM BLOOD Glucose-193* UreaN-71* Creat-1.4* Na-131*
K-4.3 Cl-93* HCO3-29 AnGap-13
[**2178-8-11**] 06:35AM BLOOD CK(CPK)-3208*
MICROBIOLOGY:
URINE CULTURE (Final [**2178-8-9**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**2178-8-7**] 4:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
51M with morbid obesity, T2DM, HTN, chronic venous stasis and
unclear history of heart failure who p/w worsening LE edema,
weight gain and shortness of breath and found to have [**Last Name (un) **].
#Dyspnea - Patient was found to have elevated WBC and RLL
opacity concerning for pneumonia. He was treated with
levofloxacin and CTX. He initially required supplemental oxygen
and Bipap, but was quickly weaned to room air and called out of
the MICU. He was ruled out for an MI. TTE showed Mild
symmetric left ventricular hypertrophy with preserved global
biventricular systolic function. Mildly dilated aortic root and
ascending aorta (EF 60-70%). Patient was not dyspneic on the
floor, and did not require supplemental O2. He finished a 5 day
course of levofloxacin for possible CAP. His dyspnea is thought
to be secondary to Obesity Hypoventilation syndrome.
#[**Last Name (un) **]/Rhabdomyolysis: unclear etiology of rhabdomyolysis. [**Last Name (un) **]
and CK elevation continued to trend down slowly. At discharge
his Cr was 1..4 and his CK was 3208. Possible etiology of CK
elevation include medication, overdiuresis, and lying in one
position for may hours at rehab.
#Agitation/elopement: patient left floor 3 times during
admission after becoming agitated and demanding a cigarette.
Patient was disconnected from tele and was allowed to go
outside, however he was informed of the risk of leaving the
floor.
#T2DM - Laxt A1c was 10.4% in [**6-/2178**] suggesting poor control.
He required significant amounts of sliding scale, so his Lantus
was increased to 90units [**Hospital1 **]
#OSA - Known OSA prior to admission, doesn't wear CPAP as he
states he cannot tolerate mask.
#Depression/anxiety - Continue home Ativan/Prozac
TRANSITIONAL-please re-check serum chemistry and CK level in [**3-13**]
days. Please follow up with PCP after discharge from rehab
facility. Patient should probably be re-challenged with statin
at some point (though could try lipitor or crestor). Also may
not need potassium supplementation (as he was receiving
previously) as his diuretics were held on discharge. Follow-up
with pulmonary for a sleep study. Encourage diet, exercise,
weight loss, and smoking cessation. Consider [**Last Name (un) **] consult for
help with insulin titration given that patient is requiring high
doses.
Medications on Admission:
-Advair 100-50 1 inhalation [**Hospital1 **]
-Amlodipine 10mg daily
-Ammonium lactate 12% cream [**Hospital1 **] to affected area
-Ferrous sulfate 325mg daily
-Fleet enema PRN
-Gabapentin 1200mg q8h
-Lidoderm patch daily
-Lisinopril 40mg daily
-Metformin 1000mg [**Hospital1 **]
-Metolazone 5mg [**Hospital1 **] prior to torsemide
-Metoprolol succinate 125mg daily
-Nicotine patch 21mg/24h
-Omeprazole 20mg daily
-KCl 20mEq daily
-Simvastatin 20mg daily
-Torsemide 80mg [**Hospital1 **]
-Lorazepam 1mg tid:PRN anxiety
-Fluoxetine 40mg daily
-Trazodone 50mg [**Hospital1 **]
-Lantus 70mg SC bid
-Humalog sliding scale (55-95 units with meals)
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Fluoxetine 40 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
4. Gabapentin 600 mg PO Q8H
5. Glargine 90 Units Breakfast
Glargine 90 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: Severe insulin resistance
6. Lidocaine 5% Patch 1 PTCH TD DAILY
7. Lorazepam 1 mg PO Q8H:PRN anxiety
8. Nicotine Patch 21 mg TD DAILY
9. Omeprazole 20 mg PO DAILY
10. traZODONE 50 mg PO HS:PRN insomnia
11. Hydrocodone-Acetaminophen (5mg-500mg [**2-9**] TAB PO Q8H:PRN pain
Hold for sedation or RR<10
12. Methadone 5 mg PO QPM
Hold for sedation or RR<12
13. Methadone 10 mg PO QAM
Hold for sedation or RR<10
14. Fleet Enema 1 Enema PR DAILY:PRN constipation
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4310**] Care and Rehabilitation Center - [**Location (un) 4310**]
Discharge Diagnosis:
Primary: acute kidney injury, rhabdomyolysis
Secondary: pneumonia, obesity hypoventilation syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure to take care of you at [**Hospital1 18**]. You were
treated for shortness of breath and kidney injury. You were
given antibiotics for pneumonia, and fluid to improve your
kidney function. Your kidney function improved significantly
during your time here.
Your blood pressure medications, water pills, and cholesterol
medications were stopped because of your blood pressur being
low. Your methadone and gabapentin doses were decreased because
of your kidney function.Please follow up with your primary care
physician [**Last Name (NamePattern4) **] 3 days to re-dose your medications.
Followup Instructions:
Please follow up with your rehab facility primary care provider
[**Last Name (NamePattern4) **] 3 days to re-dose your medications and follow up with your
kidney labs (CHEMISTRY, CK)
Department: [**Hospital3 249**]
When: TUESDAY [**2178-9-1**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PSYCHIATRY
When: TUESDAY [**2178-9-1**] at 5:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
Completed by:[**2178-8-11**]
ICD9 Codes: 4019, 3051, 5849, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4268
} | Medical Text: Admission Date: [**2101-6-18**] Discharge Date: [**2101-7-5**]
Date of Birth: [**2066-10-31**] Sex: F
Service: NEUROLOGY
ADMISSION DIAGNOSIS:
Continued seizures.
HISTORY OF PRESENT ILLNESS: The patient is a 34 year-old
woman with a history of [**Doctor Last Name **] encephalitis at age 8
transferred from [**Hospital6 5016**] with seizures. She was
at her group home when she began having right sided facial
twitching, which progressed to right arm flexion with
unresponsiveness, which typically lasted one minute. She was
given Valium, Dilantin 200 mg intravenous, Phenobarbital 60
mg and Kepra 500 mg with Ativan 2 mg intravenous and vago
nerve stimulator was used without resolution of seizures.
Vancomycin and Ceftriaxone for an aspiration pneumonia three
days prior to presentation and she continued to have copious
output from her trach tube.
Her significant history includes left sided partial
hemispherectomy, which resulted in a right sided hemiplegia
and inability to speak, but comprehension appears intact.
She is MRSA positive and is status post tracheostomy and PEG
tube placement. At baseline she uses a wheel chair to
ambulate and communicates with her mother with writing and
hand squeeze.
In the Emergency Room she was found to be febrile at 102.7
and after culture and lumbar puncture was done she was given
2 grams of Ceftriaxone, Ancef and Vancomycin. She continued
to be seizure and therefore was given a total of 15 mg per
kilogram intravenous Dilantin, 60 mg of Phenobarbital and 4
mg of Ativan, 500 mg of Kepra. This has decreased the
frequency of seizures, but not aborted them completely. We
observed a seizure, which starts as a right facial
contraction with eyes rolled upward and to the right. Her
right arm had a marked flexion.
PAST MEDICAL HISTORY: 1. Seizures disorder. 2.
[**Doctor Last Name **] encephalitis. 3. Left hemisphere
encephalomalacia. 4. Right spastic hemiparesis. 5. Mental
retardation. 6. Thoracolumbar scoliosis. 7. Vagal nerve
stimulator in 1/[**2099**]. 8. Status post left partial
hemispherectomy.
ALLERGIES: Penicillin.
MEDICATIONS: 1. Dilantin t.i.d. 200/100/200 mg. 2.
Phenobarbital t.i.d. 45/45/60. 3. Kepra 500 mg po b.i.d.
SOCIAL HISTORY: The patient lives in a group home. The rest
is not obtainable. She has her mother visiting quite often.
Her mother's telephone number is [**Telephone/Fax (1) 40424**].
FAMILY HISTORY: No seizures.
PHYSICAL EXAMINATION: Vital signs temperature max 102.4.
Temperature current 98.8. Blood pressure 111/60. Heart rate
90. SPO2 98% on trach collar. In general, the patient is a
young woman in no acute distress, but continuously seizing.
Head and neck, normocephalic, atraumatic, supple, trach in
place. Cardiovascular regular rate and rhythm. Pulmonary
good air movement with some coarse sounds. Abdomen positive
bowel sounds, soft. Mental status, awake, nonverbal, but
between seizures she is able to follow commands, but cannot
attend for any length of time. Uncooperative with the rest
of the mental status examination. Cranial nerves pupils are
equal, round and reactive to light. Fundi are normal.
Extraocular movements appears full. Motor tone and bulk are
adequate, although some increased tone on the right hemibody.
Strength is full on the left. Right side will not move to
command. Right arm is flexed. However, she provides some
resistance on the right iliopsoas. Reflexes cannot elicit.
toes are up going bilaterally. Sensation is not testable.
LABORATORY: Sodium 138, potassium 4.2, chloride 102,
bicarbonate 25, BUN 16, creatinine 0.4, glucose 96, phenytoin
10.3, phenobarbital 18.5, white count 7.45, hemoglobin 8.6,
hematocrit 26.9, platelets 584. Differential PMNs of 77.7,
lymphocytes 17.6. Urinalysis with a white count of 610. CT
scan revealed no acute hemorrhage.
HOSPITAL COURSE: Ms. [**Known lastname **] was admitted to the Intensive Care
Unit where she was further loaded with Dilantin and
phenobarbital and her Keppra dosages were adjusted and her
status epilepticus was aborted. She also had low blood
pressures in the setting of a fever, which was concerning for
septicemia. Cultures were sent and the patient was started
on the usual Intensive Care Unit measures including central
venous access and arterial line for continues blood pressure
monitoring.
After several liters of normal saline bolus, Ms. [**Known lastname **]
improved clinically and her blood pressure responded
appropriately. She was found to have a Pseudomonas
pneumonia, which was resistant to Ciprofloxacin. At this
time all of her antibiotics were discontinued and she was
started on a fourteen day course of Ceftazidime. She is at
the time of this dictation on day ten of a fourteen course of
Ceftaz.
With regard to her seizures as they were broken in the
Intensive Care Unit with adjustments of her antiepileptic
medications. She was given intermittent phenytoin and
phenobarbital. Phenobarbital levels were kept in the low to
mid 30s while phenytoin was kept in the low to mid 20s
without any clinical signs or symptoms of overdose. Ms.
[**Known lastname **]' Kepra was also increased to 1000 b.i.d. at that time.
She remained seizure free for the remainder of her Intensive
Care Unit stay and was transferred out to the medical floor.
Three or four days subsequently she developed facial
twitches, which is consistent with epilepsia partialis
continua and therefore her medications were adjusted
accordingly. Currently she is continued on phenobarbital 60
mg per nasogastric t.i.d. with phenytoin suspension 350 mg
per nasogastric q 12 hours along with Kepra 1500 mg po b.i.d.
per nasogastric. Although she continues to have some facial
twitching these do not bother her and they are of decreased
frequency. Although it is possible to increase her
antiepileptic medications we anticipate that given the high
drug levels, we would be approaching the toxic levels
shortly.
Clinically [**Known firstname **] is stable. She has remained seizure free
since two days after admission. She has done well from a
neurological perspective. With regard to her pneumonia and
need for frequent suctioning, this has significantly improved
during the course of this hospitalization. She now only
requires intermittent suctioning and has two more days of
Ceftazidime.
We note that Ms. [**Known lastname **] has a very small tracheostomy tube and
we have been informed by her interventional pulmonologist
that this tube should not be decannulated outside of a
medical Intensive Care Unit. Tracheostomy care, however, is
per usual. The only caveat is any tracheostomy decannulation
or change needs to be done in a monitored Intensive Care
Unit.
DISCHARGE CONDITION: Markedly improved.
DISCHARGE STATUS: Discharged to a rehabilitation facility
when a bed is available.
DISCHARGE DIAGNOSES:
1. [**Doctor Last Name **] encephalitis.
2. Seizure disorder.
3. Right spastic hemiparesis.
4. Recurrent aspirations pneumonia.
DISCHARGE MEDICATIONS: 1. Phenobarbital 60 mg nasogastric
t.i.d. 2. Dilantin suspension 350 mg per nasogastric b.i.d.
3. Kepra 1500 mg per nasogastric b.i.d. 4. Zoloft 50 mg
per nasogastric tube q day. 5. Folate 1 mg per nasogastric
q day. 6. Zantac 150 mg per nasogastric b.i.d. 7. Colace
100 mg po b.i.d. 8. Dulcolax 10 mg po pr b.i.d. prn
constipation. 9. Ceftazidime 1 gram intravenous q 8 hours
for Pseudomonas pneumonia day ten of twelve. 10. Heparin
5000 units subQ b.i.d. while immobile. 11. Ativan 0.5 mg po
q 4 to 6 hours prn facial twitching with a maximum of 2 mg q
day. 12. Cyanocobalamin 50 micrograms po q day.
FOLLOW UP: Ms. [**Known lastname **] will follow up with her neurologist Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**].
[**First Name8 (NamePattern2) 7495**] [**Name8 (MD) **], M.D.
[**MD Number(1) 7496**]
Dictated By:[**Last Name (NamePattern4) 40425**]
MEDQUIST36
D: [**2101-7-5**] 07:41
T: [**2101-7-5**] 08:10
JOB#: [**Job Number 40426**]
cc:[**Last Name (un) 40427**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4269
} | Medical Text: Admission Date: [**2100-12-21**] Discharge Date: [**2100-12-25**]
Date of Birth: [**2038-11-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
He presented with exertional shoulder pain and was
found to have significant ST segment depression on stress
test with inferior ischemia. He underwent cardiac
catheterization which demonstrated triple-vessel coronary
artery disease.
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x3(LIMA-LAD,SV-RI,SV,OM2) [**12-21**]
History of Present Illness:
Mr. [**Known lastname 5655**] is a 62-year-old man with a
history of coronary artery disease that has been medically
managed. He presented with exertional shoulder pain and was
found to have significant ST segment depression on stress
test with inferior ischemia. He underwent cardiac
catheterization which demonstrated triple-vessel coronary
artery disease. He was then referred for surgical
revascularization.
Past Medical History:
HTN, CAD, [**Doctor Last Name 9376**] syndrome, Fx L clavicle, ruptured L achilles
tendon, R dental implant
Social History:
very active 62 yo male who runs 21 miles/week.
non-smoker
occas ETOH
Physical Exam:
Discharge
VS T 98.5 HR 54SR BP 107/56 RR 18 O2sat 93%RA
Gen NAD
Neuro A&Ox3, nonfocal exam
CV RRR, sternum stable. Incision CDI
Pulm CTA-bilat
Abdm soft, NT/+BS
Ext warm well perfused. Trace edema bilat. Left SVG site w/steri
strips
Pertinent Results:
[**2100-12-21**] 02:36PM PT-14.4* PTT-27.0 INR(PT)-1.2*
[**2100-12-21**] 02:36PM PLT COUNT-185
[**2100-12-21**] 02:36PM WBC-8.3 RBC-2.84*# HGB-9.3*# HCT-25.4*#
MCV-89 MCH-32.8* MCHC-36.7* RDW-13.6
[**2100-12-21**] 02:36PM GLUCOSE-133* LACTATE-1.6 NA+-135 K+-4.7
CL--107
[**2100-12-21**] 04:15PM WBC-8.8 RBC-3.35* HGB-10.9* HCT-29.4* MCV-88
MCH-32.4* MCHC-37.0* RDW-13.8
[**2100-12-21**] 04:15PM UREA N-15 CREAT-0.9 CHLORIDE-113* TOTAL
CO2-24
[**2100-12-21**] 04:21PM GLUCOSE-74 NA+-138 K+-4.2
[**2100-12-24**] 12:35PM BLOOD WBC-8.7 RBC-3.17* Hgb-10.4* Hct-28.1*
MCV-89 MCH-32.9* MCHC-37.0* RDW-14.4 Plt Ct-170
[**2100-12-24**] 12:35PM BLOOD Plt Ct-170
[**2100-12-22**] 08:04AM BLOOD PT-13.8* PTT-28.5 INR(PT)-1.2*
[**2100-12-24**] 12:35PM BLOOD Glucose-94 UreaN-20 Creat-1.1 Na-140
K-4.3 Cl-100 HCO3-31 AnGap-13
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 42537**] (Complete)
Done [**2100-12-21**] at 12:33:55 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: [**2038-11-24**]
Age (years): 62 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Chest pain. Coronary artery disease.
ICD-9 Codes: 402.90, 440.0
Test Information
Date/Time: [**2100-12-21**] at 12:33 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 45% to 55% >= 55%
Findings
LEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection
velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic root. Normal ascending aorta diameter. Simple
atheroma in ascending aorta. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is normal in size. No thrombus is
seen in the left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 %).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
7. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. In sinus rhythm.
Preserved biventricular systolic function post CPB. Trivial MR.
Aortic contour is preserved post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **]
[**Known lastname **],[**Known firstname **] [**Medical Record Number 42538**] M 62 [**2038-11-24**]
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
s/p ct removal ? ptx
Final Report
HISTORY: Status post CABG with chest tube removal.
FINDINGS: In comparison with the earlier study of this date, the
left chest tube has been removed. No convincing evidence of
pneumothorax. Persistent opacification at the left base.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: [**First Name8 (NamePattern2) **] [**2100-12-23**] 5:08 PM
Brief Hospital Course:
On [**12-21**] Mr [**Known lastname 5655**] was a direct admit to the operating room for
coronary bypass surgery. At that time he had CABG x3 with Left
internal mammary to left anterior descending artery, saphenous
vein to Ramuus and saphenous vein to Obtuse marginal. He
tolerated the operation well and was transferred to the cardiac
ICU in stable condition. He was hemodynamically stable i and was
extubated shortly after arriving in the ICU. On POD1 he was
transferred to the step down floor for continued post-operative
care. He progressed well over the next several days, all tubes,
drains and wires were removed according to Cardiac surgery
protocol. His activity was advanced and on POD5 he was
discharged home with VNA
Medications on Admission:
Lipitor 40', Ramipril 10', Cardizem 120', ASA 81'
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. 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. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD x7 days then 200mg QD.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
hyperlipidemia
[**Doctor Last Name 9376**] syndrome
hypertension
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 3 weeks @ [**Hospital1 **] [**Telephone/Fax (1) 20259**]
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 27772**] in [**12-17**] weeks ([**Telephone/Fax (1) 12295**])
Dr. [**Last Name (STitle) 5874**] in 3 weeks
please call for appointments
Completed by:[**2100-12-25**]
ICD9 Codes: 9971, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4270
} | Medical Text: Admission Date: [**2180-8-24**] Discharge Date: [**2180-8-29**]
Date of Birth: [**2108-6-24**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 72-year-old gentleman
with a history of CAD presenting with a 10 day history of
substernal chest pain radiating down his left arm.
The patient is a former smoker with history of hypertension
and family history of CAD, who had PTCA of RCA/LAD in [**2168**],
PTCA of LAD [**5-/2172**] and PTCA of RCA in 9/93. Has been
relatively healthy since. On Labor Day, the patient noted
significant substernal chest pain radiating to back/left arm
associated with dyspnea. There was no syncope, nausea,
vomiting, diaphoresis; patient has no history of PND or
orthopnea. He presented to an outside hospital where he
ruled out for myocardial infarction based on enzymes and EKG
criteria. He underwent a cardiac catheterization on [**8-24**]
which showed a 95% occlusion of the RCA and 85% occlusion of
the LAD, a 60% occlusion of the proximal circumflex and an
80% occlusion of the middle circumflex. He was transferred
to the [**Hospital1 69**] for elective
CABG.
PAST MEDICAL HISTORY: Significant for non insulin dependent
diabetes mellitus, hypertension, upper GI bleed, hepatitis A
and B, benign prostatic hypertrophy, degenerative joint
disease, herpes zoster, Guillain [**Location (un) **]. The patient is
status post appendectomy and status post right hip
hemiarthroplasty for avascular necrosis secondary to steroid
treatment.
MEDICATIONS: On admission, Lopressor 100 mg po bid, Cardizem
CD 180 mg q d po, Avandia 4 mg po q a.m., Imdur 30 mg po q d,
Plavix 75 mg po q d.
PHYSICAL EXAMINATION: On admission patient was afebrile with
stable vital signs. He was in no acute distress. He was
alert and oriented times three. He had a right carotid
bruit. His lungs were clear. His heart had a regular rate
and rhythm with a fixed split S1, no murmurs, rubs or
gallops. He was soft, nontender, non distended with
normoactive bowel sounds and no masses. His extremities were
warm, well perfused. He had a 2+ pulse in his posterior
tibial artery, he had no edema. Neurologically he was
grossly intact.
HOSPITAL COURSE: The patient was admitted to the hospital
and on [**8-25**] he underwent an uncomplicated coronary artery
bypass graft times four with left internal mammary artery to
the left anterior descending; reversed saphenous vein graft
to the first diagonal branch; aortic saphenous vein graft to
the major obtuse marginal branch and an aorta saphenous vein
graft to the posterior descending artery. The patient
tolerated the procedure well, was transferred to the
Cardiothoracic Intensive Care Unit, intubated and in stable
and satisfactory condition.
Postoperatively in the CSRU the patient was noted to have a
high chest tube output, approximately 450 cc for the first
hour and 110 cc for the second. Hematocrit at that time was
24.5 and he was treated with two units of packed red blood
cells. Unfortunately the patient had taken his morning dose
of Plavix the day of surgery and it was believed that this
would potentially be a complicating factor in his hemostasis.
Therefore he was given two units of FFP and 6 bags of
platelets. Unfortunately, the patient's chest tube output
remained at 100-200 cc per hour and the decision was made to
bring the patient back to the OR for exploration of his
source of postoperative bleeding.
Once in the OR the patient underwent a mediastinal
exploration and it was found that he had a chest wall bleeder
from a small arterial branch off of the subclavius muscle.
This was subsequently controlled with hemostasis clips and
electrocautery. The patient tolerated the procedure well and
he was transferred back to the cardiothoracic intensive care
unit in stable and intubated condition.
On postoperative day #1 the patient's Nitroglycerin and
Neo-Synephrine drips were discontinued. He remained sedated
on Propofol which was subsequently weaned over the course of
the day. He was also weaned off of the ventilator with
subsequent extubation occurring later that day without
incident. It was also loaded with Amiodarone for a run of
atrial fibrillation with ultimate conversion to a normal
sinus rhythm. The patient has a history of herpes zoster and
in fact, was having an attack perioperatively. He was
subsequently started on Zovirax with good effect.
On postoperative day #2 the patient had his Amiodarone drip
converted to po and he was subsequently transferred to the
floor in stable condition. On postoperative day #3 the
patient remained afebrile with stable vital signs. His chest
tube output was minimal and his chest tube was subsequently
removed. A post removal chest x-ray was remarkable for the
absence of any signs of a pneumothorax. It was noted that
the patient had a hematocrit of 22.4 and was feeling
lightheaded and he was subsequently transfused with one unit
of packed red blood cells without complication. On
postoperative day #4, the patient had a brief episode of
atrial fibrillation, which resolved after giving his usual
dose of Amiodarone and Lopressor. Nonetheless, the decision
was made to start the patient on low dose Coumadin to achieve
an INR goal of around 2.0. The patient is discharged to
rehab on postoperative day #4 in stable condition.
Discharge Exam: The patient was in NAD and A&O times three.
His neck was supple, lungs were CTAB with a stable sternum
and incisions that were clean, dry and intact. His heart had
a regular rate and rhythm. His belly was soft, nontender and
non distended. His extremities were warm and well perfused
with his incisions clean, dry and intact.
DISCHARGE MEDICATIONS: Lasix 20 mg po bid, Potassium
chloride 20 mEq po bid, Colace 100 mg po bid, Aspirin 81 mg
po q d, Protonix 40 mg po q d, Amiodarone 400 mg po tid times
three days, then 400 mg po bid times 7 days, then 400 mg po q
d, Lopressor 75 mg po bid, Percocet 1-2 tablets po q 3-4
hours prn pain.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post CABG times three.
DISCHARGE CONDITION: Stable to rehab.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2180-8-29**] 10:33
T: [**2180-8-29**] 10:39
JOB#: [**Job Number 40100**]
ICD9 Codes: 4111, 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4271
} | Medical Text: Admission Date: [**2173-7-24**] Discharge Date: [**2173-8-3**]
Date of Birth: [**2092-8-7**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
Code Stroke Transfer.
Major Surgical or Invasive Procedure:
PEG
History of Present Illness:
Patient arrived as code stroke transfer from [**Location (un) **] ED. He
is an 80 yo man with h/o HTN, CLL, NIDM small stroke 4 yrs ago
who had a suddent onset left facial droop and left hemiparesis
at
2230 while having sexual intercourse with his wife. His wife
was
quite certain about time of onset being 2230 and states his last
known baseline state as 2230. He was taken to [**Hospital3 **]hospital where he had a CT of the head. Around this time he
started to improve. However, soon after he ws noted to again
worsen back to hius previous state.
He was transferred from the [**Location (un) **] ED to [**Hospital1 18**] ED by [**Location (un) **].
TPA not given prior to transfer as patient's symptoms seemed to
be fluctuating.
His stroke 4 yrs ago presented in setting of confusional
episode.
Had "tiny" stroke diagnosed on imaging. Had no residual
deficits.
Past Medical History:
HTN
DM
CLL
Social History:
Arricept, Captopril, Metformin, HCTZ, ASA 81
Family History:
strokes and MI
Physical Exam:
BP- 184/82 HR-85 RR- 21 O2Sat 94 2 L
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
NIH Stroke scale 15. (1 LOC,
Neurologic examination:
Mental status: Awake and mildly lethargic, cooperative with most
of exam, flat
affect. Oriented to person. Mildly inattentive with exam.
Speech is non fluent, sparse, dysarthric to extent of often
being
incoherent. comprehension intact. naming intact [**1-20**]. Has left
sensory/visual neglect.
Cranial Nerves:
Pupils equal. Left field cut. Extraocular movements intact
bilaterally, no nystagmus. Left face completely weak lower,
trace
weak upper. Hearing intact. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
Left pronator drift
Strength was 4+/5 left triceps. [**4-22**] left Deltoid. [**5-22**] left IP
and DF. Stnregth grossly intact on right.
Sensation: intact to LT throughout but extinction to DSS on
left.
Reflexes: NA
Coordination: finger-nose-finger normal ataxic left, heel to
shin
normal bilaterally.
Gait: NA.
Romberg: NA
Pertinent Results:
[**2173-8-2**] 06:55AM BLOOD WBC-44.2* RBC-4.02* Hgb-12.6* Hct-34.6*
MCV-86 MCH-31.4 MCHC-36.5* RDW-14.6 Plt Ct-202
[**2173-7-24**] 01:00AM BLOOD WBC-50.0* RBC-4.52* Hgb-14.3 Hct-38.7*
MCV-86 MCH-31.7 MCHC-37.0* RDW-13.9 Plt Ct-170
[**2173-7-25**] 01:44AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2173-7-24**] 01:00AM BLOOD PT-12.6 PTT-24.6 INR(PT)-1.1
[**2173-8-2**] 06:55AM BLOOD Glucose-192* UreaN-16 Creat-0.7 Na-140
K-3.7 Cl-106 HCO3-29 AnGap-9
[**2173-7-24**] 01:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2173-7-24**] 08:37AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2173-7-24**] 03:32PM BLOOD CK-MB-3 cTropnT-<0.01
[**2173-7-24**] 03:42AM BLOOD %HbA1c-7.6*
[**2173-7-24**] 01:00AM BLOOD Triglyc-78 HDL-29 CHOL/HD-3.3 LDLcalc-51
[**2173-7-28**] 06:45AM BLOOD TSH-4.1
CTA HEAD W&W/O C & RECONS:
Question of early infarct in the right insular cortex. Chronic
right-sided caudate nucleus and occipital lobe infarcts.
Atherosclerotic disease at the carotid bifurcations without
high-grade stenosis. No definite evidence of vascular occlusion
or stenosis in the intracranial circulation which demonstrate
bilateral cavernous carotid calcifications.
Echo:
No obvious intracardiac source of embolism identified, although
interatrial septum not well-visualized. Normal biventricular
systolic
function. Moderate pulmonary hypertension. Small pericardial
effusion
posterior to inferolateral wall. Mild mitral regurgitation.
MR:
1. Acute infarct of the right insular cortex and right parietal
lobe in the distribution of the superior division of the right
middle cerebral artery. No evidence of hemorrhage.
2. Encephalomalacic changes of the caudate nucleus and right
occipital lobe consistent with chronic infarcts.
3. Normal MRA.
Carotid Dopplers:
Bilateral less than 40% ICA stenosis
Brief Hospital Course:
80 yo man with h/o HTN, CLL, old stroke, NIDDM who presented to
the ED with sudden onset of left hemiparesis and dysarthria. In
the ED he was found to have L arm and leg weakness. He had a NIH
stroke scale of 15. He received tPA at 0155 which
placed him at 3 hrs 25 minutes.
He was admitted to the ICU for further monitoring s/p TPA
protocol. strict glycemic and thermic control was done. He
underwent an MR showed an Acute infarct of the right insular
cortex and right parietal lobe. His stroke work-up included an
echo which did not show a cardiac source of embolism. Carotid
dopplers also showed less than 40% ICA stenosis bilaterally. His
lipid panel was excellent and his A1c was elevated at 7.6. He
was empirically treated with statin, aggrenox and lisinopril.
His BP was initially allowed to autoregulate and then he was
started on Lisinopril for improved control. He was also
monitored on tele without events.
Mr. [**Known lastname **] was transferred to the step down. He was noted to have a
PNA on transfer, likely from aspiration and was treated with
Levofloxacin and flagyl. He completed a course and remained
afebrile w/o a leukocytosis. Speech evaluated him for
aspiration. He repeatedly failed evaluation and a PEG was placed
for long term feeding.
His discharge exam spontaneous speech w/ mild dysarthria and
paucity, EOM crossing midline, L facial droop, extinction to
light touch on L, R arm antigravity, L arm w/ effort but still
flacid, bilateral legs move against gravity
Medications on Admission:
Arricept, Captopril, Metformin, HCTZ, ASA 81
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
5. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever > 100 or pain.
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16844**] Hospital - [**Location (un) 1157**]
Discharge Diagnosis:
Stroke
HTN
DM
CLL
Discharge Condition:
Stable:
Discharge Instructions:
1. Please follow-up with your scheduled appointments
2. Take all medications as prescribed
3. Please return to the hospital if you have new symptoms
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2173-10-5**] 1:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
ICD9 Codes: 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4272
} | Medical Text: Admission Date: [**2187-7-26**] Discharge Date: [**2187-8-10**]
Date of Birth: [**2163-3-3**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Multi-trauma
Major Surgical or Invasive Procedure:
[**7-26**]
PROCEDURES:
1. Exploratory laparotomy.
2. Right chest tube placement.
[**2187-7-27**]
PROCEDURES:
1. Unpacking of liver injury.
2. Hemostasis of residual hepatic hemorrhage.
3. Abdominal closure.
[**2187-7-30**]
PROCEDURES:
1. T3 through T5 laminectomy.
2. Right T4 transpedicular decompression.
3. Repair of a spinal fluid leak primarily.
4. Local autograft.
5. Right iliac crest bone graft (nonstructural) graft
through a separate incision.
6. Pedicle screw instrumentation ([**Last Name (un) 83297**] Expedium) from T2
to T8.
7. Posterolateral arthrodesis, T2 through T8.
History of Present Illness:
24 year old male who was involved in a high speed motor vehicle
crash. He was ejected from the car and suffered a grade 4 liver
laceration, multiple cervical and thoracic spine fractures, as
well as a possible vertebral artery dissection. He was
transported to [**Hospital1 18**] for further care.
Past Medical History:
s/p Right arm surgery
Family History:
Noncontributory
Physical Exam:
T: 37.4 BP: 114/75 HR: 136 R 19 O2Sats 98% intubated
Gen: intubated, paralyzed, open abdomen
HEENT: Pupils: pinpoint, non reactive EOMs UTA
Extrem: Warm and well-perfused.
Mental status: intubated, paralyzed, sedated.
Cranial Nerves:
UTA
Motor: UTA
Sensation: UTA.
Reflexes: B T Br Pa Ac
Right UTA
Left UTA
Coordination: UTA
Pertinent Results:
[**2187-7-26**] 07:44PM TYPE-ART PO2-135* PCO2-42 PH-7.36 TOTAL
CO2-25 BASE XS--1
[**2187-7-26**] 07:44PM LACTATE-4.7*
[**2187-7-26**] 07:30PM GLUCOSE-118* UREA N-11 CREAT-0.9 SODIUM-143
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-22 ANION GAP-14
[**2187-7-26**] 07:30PM CALCIUM-7.8* PHOSPHATE-3.6 MAGNESIUM-1.3*
[**2187-7-26**] 07:30PM WBC-11.4* RBC-3.61* HGB-10.7* HCT-29.9*
MCV-83 MCH-29.5 MCHC-35.7* RDW-14.8
[**2187-7-26**] 07:30PM PLT COUNT-100*
[**2187-7-26**] 07:30PM PT-13.7* INR(PT)-1.2*
CT Head [**2187-7-26**]
IMPRESSION:
1. Increased diffuse cerebral edema with partial effacement of
the cisterns and ventricular system and loss of [**Doctor Last Name 352**]-white
differentiation consistent with diffuse edema, possibly related
to [**Doctor First Name **]. Close clinical followup is recommended. Pl. see above
details regarding inadequate evaluation for tonsillar
herniation.
2. Decreased conspicuity to small right-sided tentorial subdural
hematoma
noted on outside imaging. No regions of subarachnoid hemorrhage
identified on current exam.
CTA neck [**2187-7-26**]
IMPRESSION:
1. Lateral mass/articular facet fracture of C2 with comminuted
right
transverse process fractures at C2, C3, and C4 with right
vertebral artery
caliber change at the C3 and C4 level suspicious for intimal
injury or
dissection. Further delineation can be attempted with MRA neck
if clinically
indicated .
2. Complex unstable appearing comminuted and distracted
posterior element
fractures involving T3 and T4 partially visualized. Comminuted
left scapular body fracture.
3. Increased contusion and/or effusion at the left apex. No
visualized
pneumothorax within the included portions of the upper lungs.
CT Chest/Abdomen [**2187-7-26**]
IMPRESSION:
1. No evidence of active extravasation. This patient is status
post
exploratory laparotomy left open with surgical packing
surrounding the liver
2. Left greater than right pleural effusion and bilateral
atelectasis.
3. Right basilar chest tube, nasogastric tube in standard
positions.
4. Stable appearance of known right renal laceration.
5. Markedly edematous loops of small and large bowel with free
abdominal
fluid and pericholecystic fluid that is suggestive of third
spacing.
6. Replaced left hepatic artery arising from the left gastric
and replaced
right hepatic artery arising from the common hepatic artery
which originates from the SMA.
MRI Cervical/Thoracic Spine [**2187-7-28**]
IMPRESSION:
1. Ligamentum flavum disruption at T2-3 and T3-4 level with
widening of the interspinous distance indicative of flexion
injury with fractures of right superior articular process of T3
and T4 and left superior articular process of T3 and fracture of
the anterior superior portion of T4 vertebra. This combination
of findings indicates an unstable flexion injury at this level.
2. Paraspinal hematoma seen with probable hematoma within the
right side of the spinal canal at T3-4 level with narrowing of
the spinal canal and
displacement of the spinal cord to the left side. The narrowing
also is
contributed by malalignment and displacement of the bony
structures to the
right side of the spinal canal. Although there is an indentation
on the
spinal cord at T3-4 level, no definite increased spinal cord
signal is seen. However, the evaluation is limited secondary to
artifacts and a small area of spinal cord contusion cannot be
excluded.
Brief Hospital Course:
He was taken to the operating room on arrival to [**Hospital1 18**] for
exploratory laparotomy and was found to have a grade 4 liver
laceration. His abdomen was packed in order to control the
hemorrhage. He was then taken to the Trauma ICU.
Postoperatively Neurosurgery was consulted and an intracranial
bolt was placed to monitor his ICP. They were consistently in
the range of [**6-6**]. During the first 24 hours he received >30
units of blood products including PRBC's, FFP, platelets, cryo,
and Factor VII. His abdomen was left because of his severe edema
and 3rd spacing. On POD 1 he returned to the OR to remove the
packing and to close his abdomen. His bladder pressures were
closely monitored and remained within the normal range. He was
started on beta blockers for tachycardia and elevated blood
pressures.
Two days later he was taken back to the operating room by
Neurosurgery for posterior fusion of his severe T2-8 fractures.
There were no intraoperative complications. Postoperatively he
was maintained in the hard cervical collar and was taken back to
the Trauma ICU where he remained for another 6-7 days. He was
weaned from sedation and the ventilator and was finally
extubated. He was later transferred to the regular nursing unit.
While on the nursing unit he continued to progress slowly; his
mental status improved significantly over the remainder course
of his stay. His blood pressures were intermittently elevated
and he was continued on his Lopressor. He was tolerating regular
diet and was not reporting any pain issues.
He was evaluated by Physical and Occupational therapy and was
cleared for home with 24 hour supervision. He was given
prescriptions for outpatient PT and OT.
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-23**]
hours as needed for pain.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
3. Outpatient Occupational Therapy
Dx: s/p Motor vehicle crash; Traumatic Brain Injury
Sig: Evaluate & treat 1-2x/week
4. Outpatient Physical Therapy
Dx: s/p Motor vehicle crash; Traumatic brain injury
Sig: Evaluate and treat 1-2x/week
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motor vehicle crash
Subarachnoid hemorrhage
Subdural hematoma
Liver laceration Grade III-IV
Comminuted right transverse process fracture C2-4
Lateral mass/articular facet fracture C2-4
Left scapular fracture
Posterior element fracture T3-4
Acute blood loss anemia
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adeqautely controlled.
Discharge Instructions:
You must continue to wear the cervical collar until follow up
with Dr. [**Last Name (STitle) 548**] in 4 weeks.
DO NOT participate in any contact sports of any kind or other
activity that may cause injury to your abdomianl region because
of your liver injury.
Return to the Emergency room immediately if you develop:
-Sudden onset of dizziness, become lightheaded as if going to
pass out as these are signs thta you may be having internal
bleeding from your liver injury.
-Fevers, right sided abdominal pain or hiccups as these are
symptoms concerning for a fluid collection or abscess in your
abdomen as a result of your liver injury.
Return to the Emergency room if you develop any fevers, chills,
headaches, dizziness, chest pain, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea and/or any other symptoms that
are concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 548**], Neurosurgery in 4 weeks, you will need
repeat CT scan for this prior to appoint - call [**Telephone/Fax (1) 2992**] for
appt date and time.
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks, Trauma surgery for follow
up of your exploratory laparotomy. Call [**Telephone/Fax (1) 6429**] for an
appointment.
Completed by:[**2187-8-15**]
ICD9 Codes: 2851, 486, 5180, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4273
} | Medical Text: Admission Date: [**2165-9-9**] Discharge Date: [**2165-9-19**]
Date of Birth: [**2107-3-17**] Sex: F
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old
female with a prior cardiac history of severe mitral
regurgitation and severe tricuspid regurgitation, as well as
dilated cardiomyopathy with biventricular failure and an
ejection fraction of 25 to 30%, with complaint of increasing
leg edema, increasing abdominal distention times the last two
weeks. She denies fever, chills, shortness of breath,
positive cough with production of green brown sputum and
nausea always present at baseline. No vomiting, no
palpitations, no diaphoresis. She was admitted for
preoperative diuresis prior to a scheduled mitral valve
replacement and tricuspid valve repair scheduled for
[**2165-9-12**].
PAST MEDICAL HISTORY: Significant for:
1. Myocarditis at age 11.
2. Dilated cardiomyopathy with biventricular failure.
3. Severe tricuspid regurgitation.
4. Severe mitral regurgitation.
5. Atrial fibrillation with cardioversion and placement of a
DDD pacer on [**5-12**], currently in VVI mode.
6. Hypertension.
7. Chronic renal insufficiency with a baseline creatinine of
1.4 to 2.0.
8. Hypothyroidism.
9. Iron deficiency anemia.
10. Methicillin resistant Staphylococcus aureus pneumonia.
11. Peptic ulcer disease.
12. Migraine headaches.
13. Chronic sinusitis.
14. Panic disorder.
15. Malnutrition/anorexia.
16. Status post Billroth II in [**2153**].
17. Status post roux-en-y in [**2156**].
18. Status post volvulus with hemicolectomy and ileosigmoid
anastomosis in [**2160**].
19. Status post perforated small bowel obstruction.
ALLERGIES: Gentamicin, Bactrim, Chloramphenicol and
Penicillin.
MEDICATIONS ON ADMISSION:
1. Lasix 80 mg twice a day.
2. Zaroxolyn 2.5 mg twice a day.
3. Captopril 12.5 mg three times a day.
4. Amiodarone 200 mg once daily.
5. Coumadin 7.5 mg once daily which was discontinued as of
[**2165-9-3**].
6. Synthroid 125 mcg once daily.
7. Actigall 300 mg twice a day.
8. Calcium one gram once daily.
9. Protonix 40 mg once daily.
10. Klonopin 1 mg three times a day.
11. Prozac 80 mg once daily.
12. Fioricet p.r.n.
13 [**Doctor First Name **] 60 mg twice a day.
14. Nasacort Spray p.r.n.
15. Compazine suppository 25 mg twice a day p.r.n.
16. Multivitamin one once daily.
17. Potassium Chloride 80 meq twice a day.
SOCIAL HISTORY: The patient lives with fiancee. Positive
tobacco use, quit several years ago. Former benzodiazepine
addiction.
PHYSICAL EXAMINATION: At the time of admission, vital signs
revealed temperature 97.6, blood pressure 102/64, heart rate
86, respiratory rate 16, oxygen saturation 100% in room air.
In general, the patient is a very thin, small frame woman in
no distress. Head, eyes, ears, nose and throat - The
oropharynx is pink. Mucous membranes are moist. The tongue
is moist. Extraocular movements are intact. Cardiovascular
regular rate and rhythm, paced, II/VI systolic murmur and
soft distant heart sounds. The chest reveals good
inspiratory effort, bilaterally clear to auscultation,
occasional crackles in bibasilar area. No wheezes and no
rhonchi. The abdomen is soft, positive bowel sounds, no
distention, nontender, no guarding. Extremities - bilateral
lower extremity edema 2 to 3+ from the dorsal foot up to the
patella, unable to palpate pulses secondary to edema, no
cyanosis.
LABORATORY DATA: White count 6.1, hematocrit 25.3, platelets
315,000. Sodium 133, potassium 3.0, chloride 95, CO2 22,
blood urea nitrogen 51, creatinine 1.4, glucose 181. Albumin
3.0.
HOSPITAL COURSE: The patient was admitted to the Medical
service. The heart failure service and cardiology service
were both consulted and the patient was vigorously diuresed
over the several days prior to her scheduled surgery. She
was also seen and cleared by the dental service while she was
an inpatient.
On [**2165-9-12**], the patient was brought to the operating room
for scheduled surgery. Please see the operative report for
full details. In summary, the patient underwent a mitral
valve replacement with a #29 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical valve and
tricuspid valve repair with a #32 [**Doctor Last Name **] annuloplasty ring.
She tolerated the operation well and was transferred from the
operating room to the Cardiothoracic Intensive Care Unit. At
the time of transfer, she had Neo-Synephrine at 2.0
mcg/kg/minute, Dobutamine at 5 mcg/kg/minute and Propofol at
50 mcg/kg/minute. The patient did well in the immediate
postoperative period following her arrival in the
Cardiothoracic Intensive Care Unit. Her anesthesia was
reversed. She was weaned from the ventilator and
successfully extubated.
Postoperative day one, the Electrophysiology service was
consulted and the patient's intrinsic pacer seemed to be
missensing and misfiring. Also on postoperative day one, the
patient was weaned from her Dobutamine and Neo-Synephrine.
During that time, she remained hemodynamically stable despite
being in accelerated junctional rhythm.
On postoperative day two, the patient had been on all
cardioactive drugs 24 hours. She was started on Lasix,
Lopressor and Aspirin as well as Coumadin and transferred to
the floor for continuing postoperative care and cardiac
rehabilitation.
Over the next several days, the patient remained
hemodynamically stable. Her active level was advanced with
the assistance of the nursing staff and physical therapy.
The patient continued to be followed by the heart failure
service as well as the electrophysiology service. She did
show no further evidence of pacemaker malfunction.
On postoperative day five, the pacemaker was again
interrogated by electrophysiology and was found to be
functioning at the same level as it had been prior to her
surgery, and therefore the plan to electively reposition
wires postoperatively was aborted. Electrophysiology service
signed off with the plan to follow-up with the patient as an
outpatient in Device Clinic on [**2165-10-1**].
The patient is to be restarted on Coumadin at this point
given her mechanical mitral valve and history of atrial
fibrillation. Her goal INR will be 3.0. It is anticipated
that the patient will be stable and ready for discharge
within the next two days.
At this time, the patient's physical examination is as
follows: Vital signs revealed temperature 97.1, heart rate
90, atrial fibrillation, blood pressure 100/60, respiratory
rate 18, oxygen saturation 97% in room air. Preoperative
weight was 110 pounds and discharge weight is 106.7 pounds.
Laboratory data as of [**2165-9-17**], is white blood cell count
10.0, hematocrit 27.3, platelet count 268,000. Sodium 135,
potassium 3.2, chloride 96, CO2 23, blood urea nitrogen 59,
creatinine 1.6, glucose 112.
The patient is alert and oriented times three, moves all
extremities, follows commands. Breath sounds, scattered
crackles, diminished at the bases bilaterally.
Cardiovascular regular rate and rhythm, S1 and S2, with
positive mechanical click. The abdomen is soft, nontender,
minimally distended. Extremities are warm, perfused with 2+
edema bilaterally. Sternal incision is stable, clean and
dry, open to air, closed with staples, no erythema.
DISCHARGE DIAGNOSES:
1. Status post mitral valve replacement with #29 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
mechanical valve.
2. Status post tricuspid valve repair with #32
[**Last Name (un) 3843**]-[**Doctor Last Name **] annuloplasty ring.
3. Cardiomyopathy.
4. Atrial fibrillation.
5. Hypertension.
6. Chronic renal insufficiency.
7. Hypothyroidism.
8. Anemia.
9. Peptic ulcer disease.
10. Migraines.
11. Sinusitis.
12. Panic disorder.
13. Anorexia.
14. Status post Billroth II.
15. Status post roux-en-y.
16. Status post volvulus with hemicolectomy and an
ileosigmoid anastomosis.
17. Perforated small bowel obstruction.
18. Methicillin resistant Staphylococcus aureus pneumonia.
MEDICATIONS ON DISCHARGE:
1. Lisinopril 5 mg once daily.
2. Lasix 80 mg twice a day.
3. Potassium 20 meq twice a day.
4. Amiodarone 200 mg once daily.
5. Metoprolol 12.5 mg twice a day.
7. Fioricet one to two tablets q4hrs p.r.n.
8. Clonazepam 0.5 mg three times a day.
9. Fluoxetine 80 mg once daily.
10. Actigall 300 mg twice a day.
11. Levothyroxine 125 mcg once daily.
12. Colace 100 mg twice a day.
13. Ranitidine 150 mg twice a day.
14. Coumadin 5 to 7.5 mg once daily to reach a goal INR of
2.0 to 3.0.
15. Ambien 5 mg q.h.s. p.r.n.
The patient is to be discharged to home with VNA and home
rehabilitation services. She is to have follow-up in the
[**Hospital **] Clinic on [**2165-10-1**], at 1:30 p.m. in the [**Hospital Ward Name 23**]
Building. She is also to have follow-up with the Heart
Failure Clinic. She is to have follow-up in [**Hospital 409**] Clinic in
two weeks. She is to have follow-up with Dr. [**Last Name (STitle) **] in three
to four weeks and follow-up with her primary care physician
also in three to four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2165-9-17**] 17:42
T: [**2165-9-17**] 18:21
JOB#: [**Job Number 18104**]
ICD9 Codes: 4240, 2768, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4274
} | Medical Text: Admission Date: [**2175-8-19**] Discharge Date: [**2175-8-23**]
Date of Birth: [**2122-1-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
suicide attempt
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: This is a 53 year-old male with past suicide attempts who
presents with antidepressant overdose in an apparent suicide
attempt. He was transported to [**Hospital1 18**] by EMS ambulance after
being observed stumbling in the street. He reported that he
wanted to kill himself and had taken a whole bottle of his
diabetes medication and an entire bottle of his antidepressants,
but was unable to identify what he had ingested. On arrival, he
was hypotensive to the 80's, diaphoretic with altered mental
status.
In the ED, he received 2X Narcan with no effect; 2L NS with good
effect; and was intubated for airway protection given worsening
mental status, with BP rising transiently to the 160's.
Toxicology recommended checking the QRS, which was 102, with a
"normal" QTc and deferral of activated charcoal given inability
to identify the overdosed medications. Otherwise, Cr was
elevated to 2.8, lactate to 5.4, ut mag, potassium remained wnl.
Psychiatry was consulted.
.
On transfer to the [**Hospital Unit Name 153**], his SBP was in the 130's. He was
sedated on propofol and placed on A/C 400x 14 FiO2 1.0, peep 5.
No ABG was drawn in the ED on these settings. His access is an
EJ 18g on the right, 22 in hand.
.
.
ROS: unable to be obtained given that patient is intubated and
sedated.
Past Medical History:
Depression with history of suicide attempts x 2
Schizoaffective/Bipolar disorder
Non-insulin-dependent diabetes mellitus.
History of Grave's disease/Hypothyroidism
Status post right leg surgery secondary to trauma.
MIBI in [**2169**] showed global hypokinesis EF 40%
Physical Exam:
Physical Exam:
Vitals: T: 95.7ax BP: 97/56 HR: 50 RR: 18 O2Sat: 100% on A/C
400x18 fio2 0.40 peep 5.
GEN: sedated on vent, no obvious trauma
HEENT: EOMI, pupils small but equal. sclerae anicteric, no
epistaxis or rhinorrhea, MMM, OP Clear, edentulous
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: very faint heart sounds, but RRR, no M/G/R, radial pulses
+2
PULM: Lungs CTAB, no W/R/R
ABD: Obese, soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: Moves all 4 extremities. Strength 5/5 in upper and lower
extremities. Plantar reflex downgoing bilaterally. No rigidity,
neck stiffness, hyperreflexia or clonus.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
Pertinent Results:
[**2175-8-19**] 07:49PM ALT(SGPT)-20 AST(SGOT)-14 LD(LDH)-143 ALK
PHOS-53 TOT BILI-0.2
[**2175-8-19**] 07:49PM ALBUMIN-3.5 CALCIUM-7.3* PHOSPHATE-3.5
MAGNESIUM-1.9
[**2175-8-19**] 07:49PM TSH-4.2
[**2175-8-19**] 07:49PM VALPROATE-<3
[**2175-8-19**] 03:27PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2175-8-19**] 03:27PM LACTATE-5.4* K+-4.5
[**2175-8-19**] 03:10PM GLUCOSE-242* UREA N-11 CREAT-1.3* SODIUM-140
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18
[**2175-8-19**] 03:10PM estGFR-Using this
[**2175-8-19**] 03:10PM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.1
[**2175-8-19**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2175-8-19**] 03:10PM WBC-8.8 RBC-4.16* HGB-12.8* HCT-37.8* MCV-91
MCH-30.8 MCHC-33.9 RDW-14.4
[**2175-8-19**] 03:10PM NEUTS-70.6* LYMPHS-21.8 MONOS-4.9 EOS-2.2
BASOS-0.5
[**2175-8-19**] 03:10PM PLT COUNT-326
ECG: Sinus rhythm at 61 bpm, normal axis, normal PR and QRS
intervals, slightly prolonged QTc interval, good R-wave
progression, no ST or T-wave changes. No significant changes
from [**2169**], but compared to serial EKG's from earlier this
evening, the patient is more bradycardic.
.
Imaging:
CXR: lower lung volumes, ETT in good position. Compared to CXR
in [**2169**], increase vascular markings, but no other obvious
change. No infiltrates.
.
Ct head: Provisional Findings Impression: No intracranial
hemorrhage
Brief Hospital Course:
Assessment: This is a 53 year-old male with an extensive
psychiatric history with past suicide attempts who presents with
antidepressant overdose in an apparent suicide attempt.
SUICIDAL IDEATION / OVERDOSE -patient was initially admitted to
the ICU after intubation in the Emergency Department for airway
protection. His exact ingestion was unknown, toxicology was
consulted. He experienced no hemodynamic instability or other
signs or symptoms to suggest a specific toxidrome. He required
no specific treatment other than supportive care and
observation. He was quickly extubated and transferred to a
general medical floor where he was continued on 1:1 sitter as he
continued to be actively suicidal. He was seen by psychiatry and
continued inpatient care was recommended. He was behaviorly
stable and appropriate. Specific psychiatric medicines were held
and deferred to the inpatient psych setting.
2.DM II uncontrolled with complications -Pt may have ingested
metformin in his gesture, as evidenced by an initial lactic
acidosis on admission. His blood sugars remained stable and on
transfer to the floor his metformin was restarted. He should
continue his metformin since he will be in a monitored
environment with finger blood sugar checks with sliding scale
coverage at least twice a day. Further care of his diabetes will
be deferred to his outpatient providers.
3. SCHIZOAFFECTIVE/BIPOLAR/DEPRESSION -carries these diagnoses
prior to admit. last med list obtained included: Effexor,
Lamictal, Risperdal, and Trileptal. No specific recommendations
regarding these medications were made by the psychiatry consult
service and was deferred to his inpatient care team. He was
receiving only prn Haldol which he would request.
4. HYPOTHYROID -continued on last known replacement Synthroid
dose. TSH was within therapeutic levels.
5. HTN, BENIGN -lisinopril continued.
Medications on Admission:
unknown
Discharge Medications:
1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Tablet PO three times a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. INSULIN SLIDING SCALE
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8063**] - [**Location (un) **]
Discharge Diagnosis:
suicidal ideation / ingestion
schizoaffective disorder
bipolar disorder
depression
DM II uncontrolled with complications
hypothyroid
Discharge Condition:
improved, afebrile, no complaints, no shortness of breath, no
physical pain
Discharge Instructions:
per inpatient psych facility
you should have your blood sugar checked at least 2 times a day
for the next week as your metformin has been restarted and your
blood sugars may be higher in the first few days as your
medicine is restarted.
Followup Instructions:
per psych facility
follow up with your primary provider as scheduled and/or as
needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2175-8-23**]
ICD9 Codes: 5849, 2762, 4589, 2449, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4275
} | Medical Text: Admission Date: [**2132-7-24**] Discharge Date: [**2132-8-4**]
Date of Birth: [**2080-12-23**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Diarrhea and abdominal pain
Major Surgical or Invasive Procedure:
Intubation, central line placement, dialysis catheter placement
History of Present Illness:
51 yo m w/ PMH HIV (last CD4 53 in [**4-22**], on [**Date Range 97504**]), Hep C/HCC
cirrhosis s/p liver xplant in [**1-21**] c/b biliary leak s/p ERCP,
s/p Roux-en-Y, s/p T-tube placement, recurrent c diff. Due to
elev liver enzymes is found to have recurrent HCV. Admitted [**7-24**]
w/ diarrhea and abd pain. Noted at that time to have renal
failure (Cr 2.1, baseline 1.1-1.3), low bicarb (HCO3 at 13 down
from baseline 18-20), AG = 16, elevated AST (65 -> 141),
elevated T bili 1.4 -> 7.7, elevated INR to 1.9. Since
admission his Cr has steadily worsened and the patient has
become oliguric. Now approx 4.2L positive. Noted to have ? RLL
infiltrate and was started on levofloxacin. Had been
oxygenating well on RA. Yesterday developed new O2 requirement
(2L) which was increased this evening to 5L NC. Noted to have
dramatically increased secretions. Reports that he is
increasingly SOB. Denies CP. Patient refusing to answer further
questions.
Past Medical History:
as per admit note)
-HIV (since [**2115**]), last CD4 53 and viral load < 50 in [**4-22**]
(repeat pending from [**2132-7-23**])
-cirrhosis (Hep C) s/p transplant in [**1-21**], c/b biliary leak s/p
ERCP ([**1-30**]), s/p washout/Roux-en-Y hepatojujenostomy ([**2-1**]) c/b
bile aspiration, cholecystitis in [**3-22**], h/o t-tube placement and
removal.
-h/o med-associated renal insufficiency (thought [**12-20**] tenofovir,
so was discontinued in [**3-22**])
-recurrent Hep C likely post xplant
-h/o recurrent c diff infections (most recently [**4-22**])
-H/o hepatocellular Carcinoma prior to transplant (last AFP 10.9
in [**3-22**])
-PVD w/ claudication
-h/o CVA [**2128**] (residual RLE weakness)
-HTN
-Hypercholesterolemia
-h/o substance abuse
-h/o UGIB
-h/o blood cxs + for VRE, treated with daptomycin
-hemorrhoids
-depression/anger management issues, with refusal to see
psychology at transplant center
-medical non-compliance
Social History:
currently living at [**Hospital **] Rehab. Former [**Hospital 1818**]. Former
substance abuse. Quit EtOH 3 yrs ago.
Family History:
n/c
Physical Exam:
pe:
tm 100.1, tc 100.1, bp 97-118/67-86, r 18-32, 32 on evaluation,
98% 4L nc
Deconditioned male, coughing, unable to speak in full sentences,
in mild distress
PERRL. +icteric
OP clr
9cm jvp
regular s1,s2. no m/r/g
b/l diffuse rhonchi, +exp wheeze
+midline laparatomy scar, bandage in place. c/d/i. +bs. soft.
nt. +mildly distended. no hepatomegaly.
2+ le edema.
Pertinent Results:
[**2132-7-23**] 11:36AM WBC-11.2* LYMPH-7.0* ABS LYMPH-784 CD3-56
ABS CD3-436* CD4-10 ABS CD4-82* CD8-44 ABS CD8-345 CD4/CD8-0.2*
[**2132-7-23**] 11:36AM PT-20.2* INR(PT)-1.9*
[**2132-7-23**] 11:36AM NEUTS-87* BANDS-0 LYMPHS-4* MONOS-6 EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2132-7-23**] 11:36AM LIPASE-103*
[**2132-7-23**] 11:36AM ALT(SGPT)-141* AST(SGOT)-211 LD(LDH)-517* ALK
PHOS-361* TOT BILI-7.7*
[**2132-7-23**] 11:36AM GLUCOSE-95 UREA N-34* CREAT-2.1* SODIUM-140
POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-13* ANION GAP-21*
.
DUPLEX DOPPLER LIVER ULTRASOUND:
The liver parenchyma is normal in echotexture, unchanged
compared to prior
study. No focal lesions are identified. The right, left, and
main hepatic
veins are patent and demonstrate normal flow and waveforms. The
portal venous
vasculature is patent. The main, left and right hepatic
arteries demonstrate
normal waveforms with resistive indices between 0.79 - 0.89. The
IVC is
patent.
IMPRESSION:
Similar appearance of transplanted liver with patent hepatic
vasculature.
.
ECHO
1.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic
(EF>75%).
2.There is a small to moderate sized pericardial effusion. There
are no
echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2132-7-29**],
the pericardial effusion appears slightly increased
Brief Hospital Course:
51 yo m w/ Hep C/HCC cirrhosis, HIV, recurrent c diff, s/p liver
xplant in [**1-21**] with extended post-transplant course, transferred
for mild resp distress.
.
Pt's respiratory distress initially improved dramatically with
aggressive chest PT. antibiotics were expanded to vancomycin
and zosyn for empiric therapy of PNA, given new fever, ?
infiltrate assoc w/ R pleural effusion and elev wbc. ARF -
ulytes c/w prerenal etiology. Following admission to ICU,
patient underwent volume challenge with 1.5 L NS w/ 3 amps
bicarb. UO increased transiently with this and Cr stabilized.
Altered mental status- felt to be [**12-20**] liver dz, renal failure,
and pna. risks of sedation felt to be high enough that head CT
was not obtained (patient refused test) and exam more c/w
delerium. Lactulose was titrated. S/p liver transplant -prograf
held following initial transfer due to elev levels. Re-started
on [**7-30**]. pegsasys continued to be held in unit. Diarrhea/c
diff- on transfer was on standing loperamide and vancomycin
taper. on transfer loperamide held, pt w/o diarrhea. Continued
on standing p.o. vancomycin. Metablolic acidosis- unclear
etiology. Combined anion and non-anion gap. bicarb improved w/
1.5L of NaHCO3 (3amps) from 12 to 18 however non-gap acidosis
increased slightly (likely dilutional). HIV: Pt on lamivudine,
efavirenz, abacavir as outpt, followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].
Hct drop - on [**7-30**] noted to have hct drop, guiac +. pt
non-compliant with NGT placement. The pt subsequently developed
a large GIB. EGD consistent with cultiple acute superficial
ulcers 3-10mm were found in the first part of the duodenum and
second part of the duodenum. There were stigmata of recent
bleeding. Pt was intubated for airway protection but aspirated
in the context of the event. Pt was aggressively fluid
resusciated and only transiently required pressors. A dialysis
catheter was placed in the attempt to remove fluid as pt
anasarcic and in persistent renal failure. As the pt did not
show any improvement and prognosis was infaust, decision was
made with the family to withdraw all measure. The pt expired
within minutes of extubation.
Medications on Admission:
see admission note
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
ICD9 Codes: 5845, 0389, 2762, 5070, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4276
} | Medical Text: Admission Date: [**2149-5-30**] Discharge Date: [**2149-6-8**]
Date of Birth: [**2081-8-7**] Sex: M
Service: Urology
CONDITION UPON DISCHARGE: Stable.
The patient is discharged to home.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 18685**] is a 67-year-old
male noted to have a right kidney mass consistent with a
renal cell carcinoma after presenting with microscopic
hematuria. By imaging, he was noted to have bilateral renal
cysts as well as a 2nd lesion in the right kidney that was
consistent with a Bosniak III cyst.
The patient was subsequently prepared for a right partial
nephrectomy with the knowledge of a possible right total
nephrectomy. Of note, the patient's more recent past medical
history included a recent gastrointestinal bleed from a
hiatal hernia ulcer for which he was found to be H. pylori
positive and a pulmonary embolus in the setting of the
gastrointestinal bleed where he had an IVC filter placed.
His past medical history otherwise includes:
1. Coronary artery disease, status post left anterior
descending artery stent in [**2144**], cardiac catheterization in
[**2149-3-21**], status post stent and PTCA again of the left
anterior descending artery as well as PTCA of the obtuse
marginal. Ejection fraction was 58% with anterolateral and
apical hypokinesis.
2. Congestive obstructive pulmonary disease with a FEV1 of
54% of predicted, FVC of 80% of predicted, and FEV1/FVC ratio
of 67% of predicted.
3. Gastrointestinal bleed as noted above.
4. Pulmonary embolus as noted above.
5. Hernia repair in [**2138**].
His medications at home include Nifedipine XL 30 mg po q day,
metoprolol 25 mg [**Hospital1 **], tamsulosin 0.4 mg po q day, aspirin
which was stopped [**2149-5-21**], sublingual nitroglycerin for
which he rarely uses, and an incomplete treatment for his H.
pylori.
His allergies include a question of an allergy to one of the
medications in his Prevpak.
His examination on admission shows an elderly Russian
speaking male in no acute distress. His blood pressure is
145/94. His heart rate is 78. His head and neck examination
are benign. His lungs show some diffuse scattered mild
expiratory wheezes. His heart is regular, rate, and rhythm.
His abdomen is soft and nontender with a well-healed vertical
incisional scar consistent with is previously known hiatal
hernia repair. He has no costovertebral angle tenderness.
He has slight bilateral lower extremity edema with easily
palpable pulses.
HOSPITAL COURSE: The patient was admitted status post a
right partial nephrectomy performed on [**2149-5-30**] by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 9125**]. His postoperative pain management included an
epidural which appeared to be working. At the initial night
in the Intensive Care Unit, due to a postoperative
temperature of 102 and a decreased respiratory rate felt
consistent with his residual anesthesia and epidural.
Overnight he did well with good pain control. He completed
his perioperative course of antibiotics. His temperature
curve returned to [**Location 213**]. He was slowly started on sips on
postoperative day two. He was transferred out of the
Intensive Care Unit.
On postoperative day three, the patient was originally doing
well. However, in the afternoon, he developed acute
respiratory distress. He was transferred back down to the
Intensive Care Unit, where he was intubated with a question
of an aspiration pneumonia versus lobar collapse versus
pulmonary embolus. That night he subsequently underwent a
chest, abdomen, and pelvic CT scan which showed no evidence
of pulmonary embolus and no evidence of postoperative bleed.
He was status post bronchoscopy which was unrevealing showing
no inflammation of the bronchial mucosa. He also underwent a
thoracentesis under ultrasound guidance for which 500 cc of a
bloody effusion on the right was obtained.
The effusion, bronchoalveolar lavage, and sputum cultures
were all negative. The cytologies were all negative.
Patient subsequently underwent recruitment maneuvers on the
ventilator and was subsequently extubated on postoperative
day six. He did well status post extubation, and was
transferred to the surgical floor on postoperative day seven.
He continued on a presumptive course for aspiration pneumonia
including levofloxacin and Flagyl. With the passage of
flatus, his diet was advanced as tolerated. He continued to
do well, weaning off the oxygen.
On discharge, by postoperative day nine, he was continuing on
his levofloxacin and Flagyl on day [**7-30**]. He was ambulating
without difficulty. He was on room air without any
recurrence of respiratory distress or wheeze on auscultation.
He is tolerating a regular diet. He was moving his bowels.
He is voiding without difficulty. His incision was clean,
dry, and intact. His [**Location (un) 1661**]-[**Location (un) 1662**] drain had been removed
postoperatively previously on postoperative day three.
He was subsequently discharged to home after verifying that
there is no evidence of any deep venous thrombosis for his
lower extremity edema with a lower extremity noninvasive test
on the date of discharge.
His medications on discharge include his preoperative
medications of Nifedipine XL 30 mg po q day, Lopressor 25 mg
po bid, levofloxacin 500 mg po q day, Flagyl 500 mg po tid,
Percocet 1-2 tablets po q 4 hours prn pain, Colace 100 mg po
bid, and albuterol inhaler two puffs qid prn wheeze.
He will follow up with his primary care physician to further
workup his preoperative and postoperative pulmonary issues.
Prior to discharge, his staples were removed. His pathology
results were given to him and his family. He will follow up
with Dr. [**Last Name (STitle) 9125**] in approximately two weeks as well to
reassess his wound healing and to finalize his postoperative
oncologic plan.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**]
Dictated By:[**Last Name (NamePattern1) 18686**]
MEDQUIST36
D: [**2149-6-8**] 18:35
T: [**2149-6-9**] 10:15
JOB#: [**Job Number 18687**]
ICD9 Codes: 5070, 5119, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4277
} | Medical Text: Admission Date: [**2155-10-21**] Discharge Date: [**2155-10-23**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
R sided weakness, R sided neglect and presented as Code Stroke
Major Surgical or Invasive Procedure:
IV tPA
History of Present Illness:
82 year old with a hx of HTN, A fib, not on Coumadin due to GIB
in the past, hyperlipidemia, who presents as a Code Stroke for
acute onset of R hemiparesis and R sided neglect.
Stroke code called at 4.49 pm Stroke fellow at bedside at 4.50
pm
Wife reports that pt. was in his usual state of health at 3 PM
today when she left the house to go to a meeting. When she got
back at 4:30 she found him lying on the floor. She immediately
called EMS. No EMS report is available at this time, but per ED
report they found his to have R sided neglect and R hemiparesis.
Wife reports that he has been in good health recently, with no
fevers, chills, weakness, numbness, dysarthria, dysphagia, chest
pain, or SOB.
Past Medical History:
HTN
hx TIAs, no residual per wife
"irregular heart beat" per wife, has been on Coumadin for this
in
the past, but stopped because of bleeding, wife thinks GI
L hip replacement
Arthritis
Hyperlipidemia
No Hx of DM
Social History:
Lives with wife, retired, active, does driving and his share of
cooking and chores around the house. Wife's phone number is
[**Telephone/Fax (1) 75125**]
Family History:
no FH of stroke that wife is aware of
Physical Exam:
BP- 150/87 HR- 61 RR- 16 O2Sat- 100% on RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
NIH SS:16
1a. Level of Consciousness: 0
1b. LOC questions: 1
1c. LOC commands: 1
2. Best gaze: 2
3. Visual:
4. Facial palsy: 1
5a. Motor arm, left: 4
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb ataxia: 0
8. Sensory: 1
9. Best language:
10. Dysarthria: 2
11. Extinction and inattention:
Neurologic examination:
Mental status: Awake, agitated, grabbing at sheets. Speech
markedly dysarthric, barely understandable. Does follow some
commands. Marked L sided neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. R gaze deviation, does not blink to threat on L.
Extraocular movements intact bilaterally, no nystagmus.
Sensation intact V1- V3. L UMN facial droop.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. Moves R arm and leg briskly anti-gravity. Withdraws L
leg to pain but doesn't lift off the bed. No movement L arm
with pain.
Sensation: grimaces to pain all 4 extremities
Reflexes:
+1 and symmetric throughout.
Toes downgoing R, upgoing L
Coordination, Gait: not assessed
Pertinent Results:
[**2155-10-21**] 05:05PM BLOOD WBC-8.1 RBC-4.54* Hgb-12.3* Hct-38.3*
MCV-85 MCH-27.2 MCHC-32.2 RDW-15.4 Plt Ct-313
[**2155-10-22**] 03:31AM BLOOD WBC-8.6 RBC-3.88* Hgb-10.5* Hct-32.7*
MCV-84 MCH-27.1 MCHC-32.2 RDW-15.2 Plt Ct-287
[**2155-10-23**] 04:41AM BLOOD WBC-13.2* RBC-3.56* Hgb-9.8* Hct-29.1*
MCV-82 MCH-27.6 MCHC-33.8 RDW-15.2 Plt Ct-246
[**2155-10-21**] 05:05PM BLOOD PT-12.8 PTT-30.9 INR(PT)-1.1
[**2155-10-21**] 10:55PM BLOOD PT-16.0* PTT->150 INR(PT)-1.5*
[**2155-10-22**] 11:08AM BLOOD PT-13.2* PTT-31.2 INR(PT)-1.1
[**2155-10-23**] 04:41AM BLOOD PT-12.6 PTT-29.0 INR(PT)-1.1
[**2155-10-22**] 03:31AM BLOOD Glucose-116* UreaN-14 Creat-0.8 Na-136
K-4.1 Cl-104 HCO3-25 AnGap-11
[**2155-10-23**] 10:57AM BLOOD Glucose-120* UreaN-15 Creat-1.0 Na-134
K-3.4 Cl-102 HCO3-25 AnGap-10
[**2155-10-22**] 03:31AM BLOOD ALT-15 AST-14 CK(CPK)-114 AlkPhos-89
TotBili-0.5
[**2155-10-21**] 05:08PM BLOOD CK-MB-4 cTropnT-<0.01
[**2155-10-22**] 03:59AM BLOOD cTropnT-0.03*
[**2155-10-22**] 11:08AM BLOOD CK-MB-5 cTropnT-0.02*
[**2155-10-22**] 06:15PM BLOOD CK-MB-4 cTropnT-0.01
[**2155-10-23**] 04:41AM BLOOD CK-MB-3 cTropnT-<0.01
[**2155-10-21**] 10:55PM BLOOD Calcium-7.7* Phos-3.8 Mg-1.9
[**2155-10-23**] 01:51AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.0
[**2155-10-23**] 10:57AM BLOOD Calcium-8.8 Phos-1.8* Mg-1.9
[**2155-10-22**] 03:31AM BLOOD %HbA1c-5.6
[**2155-10-22**] 03:31AM BLOOD Triglyc-91 HDL-49 CHOL/HD-3.3 LDLcalc-97
[**2155-10-23**] 10:57AM BLOOD Osmolal-286
[**2155-10-23**] 04:30PM BLOOD Osmolal-301
[**2155-10-22**] 03:30AM BLOOD Type-ART pO2-170* pCO2-45 pH-7.37
calTCO2-27 Base XS-0
[**2155-10-22**] 12:05PM BLOOD Type-ART pO2-168* pCO2-38 pH-7.43
calTCO2-26 Base XS-1
[**2155-10-22**] 02:19PM BLOOD Type-ART pO2-183* pCO2-38 pH-7.42
calTCO2-25 Base XS-0
[**2155-10-23**] 02:05AM BLOOD pO2-169* pCO2-39 pH-7.45 calTCO2-28 Base
XS-3
[**2155-10-23**] 04:38AM BLOOD Type-ART pO2-121* pCO2-40 pH-7.44
calTCO2-28 Base XS-3
[**2155-10-23**] 04:43PM BLOOD Type-ART Temp-37.0 pO2-118* pCO2-37
pH-7.43 calTCO2-25 Base XS-1 Intubat-INTUBATED
[**2155-10-21**] 05:08PM BLOOD Glucose-103 Na-139 K-4.4 Cl-98*
calHCO3-28
[**2155-10-21**] 11:10PM BLOOD freeCa-1.04*
[**2155-10-22**] 02:19PM BLOOD freeCa-1.10*
[**2155-10-23**] 02:05AM BLOOD freeCa-1.03*
[**2155-10-22**] 03:30AM BLOOD freeCa-1.13
Angio [**10-21**]:
[**Known firstname 19784**] [**Known lastname 75126**] underwent cerebral arteriography and attempted
thrombolysis of the right internal carotid artery terminis
occlusion which was unsuccessful due to the extreme tortousity
of the aortic arch and the take-off of the right common carotid
artery.
CT Perfusion [**10-21**]:
Apparent near complete occlusion of the right middle cerebral
artery at its origin. Question of technically inadequate
perfusion measurements.
CT Head [**10-21**]:
No evidence of intracranial hemorrhage. Bilateral hypodensity
within the corona radiata, possible mild focal effacement of the
right insular ribbon and thrombus within the right middle
cerebal artery, which are consistent with acute infarction.
CT Head [**10-22**]:
Interval development of essentially complete right middle
cerebral artery territory infarction and probable infarction
within at least a portion of the right anterior cerebral artery
territory.
CT Head [**10-23**]:
Interval significant worsening of mass effect by right middle
cerebral artery territory infarction on the right lateral
ventricle, as well as development of significant subfalcine and
uncal herniation.
Echo [**10-22**]:
The left atrium is dilated. There is symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is normal (LVEF>55%). There is a
mild resting left ventricular outflow tract obstruction. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No masses or vegetations are seen on the aortic
valve. Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension.
Brief Hospital Course:
Mr. [**Known lastname 75126**] was admitted to the ICU after attempted MERCI without
success. He was intubated for airway protection and maintained
on a SBP of less <185 systolic and <105 diastolic after the IV
tPA was given. He was also started on a Statin. His cardiac
enzymes were cycled and he had slight increase in his troponin
which resolved. He was extubated the following day without
difficulty but remained unarousable on exam, without response to
noxious stimuli in the upper extremities. Over the following
evening he was noted to have increased edema on the repeat head
CT. By the early morning he had developed marked anisocoria and
a fixed, dilated pupil on the right. He had an absent gag but
corneals were present. He was re-intubated and hyperventilated.
Mannitol was started and Neurosurgery was consulted. Given the
extent of his MCA infarct they did not recommend surgical
intervention. A repeat head CT showed worsening edema with a
mildline shift. A goals of care discussion with his wife and
daughter occurred initially in the morning and he was made DNR.
In the afternoon he began vomiting and his exam worsened with
both pupils being fixed and dilated with anisocoria. A second
family meeting occurred and they decided to make Mr. [**Known lastname 75126**] [**Last Name (Titles) 3225**].
He was extubated and treated with morphine, scopolamine, and
Ativan. He died later that evening. The family declined an
autopsy.
Medications on Admission:
Plavix
Lisinopril
ASA 81 mg QD
Lopressor
HCTZ
MVI
KCl
Prednisone (wife thinks this is for arthritis
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
MCA infarct with herniation
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
ICD9 Codes: 4019, 2724, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4278
} | Medical Text: Admission Date: [**2158-5-22**] Discharge Date: [**2158-6-9**]
Date of Birth: [**2096-4-23**] Sex: M
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: A 62-year-old male with end-
stage liver disease, cirrhosis secondary to alcohol,
encephalopathy, peripheral edema, ascites requiring
paracentesis, upper gastrointestinal bleed from grade 2
varices one time, portal hypertension hepatocellular
carcinoma non-metastatic, status post radiofrequency ablation
in [**2157-11-7**], followed for availability of liver
transplant. The patient is without new complaints at the
time of admission.
MEDICATIONS ON ADMISSION:
1. Lasix 40 mg once a day.
2. Lactulose one tablespoon once a day.
3. Propranolol 40 mg twice a day.
4. Lithium 900 mg once a day.
5. Protonix 40 mg twice a day.
6. Spironolactone 100 mg twice a day.
7. Mycelex five.
8. Meclizine 25 mg once a day.
9. NPH insulin 100 units q. a.m., 50 units q. p.m.
10. Doxazosin 1 mg once a day.
PHYSICAL EXAMINATION: Upon admission this patient was
afebrile with stable vital signs with a weight of 120.0
kilograms. Head, eyes, ears, nose and throat examination was
normal. Neck was supple. Lungs clear to auscultation
bilaterally. Cardiovascular examination: Regular rate and
rhythm, no murmurs, rubs or gallops. Abdominal examination:
Revealed mild ascites, non-tender throughout. Extremity
examination revealed 1 plus ankle edema.
LABORATORY ON ADMISSION: Hematocrit 38.5, white blood cell
count 11.2, platelet count 140,000. Sodium 143, potassium
3.4, chloride 103, carbon dioxide 34, blood urea nitrogen 16,
creatinine 1.0, glucose level 50. Calcium 10.0, phosphorus
82.6, magnesium 1.6. AST was 61, ALT was 52 and alk phos was
83. Total bilirubin was 1.7. His prothrombin time was 14.3,
his PTT was 26.4. His fibrinogen was 267 and his INR was
1.4.
HOSPITAL COURSE: So at this time the patient was admitted
with end-stage liver disease for a liver transplant. He was
placed nil per os. Consent was signed. CellCept, Solu-
Medrol, Unasyn, fluconazole were started. Labs were drawn.
Urinalysis was performed. A chest x-ray was performed and an
electrocardiogram was performed. Anesthesia consent was also
obtained as he was seen by their staff.
On [**2158-5-23**], liver transplant was performed under
general anesthesia. The patient was brought to the Surgical
Intensive Care Unit after the operation. The patient was
progressing well at this time and on postoperative day one
the plan was to use morphine sulfate for pain as needed. A
transesophageal echocardiogram had shown residual clot and
adequate biventricular function. A chest x-ray was sent and
the patient was weaned off of FiO2. The patient was also nil
per os at this time and on an nasogastric tube. The patient
was also on a Foley catheter to follow urine output closely.
Infectious Disease: The patient was placed on Unasyn times
three days. The patient was also transfused platelets, fresh
frozen plasma and cryoprecipitate at this time and the
patient began the immunosuppressive regimen with Solu-Medrol
at 140 twice a day, CellCept 1 gram twice a day, ________
times one intraoperatively and, in terms of endocrine,
patient was placed on a regular insulin sliding scale at this
time with a plan to move to an insulin drip if glucose levels
trended upwards. The patient continued to progress well
during his stay and continued to oxygenate well and was able
to be weaned off of oxygen, FiO2 as he was weaned off of
propofol at this time. Prophylactic medications, Bactrim and
fluconazole, were continued at this time.
The patient continued to progress well at this time and on
the [**5-25**] propofol was discontinued. An
electrocardiogram was taken showing no ischemic changes. The
patient did not need a beta blocker at this time. Patient
was receiving Nipride which was being held for systolic blood
pressure less than 160. The patient was given Lasix to
diurese and established an adequate urine output. The
patient was started on total parenteral nutrition and Unasyn
was discontinued at this time.
On [**2158-5-26**], the patient continued to progress taking
Dilaudid p.r.n. for pain at this time. Stable vital signs.
Patient receiving CPAP and his total bilirubin and other
liver function tests including ALT and AST continued to trend
downward. Good bile output out of the drain. His liver
function tests on this day were 155 for AST, 614 for ALT and
64 for alk phos. The previous day on [**5-25**] were AST of
252, ALT of 309 and alk phos of 65. The patient was
continued on Lasix diuresis and continued on prophylactic
Bactrim, fluconazole and ganciclovir. The patient at this
time was on an insulin drip.
The patient continued to progress on the [**5-27**] and was
being followed at this time by the inpatient clinical
Nutrition team. They recommended titrating insulin drip as
needed and set up a TPN to regiment with a goal of 2,150
kilocalories per day.
On [**2158-5-28**], the patient continued to progress well.
His wound was noted to be without pus or erythema at this
time. He was continued on Dilaudid as needed for pain. He
was still being followed by the SICU team in the Surgical
Intensive Care Unit. At this time patient was able to change
to largely oral medications. He had stable respiratory
status and was now off of ventilation.
On postoperative day nine, [**5-30**], the patient continued
to be stable but appeared somewhat confused upon examination.
It was recommended at this time the patient be transferred to
the floor and later in the day he was transferred to [**Hospital Ward Name 121**] 10.
Date of extubation for this patient was [**5-28**]. The
patient began to be evaluated by Physical Therapy on [**2158-5-29**].
On [**2158-5-31**], it was noted they found the patient to be
alert and oriented but mildly inappropriate with tangential
speech. They noting that he was practicing even coordinated
breathing. Their general impression was that this man's
mobility would improve. He was tolerating being out-of-bed
well but that he would require short term rehabilitation upon
discharge to maximize functional status. They also stated
that his potential to return to baseline was good. They
recommended one to three more weeks of physical therapy or
until discharge to rehabilitation.
The patient began to be followed by the [**Last Name (un) **] consult team
on the [**6-1**]. The [**Last Name (un) **] attending noted that the
patient was now transitioning to eating meals and suggested
starting Lentes and Humalog regimen. As per their request
after they reviewed the chart they noted that his prior
regimen was likely suboptimal and that his insulin needs
would be significantly different after this liver
transplantation due to the effects of steroids and his new
liver and they began to discuss outpatient regimens for the
patient. The patient was also receiving Occupational Therapy
evaluations and it was noted on [**2158-6-1**], by
Occupational Therapy that patient was minimally confused and
that he would likely need rehabilitation prior to returning
home.
On the [**6-2**] the patient continued to progress well,
complained of some mild abdominal pain but noted significant
improvement since the immediate postoperative time. There
were noted to be multiple ecchymotic areas over his right
upper extremity at this time and four to five skin
ulcerations on his left upper extremity. Ancef 1 gram every
eight hours was started at this time and a full HUS workup
was commenced and Hematology was consulted. A blood smear
was sent that was viewed by Hematology not to contain any
schistocytes and that most likely a hemolytic-uremic syndrome
workup was not necessarily warranted but that they would
follow the results.
On postoperative day 12, [**6-3**], the patient continued to
progress well and began to be screened for rehabilitation.
He continued to be followed by [**Last Name (un) **] for glucose levels and
was continued on Ancef at this time. His vital signs were
stable and the patient was without pain at this time. He was
passing gas and having bowel movements and was noted an
increased appetite. The patient continued to be followed by
Nutrition, Respiratory Care and his liver function tests
continued to trend downwards. Cyclosporin levels were found
to be therapeutic and it was determined again by Transplant
staff that the patient would likely need rehabilitation.
[**Last Name (un) **] continued to follow the patient at this time and
recommended that the patient continue with current Lentes and
Humalog sliding scale regimen.
On the [**6-5**] the patient was doing well with only mild
abdominal pain with lunging or reaching movements. He was
still passing gas and having bowel movements and taking solid
foods at this time. The patient still appeared somewhat
distant in conversation and a Psychiatry consult was ordered.
Per Psychiatry's request, the lithium level was sent and
found to be 1.9. At this time Psychiatry recommended that
lithium be held and Haldol be used as needed for agitation.
At this time it was noted that the patient was not taking
enough food orally and a feeding tube was placed by
Interventional Radiology.
Then on the morning of [**2158-6-7**], the patient went on to
pull the feeding tube from its position and it was determined
that total parenteral nutrition would be delivered through a
PICC line placed on the [**2158-6-6**]. The patient
continued to improve at this time and was followed again by
Psychiatry who suggested 1 mg dose of Haldol for standing
order at night and their formal consultation was noted in the
chart. The patient's mental status was significant for
confusion and inattention and tangential thought at this
time. His lithium level and renal function were noted to be
improving at this time. His lithium level was now down to
1.6.
On [**6-8**] the patient continued to feel better and continued
to note improving appetite. He was noted by the staff to be
taking all of his meals. Calorie counts were occurring at
this time. The patient continued to be screened for
rehabilitation. The patient was continued on total
parenteral nutrition. [**Last Name (un) **] was notified of the total
parenteral nutrition and they advised adding 10 units of
insulin to his TPN order which was done.
On [**6-9**], the day of discharge, the patient was doing very
well, not complaining of any pain, with increasing appetite.
Had been out-of-bed three times the previous day. On
physical examination vital signs were temperature maximum
over the last 24 hours of 98.4 degrees. Current temperature
97.6 degrees. 59 beats per minute. Blood pressure 132/71.
Respiratory rate of 20. Oxygen saturation 94 percent on room
air. His weight was 123.3 kilograms. His fingersticks were
in the low 100's. The patient was in no apparent distress.
His cardiac examination revealed regular rate and rhythm with
no murmurs, rubs or gallops. His respiratory examination
revealed clear to auscultation bilaterally. No wheezes,
rales or rhonchi. On abdominal examination the patient was
noted to be non-distended, normoactive bowel sounds, soft and
non-tender throughout with a well-healing wound. It was
clean, dry and intact. Screening for rehabilitation at this
time continued and it was determined that patient would be
discharged on this day.
His laboratory values at this time were the following: PT
time 12.5, PTT 22.4, INR 1.0, fibrinogen 431. On [**2158-6-8**], his cyclosporin level was 944. His liver function
tests revealed an ALT of 14, an AST of 15, alk phos of 127, a
total bilirubin of 1.8 and albumin of 2.8. White count at
this time was 12.9, hematocrit 27.6 and platelet count
137,000.
DISCHARGE DIAGNOSES: Status post orthotopic liver transplant
[**2158-5-22**], for hepatitis B/alcoholic cirrhosis.
Cirrhosis with encephalopathy.
Peripheral edema.
Ascites requiring paracentesis.
Upper gastrointestinal bleed with grade 2 varices with one
episode of banding.
Hepatocellular carcinoma status post radiofrequency ablation
[**2157-11-7**].
Diabetes mellitus type 2.
Congestive heart failure with diastolic dysfunction.
Pulmonary hypertension.
Hypertension.
Benign prostatic hypertrophy.
Left lower extremity deep venous thrombosis with pulmonary
embolism in [**2156-12-8**].
Obstructive sleep apnea.
Bipolar disorder.
Post traumatic stress disorder.
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS: The patient was instructed to call
if fevers, chills, nausea, vomiting or increased redness or
drainage started to occur from the wound site. The patient
was to be sent to rehabilitation at this time. Laboratory
levels were to be drawn twice weekly to measure levels of
immunosuppressive drugs and liver function tests. The
patient's first appointment with the Liver [**Hospital 1326**] Clinic
at the Transplant Center was to occur at the [**Last Name (un) 2577**] Building
[**Hospital 1326**] Clinic on Wednesday, [**2158-6-14**], at 10:50 a.m.
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg by mouth once a day.
2. Bactrim one tablet by mouth once a day.
3. Metoprolol 75 mg by mouth twice a day with hold for heart
rate less than 60 or systolic blood pressure less than
100.
4. Hydralazine 75 mg by mouth four times a day. Hold for
systolic blood pressure less than 110.
5. Bisacodyl 20 mg per rectum once a day as needed.
6. Mycophenolate mofetil 1000 mg by mouth twice a day.
7. Insulin Glargine 60 units subcutaneously once per night.
8. Insulin sliding scale on fixed dose.
9. Fluconazole 200 mg by mouth once a day.
10. Valganciclovir 450 mg by mouth every other day.
11. Prednisone 50 mg by mouth once a day.
12. Doxazosin 1 mg by mouth at night.
13. Haldol 1 mg by mouth at night one tonight.
14. Meclizine 25 mg by mouth once a day.
15. Cyclosporin 150 mg by mouth twice a day, 8:00 p.m.
and 8:00 a.m.
16. Furosemide 40 mg by mouth twice a day.
17. The patient received two more doses of Ancef at this
time, 1 gram IV q. 8h.
18. Haldol 2.5 mg IV three times a day as needed for
agitation.
Again, labs are to be drawn on a twice weekly basis and
levels to be followed by the Transplant team.
DISPOSITION: To rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PhD [**Numeric Identifier 8353**]
Dictated By:[**Last Name (NamePattern1) 48464**]
MEDQUIST36
D: [**2158-6-9**] 12:44:51
T: [**2158-6-9**] 15:25:37
Job#: [**Job Number 48465**]
ICD9 Codes: 4280, 9971, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4279
} | Medical Text: Admission Date: [**2152-12-6**] Discharge Date: [**2152-12-11**]
Date of Birth: [**2116-2-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Milk / Morphine / Haldol / Ibuprofen
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
clonidine overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
36M s/p Clonidine overdose. patient took ~30 pills of unknown
dose and got onto ferry to [**Hospital3 **]. The patient was
MedFlighted from [**Hospital3 **] to [**Hospital1 **] after alerting the
crew that he overdosed and was subsequently found unresponsive.
He reported that he took 30 Clonidine, 1 Soma, & 1 beer.
.
Patient was brought to the ED, Toxicology was consulted who
suggested that he should be intubated for airway protection and
his course should be that of hypertension followed by that of
hypotension. Patient may also be bradycardic.
.
Patient was also given Charcoal in the ED and given atropine x1
for bradycardia.
Past Medical History:
DM2
asthma
Depression
Prior hx of SI
Social History:
recently broke up with fiance.
Family History:
unknown
Physical Exam:
Vitals - T:99.5 BP:154/120 HR:47 RR:23 02 sat:100
VENT SETTINGS: AC 525x16 1.0 PEEP%
GENERAL: intubated and sedated
SKIN: many scars on L forearm, warm and well perfused
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
.
Pertinent Results:
[**2152-12-6**] 09:48AM OSMOLAL-304
[**2152-12-6**] 09:48AM WBC-14.7* RBC-4.79 HGB-16.1 HCT-47.6 MCV-99*
MCH-33.6* MCHC-33.8 RDW-14.0
[**2152-12-6**] 09:48AM PLT COUNT-304
[**2152-12-6**] 09:21AM TYPE-ART TEMP-37.2 RATES-16/4 TIDAL VOL-500
O2-60 PO2-137* PCO2-41 PH-7.39 TOTAL CO2-26 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED
[**2152-12-6**] 09:21AM LACTATE-1.8
[**2152-12-6**] 06:17AM VoidSpec-SPECIMEN L
[**2152-12-6**] 04:36AM GLUCOSE-171* UREA N-10 CREAT-0.8 SODIUM-144
POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-22 ANION GAP-15
[**2152-12-6**] 04:36AM estGFR-Using this
[**2152-12-6**] 04:36AM ALT(SGPT)-36 AST(SGOT)-28 CK(CPK)-39 ALK
PHOS-94 TOT BILI-0.5
[**2152-12-6**] 04:36AM LIPASE-21
[**2152-12-6**] 04:36AM cTropnT-<0.01
[**2152-12-6**] 04:36AM CK-MB-NotDone
[**2152-12-6**] 04:36AM CALCIUM-8.4 MAGNESIUM-2.4
[**2152-12-6**] 04:36AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2152-12-6**] 04:32AM TYPE-[**Last Name (un) **] RATES-/14 TIDAL VOL-500 O2-100
PO2-71* PCO2-56* PH-7.26* TOTAL CO2-26 BASE XS--2 AADO2-595 REQ
O2-96 -ASSIST/CON INTUBATED-INTUBATED
CHEST (PORTABLE AP) [**2152-12-7**] 4:21 AM
CHEST (PORTABLE AP)
Reason: Please eval for interval change
[**Hospital 93**] MEDICAL CONDITION:
36 year old man found unresponsive after drug ingestion.
Intubated.
REASON FOR THIS EXAMINATION:
Please eval for interval change
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Patient found unresponsive after drug
ingestion.
Comparison is made to prior study performed a day earlier.
Patient has been extubated. Cardiomediastinal contour is normal.
There has been almost complete resolution of the opacities
described in the left upper lobe and left lower lobe, a faint
opacity remains in the left upper lobe, there is no pneumothorax
or sizable pleural effusions. Note is made that the left lateral
CP angle was not included on the film.
CHEST (PORTABLE AP) [**2152-12-6**] 3:36 AM
CHEST (PORTABLE AP)
Reason: Evaluate ETT placement, evaluate for intrathoracic
pathology
[**Hospital 93**] MEDICAL CONDITION:
36 year old man found unresponsive after drug ingestion.
Intubated en route to hospital.
REASON FOR THIS EXAMINATION:
Evaluate ETT placement, evaluate for intrathoracic pathology.
HISTORY: Drug OD status post intubation.
No prior comparison exams are available.
SUPINE PORTABLE CHEST RADIOGRAPH
FINDINGS: Ill-defined opacity is noted in the retrocardiac
region, causing slight obscuration of the left hemidiaphragm, as
well as the left upper lung zone. Remaining lungs appear clear
with overall exam somewhat limited due to low lung volumes. The
hilar contours appear slightly prominent, likely related to low
lung volumes and bedside technique. No evidence of pneumothorax,
pulmonary edema, or large effusion. Endotracheal tube terminates
4.5 cm from the carina and orogastric tube tip can be traced as
distal as the gastroesophageal junction.
IMPRESSION:
1. Retrocardiac consolidation with air bronchograms, and
probable left upper zone opacity. Likely infectious, and
aspiration-related. Radiographic followup is recommended.
2. Appropriately positioned endotracheal tube. Nasogastric tube
appears to terminate at the GE junction. Advancement is
recommended.
Brief Hospital Course:
.
#Clonidine Overdose: Patient reportedly ingested 30-50 pills of
Clonidine and 20 pills of SOMA. The patient was initially given
Charcoal in the ED and received Atropine for bradycardia. He
was intubated for airway protection. Clonidine overdose may
cause hypertension and bradycardia followed by hypotension, thus
an A-line was placed for BP monitoring. Poison
control/toxicology was consulted. He had an episode of HTN and
bradycardia thought to be secondary to rebound from teh
Clonidine. He was given hydralazine for BP control given his
reflex hypertension. Atropine was at the beside given his
reflex bradycardia but was not used (HR was 30's to 40's
initially). On day 2 in the MICU his BP normalized and his HR
increased to the 50'[**05**] range. The patient was subsequently felt
to be stable and transferred to the floor. On the floor, the
patients vitals remained stable. A repeat EKG did not show any
changes. No further intervention was needed at that point.
.
#Leukocytosis-Originally thought to be secondary to a stress
reaction after the overdose. A CXR and U/A did not show any
evidence of infection. WBC improved on its own. No further
intervention taken.
.
#Suicide attempt/depression: Patient was evaluated by psychiatry
and social work. A formal psychiatric diagnosis was not made
and pharmacologic agents were not started given the above
overdose. Pt had 2 Code purples on [**12-10**] for extreme agitation
and violent behavior. He was upset because he was not allowed to
smoke, and subsequently broke the end of the bed by kicing it as
well as taking a butter knife and cutting up the mattress. He
received PO Zyprexa and Ativan in response to this episode. In
adiiton, after this initial incident, he was asked not to leave
his room which further agitated him. He then threw the phone at
the wall and was threatening to all those who came in the room.
He broke a second bed by kicking the end off. Security was
called during both incidents. After the 2nd incident, he was
ordered for 24 hour security monitoring and started in Zyprexa
2.5mg TID per psychiatry recommendations. He was ordered for a
safe tray, all objects were removed from his room that could be
harmful, and he had zyprexa and ativan for any further
agitation. Pt was discharged directly to an inpatient
psychiatric unit for further care. Of note, just before time
of discharge patient was found to be tachycardic to the 120s and
pt was getting increasingly agitated and frustrated with staff
and with discharge procedures. He subsequently attempted to
punch a security officer. After discussing with psychiatry,
patient calmed down and received PO zyprexa and Ativan before
leaving.
.
#Asthma: Patient was continued on his home inhalers prn.
.
#HTN: Pt was taken off his home CLonidine medication given the
overdose. His BP remained stable once on the floor. The
medication was not resumed on discharge because it was felt
medically unnecessary. .
.
#DM2: Patient was recently diagnosed with DM and is currently
diet controlled at home. He was monitored with finger sticks
QID and an insulin sliding scale was in place. He was maintained
on a diabetic diet.
================================================
Medications on Admission:
unknown but then patient told us after extubation:
advair 500/50
singulari 10mg daily
albuterol
flovent
clonidine 0.2mg [**Hospital1 **]
prednisone 20mg daily
soma
lortab
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] PRN as needed for
shortness of breath or wheezing.
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TWO times a
day: per MOST RECENT [**Hospital1 18**] psychiatry service notes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1680**] Hospital - [**Location (un) 538**]
Discharge Diagnosis:
Depression
Suicide Attempt
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for overdosing on clonidine
and soma in a suicide attempt. You were initially admitted to
the intensive care unit for close monitoring. You were intubated
initially monitor you closely but subsequently extubated. You
were medically stable since then. You were evaluatd by
psychiatry who feels you were still at risk for injuring
yourself. They recommended further care at an inpatient
psychiatric facility. You will be discharged to a facility for
close monitoring.
You were started on a medication called Protonix which is to
help your reflux symptoms. You will need to take this everyday.
Your Clonidine was held because your Blood pressure was stable
during the hospital and there was concern that you could
overdose again.
Followup Instructions:
Please follow up with with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 6585**](orthopedic NP) at
[**Telephone/Fax (1) **] after discharge.
You will need to follow up with psychiatry per their
recommendations.
ICD9 Codes: 4019, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4280
} | Medical Text: Admission Date: [**2129-8-17**] Discharge Date: [**2129-8-25**]
Date of Birth: [**2077-5-13**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Found unresponsive by family
Major Surgical or Invasive Procedure:
Bilateral myringotomies
History of Present Illness:
52 year old male w/ 2 week hx of fevers, ear pain, and cold
symptoms, presented with acute mental status change, found to
have mastoiditis on CT, and confirmed to have strep pneumo
meningitis.
Patient history was obtained primarily from family. Family notes
that the patient initially had a head cold that was intermittent
for a few weeks and then developed increasing ear pain and
fatigue for the past week. 2 days PTA, he became progressively
lethargic. He presented to his PCP 1 day PTA, who gave him a
prescription for azithromycin. The patient was found the next
day, [**2129-8-16**] at 8PM, to be unresponsive by family members after
attempting to wake him from a nap. He was taken to [**Hospital 8641**]
hospital, where he was given a few doses of antibiotics, and
subsequently transferred to [**Hospital1 18**] after being stabilized and
intubated.
In the ED, initial vs were: T 105 P 73 BP 120/63. U/A and blood
cultures were drawn. U/A was negative. Head CT in the ED was
concerning for bilateral mastoiditis and pneumocephalus on the
left. Neurosurgery was consulted, but they did not recommend
surgical intervention. Patient underwent LP which demonstrated
findings consistent with bacterial meningitis. Of note, patient
was intermittently hypotensive and bradycardic during ED stay,
and EKG demonstrated interventricular conduction delay.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. Hypertension
2. History of Substance abuse
3. Right ear infection - started approx 6 months ago. Treated
with prolonged antibiotics. Subsequent hearing loss on right.
Social History:
Patient with grown son and girlfriend. [**Name (NI) 1403**] as plumber.
- Tobacco: current smoker. smokes 20 cigars/day. lifetime smoker
- Alcohol: none recently
- Illicits: history of addiction to oxycodone. Family denies h/o
IVDU. They believe he has been sober for last 1.5 years.
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
General: intubated and sedated, no witdrawal to pain
HEENT: pupils pinpoint, minimally reactive, sclera anicteric,
MMM, oropharynx clear, unable to discern if ears tender. Right
ear and mastoid process erythematous, difficult internal ear
exam, left ear canal mildly erythematous, no pus, unable to
fully evaluate TM, right TM with possible retraction and whitish
scarring.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, hypoactive
bowel sounds, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: feet cool but arms warm & well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Pertinent Results:
Admission Labs:
[**2129-8-17**] 12:39AM BLOOD WBC-29.2* RBC-4.91 Hgb-14.2 Hct-40.7
MCV-83 MCH-29.0 MCHC-35.0 RDW-14.2 Plt Ct-218
[**2129-8-17**] 12:39AM BLOOD Neuts-87* Bands-5 Lymphs-1* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2129-8-17**] 12:39AM BLOOD PT-15.0* PTT-23.8 INR(PT)-1.3*
[**2129-8-17**] 06:35AM BLOOD Fibrino-740*
[**2129-8-17**] 12:39AM BLOOD Glucose-160* UreaN-12 Creat-0.8 Na-141
K-3.1* Cl-105 HCO3-25 AnGap-14
[**2129-8-17**] 06:35AM BLOOD Albumin-3.3* Calcium-7.8* Phos-2.6*
Mg-1.8
[**2129-8-17**] 06:35AM BLOOD ALT-33 AST-31 LD(LDH)-228 AlkPhos-116
TotBili-0.6
[**2129-8-17**] 12:39AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2129-8-17**] 01:39AM BLOOD Type-ART Rates-/20 Tidal V-500 FiO2-100
pO2-164* pCO2-45 pH-7.38 calTCO2-28 Base XS-1 AADO2-526 REQ
O2-85 -ASSIST/CON Intubat-INTUBATED Comment-TRAUMA
[**2129-8-17**] 12:38AM BLOOD Glucose-155* Lactate-2.0 Na-141 K-3.2*
Cl-104 calHCO3-22
[**2129-8-17**] 3:15 am CSF;SPINAL FLUID
GRAM STAIN (Final [**2129-8-17**]):
THIS IS A CORRECTED REPORT [**2129-8-17**] 7:15AM.
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 87111**] ([**2129-8-17**] AT 7:10AM).
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
FLUID CULTURE (Preliminary):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 2:15 PM ON [**2129-8-18**].
STREPTOCOCCUS PNEUMONIAE. RARE GROWTH.
MEROPENEM Sensitivity testing performed by Etest.
= 0.023MCG/ML.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE-----------<=0.06 S
MEROPENEM------------- S
PENICILLIN G----------<=0.06 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2129-8-17**] 4:27 pm SWAB Source: R ear.
GRAM STAIN (Final [**2129-8-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
[**2129-8-17**] 4:28 pm SWAB Source: L ear.
GRAM STAIN (Final [**2129-8-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
[**2129-8-18**] 7:44 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2129-8-18**]):
[**10-10**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
Head CT [**8-17**]:
1. Areas of pneumocephalus overlying the left hemisphere, likely
from
mastoiditis on the left. Areas of likely bony erosion noted of
the left
temporal bone. MRI could be performed for further
characterization of
intracranial involvement.
2. Opacification of right mastoid air cells also concerning for
mastoiditis.
Head CT of temporal bone and sinuses [**8-17**]:
1. Multi-sinus soft tissue changes.
2. Nasal septal defect secondary to prior surgery or mechanical
perforation.
Clinical correlation required.
3. Bilateral mastoiditis.
4. Bony erosion of the superior margin of the left temporal bone
secondary to mastoiditis.
MRI/MRV of brain [**8-17**]:
1. No evidence of brain abscess or cerebritis.
2. Abnormal signal in the sulci and fluid-fluid levels in the
ventricles are consistent with clinical diagnosis of meningitis.
3. No evidence of filling defects in the post-gadolinium images
within the
superior sagittal sinus or transverse sinuses to indicate sinus
thrombosis.
4. Extensive soft tissue changes in both mastoid air cells, with
bony
irregularity seen both on CT and MRI along the temporal bone,
suggestive of bony erosions which could result in intracranial
extension of mastoid
infection. Findings also indicate bilateral mastoiditis.
1. No evidence of sinus thrombosis.
CT Head [**2129-8-20**]:
1. Interval resolution of tiny left-sided pneumocephalus.
2. Persistent bilateral mastoiditis.
3. Unchanged tiny mucous retention cyst in the left maxillary
sinus.
4. Interval resolution of right maxillary sinus mucosal
thickening.
ECHO, 2-D [**2129-8-19**]: No obvious vegetations
Brief Hospital Course:
52 year-old man transferred to [**Hospital1 18**] from [**Hospital 8641**] hospital in NH.
He was started on broad spectrum antibiotics upon arrival to
[**Hospital1 18**] and transferred to the ICU. He was intubated for a day,
and then self-extubated. His mental status was initially fairly
poor, but improved gradually over his 8 day stay. He was
markedly improved by the time of discharge. He had extensive
physical therapy while on the general medicine floor, and
progressed to the point where PT beleived he was safe for
discharge without services, other than IV VNA. There were no
significant events that occurred during his hospitalization. He
was set up for followup by ENT, ID, and his family assured us
that he would find a new PCP to visit with in the next [**12-18**]
weeks.
PROBLEM LIST:
1. Otitis media / Mastoiditis / Pneumococcal Meningitis/
Bacteremia with Strep pneumoniae: CSF c/w bacterial meningitis.
CSF Cx +Strep pneumoniae. Head CT concerning for B mastoiditis.
NSURG said no NSURG interventions indicated. ENT performed B
myringotomies which showed suppurative drainage. ID recommended
broad-spectrum coverage, which was eventually weaned down to 2
gm IV ceftriaxone Q12H. Of note, patient did receive
dexamethasone for four days. Repeat head CT done after transfer
to general floor showed resolved pneumocephalus. ABX course
will be Ceftriaxone through [**2129-8-31**], then Augmentin PO x 2wks.
2. Hypertension: Continued on home Diovan. Amlodipine was added
to further optimize BP control.
3. Opiod-dependence: Patient's suboxone therapy was withheld
since admission to [**Hospital1 18**], and the patient did not seem to
experience any severe signs of withdrawal. He and his family
expressed desire to stop suboxone therapy, and therefore, he was
not restarted on the therapy upon discharge. He will follow up
with his PCP to determine if there is any need in the future.
4. Encephalopathy from CNS infection and pneumocephalus: Patient
improved daily in his cognition. By the day of discharge he was
able to recite 10 of 12 months of the year backwards (missing 2
months).
Medications on Admission:
1. Suboxone 8mg tabs, 2 tabs PO daily
2. Diovan 320 mg PO Daily
3. Zithromax
4. CTX (from outside hospital)
5. Vanco (from outside hospital)
Discharge Medications:
1. CeftriaXONE 2 gm IV Q12H
2. Ceftriaxone 2 gram Recon Soln Sig: Two (2) grams Intravenous
twice a day for 6 days: last dose PM [**2129-8-31**].
Disp:*13 bags* Refills:*0*
3. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary Diagnoses:
1. Bacterial Meningitis
2. Bilateral Mastoiditis
3. Bacteremia
4. Encephalopathy from meningitis and pneumocephalus
Secondary Diagnoses:
1. Hypertension
2. Opiod-dependence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to the hospital with an infection in your brain called
meningitis. You were brought to the outside hospital by your
family and you were started on antibiotics. You were transferred
from an outside hospital to [**Hospital1 18**] and went straight to the
Intensive Care Unit. You stayed here for a few days and were
eventually transferred to the general floor. You received a
special intravenous line in your left arm for antibiotic
administration. You worked with physical therapy while on the
general floor and were eventually cleared for discharge home
with visiting nursing services. You were also started on a new
blood pressure medication (called AMLODIPINE) in addition to
your home medication, Diovan.
Medications added on this admission:
1. Ceftriaxone 2gm via IV twice a day
2. Amlodipine 10 mg every day
3. Future medication ** Augmentin
You will continue the ceftriaxone for a total 14 day course,
last dose to be given on [**2129-8-31**]. Then you will need to start
taking Augmentin for another 2 week course. Please start this
medication on [**2129-9-1**] and end on [**2129-9-15**].
Please go to your follow up appointments with ENT and ID (see
below). Please also schedule an appointmwnt with your new
Primary Care doctor in the next 1 - 2 weeks.
Followup Instructions:
You have appointment with the following providers:
Ear, Nose, and Throat
Name: [**Last Name (LF) 3878**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: [**Location (un) 3881**],[**Apartment Address(1) 3882**], [**Location (un) **],[**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 2349**]
Appt: [**8-30**] at 1pm
Note: This appt is in our [**Location (un) 55**] office out side of the
hospital. Call the office with any questions.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2129-9-20**] at 10:50 AM [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You stated that you do not have a primary care provider. [**Name10 (NameIs) **]
should find a primary care provider and plan to see him/her in
the the next 1 to 2 weeks. Please have him or her call [**Hospital1 **] to have your records faxed to them prior to
your appointment.
ICD9 Codes: 7907, 3051, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4281
} | Medical Text: Admission Date: [**2164-1-10**] Discharge Date: [**2164-1-17**]
Date of Birth: [**2105-10-26**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Reglan / Quinine Sulfate / Codeine
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
syncope and BRBPR
Major Surgical or Invasive Procedure:
Upper endoscopy and colonoscopy
History of Present Illness:
HPI: 58 diabetic female with DVT in [**10-17**], sarcoid and MS
presents with w/ melena turning into BRBPR. Pt was found by
daughter on the toilet unresponsive without blood on the toilet.
There was no witnessed seizure activitiy. EMS found SBP to be in
the 80s. HR:90s. In ER, SBP of 140s (s/p 250 cc NS total,
including in ambulance). INR of 7. Hct:41 NG Lavage without
blood. Given 6units of FFP and Vitamin K and transferred to ICU.
In the ED she also developed arm twitching which resolved with
administration of morphine for pain controll.
Past Medical History:
1. MS, diagnosed [**2150**], presented with generalized weakness,
blurred left eye vision. Never had LP, but apparently had MRI
with multiple [**Male First Name (un) 4746**] lesions. Weelchair bound since [**2151**]. Never
treated with steroids
2. Stroke in [**2152**], p/w speech difficulty and L-sided weakness-no
residual deficit
3. Spinal cord compression s/p C3-7 and T2-11 laminectomies and
fusion, with residual paraparesis and absent sensation bilat LE
4. Seizures (no motor component, "staring spells"), ~1-2x/week
5. Asthma
6. DM type II, on insulin, with ? diabetic neuropathy
7. HTN
8. Hypercholesterolemia
9. Sarcoidosis-dx'd via LN bx
10. Uterine CA, s/p radical hysterectomy
11. DVT, treated with coumadin.
Social History:
lives with daughter, former alcoholic, sober since 36yo when
pregnant, 80py tobacco quit at 36yo, unable to walk but uses
wheelchair. Retired RN at [**Hospital1 756**]. *DNR/DNI*
Family History:
DM, CAD, HTN in multiple relatives. [**Name (NI) **] tumor in mother. no
DVT/PE
Physical Exam:
98.4, 145/76, 90 regular, 18, 97% RA
Gen: Obese. NAD. A/O x 3
HEENT: PEARLA. EOMI. OP: dry mm.
Neck: Obese. Unable to test ROM as s/p laminectomy
CV: Distant heart sounds. S1>S2. No murmurs.
Lungs: CTA b/l. Poor effort. No wheezes.
Abd: Obese. Soft. Mild TTP over LLQ without rebound or guarding.
Multiple hemmorhoids. Stool grossly bloody. Guaiac +
Back: Stage 1 decub over sacrum
Ext: 3+ edema on Right. 1+ edema on left. Normal cap refill.
Neuro: Motor [**6-16**] at flex/ex in upper ext but 0/5 distal to hips
b/l. Sensation diminished below waistline b/l. CN II-XII GI
(aside from mild ptosis b/l and nystagmus with horizontal gaze
~7 beats). Reflexes absent in patella. Normal babinski reflex.
Non-ambulatory.
Pertinent Results:
140 102 15
-------------<189
4.1 25 0.7
Carbamaz: 8.0
WBC: 17.6 Hct:41.4 Plt:239
(N:90.8 Band:0 L:6.4 M:2.5 E:0.1 Bas:0.2)
PT: 30.5 PTT: 38.7 INR: 7.0
Serum and urine tox (-)
U/A: (-) Nit, (-) LE. (-) Bld 0-2 WBC, 0 RBC. 0 Epi.
[**2164-1-10**] 03:35AM BLOOD WBC-19.1*# RBC-4.74 Hgb-14.4 Hct-42.3
MCV-89 MCH-30.4 MCHC-34.0 RDW-13.8 Plt Ct-241
[**2164-1-10**] 12:40PM BLOOD WBC-13.9* RBC-3.15*# Hgb-9.7*# Hct-27.2*#
MCV-86 MCH-30.9 MCHC-35.8* RDW-14.1 Plt Ct-171
[**2164-1-11**] 03:30AM BLOOD WBC-15.3* RBC-3.44* Hgb-10.6* Hct-30.1*
MCV-87 MCH-30.8 MCHC-35.2* RDW-14.3 Plt Ct-186
[**2164-1-13**] 03:10PM BLOOD Hct-30.5*
[**2164-1-17**] 06:18AM BLOOD WBC-11.0 RBC-3.84* Hgb-11.7* Hct-32.8*
MCV-85 MCH-30.5 MCHC-35.7* RDW-14.3 Plt Ct-334
[**2164-1-16**] 06:22AM BLOOD WBC-12.1* RBC-3.30* Hgb-10.1* Hct-28.4*
MCV-86 MCH-30.5 MCHC-35.4* RDW-13.9 Plt Ct-306
Colonscopy-cecal lipoma and friable mucosa at the sigmoid
flexure which was biopsied
CT abdomen-1. Wall thickening and stranding of the pericolonic
fat around the splenic flexure. Distribution is consistent with
ischemic colitis. However, other forms of colitis including
infectious or inflammatory colitis cannot be excluded based on
CT scan.
2. Probable tiny left adrenal adenoma.
3. Enlarge left paraaortic lymph nodes measuring up to 11 mm.
They are increased when compared to [**2160**]. Clinical correlation
recommended.
4. Severe degenerative changes of the thoracic and lumbar spine
with severe spinal stenosis at multiple levels as described
above. Clinical correlation is recommended.
[**2164-1-17**] 06:18AM BLOOD Plt Ct-334
[**2164-1-17**] 06:18AM BLOOD PT-14.6* PTT-87.0* INR(PT)-1.5
[**2164-1-16**] 04:10PM BLOOD PT-13.9* PTT-67.6* INR(PT)-1.3
[**2164-1-10**] 12:40PM BLOOD PT-19.9* PTT-36.8* INR(PT)-2.8
[**2164-1-10**] 03:35AM BLOOD Plt Smr-NORMAL Plt Ct-241
[**2164-1-10**] 05:20AM BLOOD PT-30.5* PTT-38.7* INR(PT)-7.0
[**2164-1-17**] 06:18AM BLOOD Glucose-157* UreaN-7 Creat-0.5 Na-143
K-3.9 Cl-106 HCO3-25 AnGap-16
[**2164-1-12**] 02:47AM BLOOD Glucose-130* UreaN-7 Creat-0.5 Na-139
K-3.7 Cl-104 HCO3-26 AnGap-13
[**2164-1-10**] 03:35AM BLOOD Glucose-172* UreaN-17 Creat-0.8 Na-138
K-3.7 Cl-102 HCO3-21* AnGap-19
[**2164-1-16**] 04:59PM BLOOD Calcium-8.4 Phos-2.4* Mg-1.9
Brief Hospital Course:
GI bleed-In the MICU the pt had a transfusion of total 6 units
of FFP, Hct dropped to 27.5 subsequently increased to 33.5. INR
was lowered to 1.8. Stable hemodynamics. EGD on [**2164-1-11**] showed
mild gastritis and duodenitis. Colonscopy on [**1-13**] tiny polyps
in the distal rectum, lipoma in the cecum, nodular infiltrate
with purplish, edematous, and friable mucosa in the left colon
near the splenic flexure from 55 to 45 cm. Erythematous and
congested mucosa with patchy ulcerations from 45 to 25 cm.
Biopsy was taken. Pt was transfered to the floor for further
management.
In the setting of supratherapeutic INR: Unclear source.
Colonoscopy showed friable mucosa in splenic flexure with
stranding on CT. Due to history of hypotensive episode and
distribution is vascular watershed area this was thought to be
due to ischemic colitis. Contributing factor was INR 7.0. Hct
has been remained stable for 72h but was transfused 1 U PRBC's
due to feeilng of weakness on [**2164-1-16**] with apropriate rise in
Hct. Biopsies from colonoscopy will need to be followed up and
relayed to the the patient likely via her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
.
# Elevated INR: Has been on couamdin for DVT and plavix for CVA.
No DVT in RLE on doppler but was a suboptimal study. Since
ischemic bowel was not thought to be due to embolic source but
pt had hx of TIA and DVT with PE heparin was starting with goal
PTT of 50-70 until coumadin was titrated to INR 2.0-2.2 with
plan for undershoot since history of GIB. After approval from GI
plavix was also restarted.
.
# Tachycardia: Intially thought to be due to GI bleed although
has been chronic. CTA in past have been negative showing no PRE
as cause. She had one episone of an asymptomatic 10 beat run of
NSVT on [**2164-1-16**]. She remained hypertensive and was started on
low dose metoprolol at 25mg [**Hospital1 **]. . WBC normal and afebrile today
- unlikely infection.
.
# Diabetes: Long-standing. On NPH and ISS with FS remaining
mostly in the 130-180 range. Continued ISS and [**2-13**] NPH as NPO.
.
# MS: No active disease per patient. Not on steroids or
immunosuppresants.
.
# Seizure history: on tegretol and Levatiracetam. CT head w/o
bleed. EEG was negative for epileptiform activity. She was seen
by neurology who witness arm twitch and felt that it was due to
seizure activity. Per neurology she was started on Keppra which
was titrated up to 1000mg [**Hospital1 **] with plan to titrate of the
carbamazepine with 100mg qid for 5 days then 100mg [**Hospital1 **] for 5
days and then discontinue. pt will follow up with Dr [**Last Name (STitle) 100771**].
# Recent DVT - Had been on coumadin. No clinical evidence of PE
at present, although she had concerning tachycardia and low
grade fever. RLE u/s was negative but LLE not done due to
patient noncompliance. Coumadin restarted as above with heparin
bridge on day of discharge heparin was at 1900 u/hr with stable
PTT.
.
Medications on Admission:
Plavix 75 daily
Coumadin
Lipitor 40 daily
Tegretol 200 qid
Insulin Regular 25 qAM, 10qPM
Insulin NPH 75 qAM, 35qPM
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Gastrointestinal Bleeding
Diabetes
Seizure Disorder
Paraplegia
Discharge Condition:
Stable Hct and blood pressure.
Discharge Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] within 1 week of leaving the
hospital. Notify your doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**] immediately of black
stool, blood in the stool, nausea, abdominal pain, dizziness,
lightheadedness, headaches, limb shaking or seizures.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] within 1 week of leaving the
hospital for a bloodwork (hematocrit) check.
Please follow-up with Dr. [**Last Name (STitle) **] (neurologist) within 2 weeks
of leaving the hospital.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
ICD9 Codes: 4271, 2720, 3572, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4282
} | Medical Text: Admission Date: [**2198-8-28**] Discharge Date: [**2198-10-11**]
Date of Birth: [**2198-8-28**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **], [**Name2 (NI) **], [**Name2 (NI) **]. 1, was
born at 28 and 4/7 weeks to a 30 year old gravida 1, para 0
mom with prenatal screens. Blood type A positive and antibody
screen negative. RPR nonreactive, rubella immune, hepatitis B
surface antigen negative. GBS status unknown. This was an in
[**Last Name (un) 5153**] fertilization pregnancy, complicated by preterm labor
at 25 weeks and again at 28 weeks with spontaneous rupture of
membranes at that time of triplet 1. Mom was treated with
ampicillin and erythromycin throughout the week prior to
delivery. She was taken for cesarean section secondary to
concern for position of twin 1 secondary to oligo
from prolonged preterm rupture of membranes. Apgar scores
were 6 and 8. He was intubated in the bili room secondary to
worsening respiratory distress. He was taken to the Newborn
Intensive Care Unit for admission and further treatment.
PHYSICAL EXAMINATION: His physical examination upon
admission showed weight of 1560 grams, length was 39.5 cm,
and head circumference 29.5 cm. His examination was notable
for molding of his head and flattened nose secondary to
positioning in utero. His lungs were with coarse breath
sounds bilaterally. His cardiac examination was normal
without murmurs. His abdominal examination was benign and his
anus was patent.
HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: He was intubated and received surfactant. He was
extubated shortly to CPAP which he remained on until he was
weaned to nasal cannula on [**2198-9-2**]. He had been
loaded with caffeine prior to extubation. He has mild apnea and
bradycardia. At the time of discharge, he is stable on RA.
Caffeine was discontinued on DOL #30.
CARDIOVASCULAR: He has had a stable cardiovascular
examination throughout his stay with normal blood pressures
and perfusion and no murmur.
FLUIDS, ELECTROLYTES AND NUTRITION: He was initially NPO
with stable electrolytes and glucose, on parenteral
nutrition. Feeds were initiated and have been increasing. He is
on PO/PG feeds at 150 cc per kg per day of breast milk 26kcal/oz.
His most recent weight was 2640 grams. Last nutrition labs Ca
10.9 PO4 7.1 Alkphos 334
GASTROINTESTINAL: [**Known lastname **] had feeding intolerance in late
[**Month (only) **] and was placed NPO, but radiographs at that time were
normal. Since then feeds have been well-tolerated. He was on
phototherapy for bilirubin that peaked at 8.0.
HEMATOLOGY: His initial hematocrit was 48.1 percent on day
of life 2. He has not received transfusion of blood products.
His most recent Hct on DOL # 10 was 43.8%.
INFECTIOUS DISEASE: He received 48 hours of rule out with
antibiotics. He had initial neutropenia but normalized CBC on
day of life 2 with a total white count of 7.1, 27 polys, 1
band. His antibiotics were discontinued at 48 hours when the
blood culture was negative. He has had no other issues with
sepsis.
NEUROLOGY: He had a head ultrasound on day of life 7 that
revealed bilateral subependymal hemorrhages. Repeat HUS on [**9-27**]
was within normal limits, no hemorrahage, no PVL. His neuro
examination has been normal.
Audiology: Hearing screen not completed at time of discharge.
Opthomology: Eye exam [**2198-10-8**] with immature zone 3. Follow up
required in 3 weeks.
Psychosocial: Parents have been visiting regularly. Much family
support.
Condition at discharge: Stable
Discharge disposition: [**Hospital **] Hospital
Care recommendations: A. Feeding as above. Meds: Iron as above.
Car seat position screening not completed. State screen as above.
Health maintenance: Hep B vaccine administered [**2198-9-27**]. First
state screen within normal limits. Last state screen sent
[**2198-10-9**]. First head u/s on [**2198-9-4**] with bilateral germinal
matrix bleed. Last HUS on [**2198-9-27**] normal.
Pediatrician Dr. [**Last Name (STitle) 3394**]
DISCHARGE DIAGNOSES:
1. Prematurity
2. Triplet gestation.
3. Respiratory distress syndrome.
4. Hyperbilirubinemia.
5. Rule out sepsis.
6. Apnea of Prematurity
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By: Dr. [**First Name4 (NamePattern1) 11709**] [**Last Name (NamePattern1) 41519**]
Updated By: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NNP
MEDQUIST36
D: [**2198-9-6**] 19:28:11
T: [**2198-9-6**] 20:53:50
Job#: [**Job Number 56868**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4283
} | Medical Text: Admission Date: [**2127-1-3**] Discharge Date: [**2127-1-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Here for Carotid Stent Placement
Major Surgical or Invasive Procedure:
Carotid Stent Placement
History of Present Illness:
84 F w/ CAD s/p CABG '[**10**], PCI '[**19**] and '[**23**], s/p MI, afib, AS,
Parkinson's disease, hyperlipidemia who is admitted to the CCU
s/p Left carotid stent. Patient was referred from OSH after
presenting to OSH with acute slurred speech and leg weakness in
[**10-21**]. The patient describes only the speech, but says they told
her she also had the weakness. No numbness, tingling, dizziness,
visual changes, other symptoms. She was admitted to OSH. During
her w/u there, an MRI demonstrated a tiny acute infarct in the
Left parietal cortex. Her L ICA had a 70-90% stenosis (R ICA was
10-20%). She was referred for carotid stent to DR. [**First Name (STitle) **]. She
notes she has not had any recurrent symptoms since [**Month (only) **].
She notes she has been weaker lately and fell last week -- the
fall occurred when she sat on blankets piled on a chair and
slipped off. No LOC, no trauma.
.
Patient had cath today with L ICA 80% ulcerated lesion which was
stented.
.
Past Medical History:
PMH:
1. hyperlipidemia
2. HTN
3. CAD s/p MI, s/p CABG [**2110**] LIMA - LAD, SVG-OM, SVGT-D,
SVG-PDA, s/p PCI in [**2113**] to SVG-PDA, PCI [**6-/2119**] (NQWMI) to
SVG-PDA, and PCI [**8-17**] to LMCA
4. ventral hernia
5. TAH/BSO
6. s/p L TKR
7. s/p R ankle sx
8. hard of hearing
9. depression
10. Prakinsons disease x 10 years
11. atrial fibrillation, not anticoagulated
12. falls
13. severe AS
Social History:
SHx: No tobacco, no etoh. Lives at home with her husband, who is
frail. Has niece who is involved and also has a helper twice a
week. Husband is verbally abusive, but not physically abusive.
.
FHx: NC
Family History:
NC
Physical Exam:
PE on discharge
VS T 97.2 HR (50s-60s) RR 18 99% RA weight 120 BP:
110-130/50s-60s
GEN: thin, elderly, NAD, lying flat
HEENT: PERRL, EOMI, o/p clear
NECK: supple
CV: +S1S2, [**5-22**] sys ejection mur - RUSB radiates to R carotid
LUNG: CTA anteriorly and at bases
ABD: soft, nt, bs+, [**Doctor First Name **] scars
EXT: no edema, DP 2+, PT dopplerable, no bruit
.
Pertinent Results:
Labs: hct 31 (from 41 [**12-23**]) baseline is low 30s
Cr 1.0
K 3.7
.
EKG: NSR 69 bpm, nl axis, LVH, q III, .5 mm depressions in V5-V6
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2127-1-7**] 06:25AM 6.2 3.19* 10.4* 30.6* 96 32.6* 34.0 13.3
69*
[**2127-1-6**] 06:30AM 6.7 3.37* 11.2* 32.3* 96 33.3* 34.8 13.2
75*
[**2127-1-5**] 06:36AM 4.8 3.24* 10.7* 32.3* 100* 33.0* 33.1
13.0 71*
[**2127-1-4**] 07:00AM 4.7 3.42* 11.3* 33.8* 99* 33.2* 33.6 13.0
91
[**2127-1-3**] 03:00PM 4.9 3.31* 10.9* 30.8* 93 33.0* 35.6 13.1
92*
.
SMA7 Glu BUN Cr Na K Cl HCO3 AnGap
[**2127-1-7**] 06:25AM 82 22* 0.9 143 4.3 109* 271 11
[**2127-1-6**] 06:30AM 89 23* 1.0 143 4.3 110* 261 11
[**2127-1-5**] 06:36AM 86 13 0.9 143 4.0 107 291 11
[**2127-1-4**] 07:00AM 75 12 1.0 141 3.7 101 321 12
.
HEMATOLOGIC B12 Folate
[**2127-1-3**] 03:00PM 432 7.9
Chol TG HDL CHOL/HD LDLcalc
[**2127-1-4**] 07:00AM 222* 103 77 2.9 124
.
Catheterization report: This is an 84 yo woman with CAD and PVD
who had a recent stroke and was found to have a 70% stenosis of
the left ICA on MRA. She is now referred for carotid angiography
with potential PTA.
COMMENTS:
1. Access was obtained via the right CFA in a retrograde
fashion.
2. Resting hemodynamics showed central aortic hypertension.
3. Thoracic aorta: Type II arch with moderate diffuse
calcifications.
4. The left vertebral artery was normal and filled the basilar
and
cerebellar arteries without lesions.
5. The right vertebral artery was small and not imaged.
6. The right CCA was normal. The ICA had no significant lesions
and
filled the ipsilateral ACA and MCA without cross-filling.
7. The left CCA was normal. The ICA had an eccentric/ulcerated
80%
lesion and filled the ipsilateral ACA and MCA.
8. Successful stenting of the left ICA with a 6-8 mm AccuLink
stent,
post-dilated to 4.5 mm.
9. The right femoral arteriotomy site was closed with a 6
French
Angioseal.
FINAL DIAGNOSIS:
1. Successful stenting of the left ICA.
Brief Hospital Course:
Course:
1.Neuro: The patient was admitted to step-down s/p carotid
revascularization. ASA, Plavix were initiated with plan for Neo
prn. The pt was not on a statin, so FLP was obtained showing low
lipids. Patient underwent successful catheterization of the L
ICA on [**2127-1-3**].
.
Hypotension: Pt was hypotensive throughout post cath day 1 -
generally in 100's with HR in 50's. Periodically dipping to SBP
70's to 80's temporarily. Boluses of 500cc NS x 2 given with
some response. Pt was tx'd to CCU for possible NeoSynephrine.
Following day started on neosynephrine gtt (low dose). weaned
off overnight, however at night SBP~88-90 with MAP near 60,
given 250 cc bolus with good response.
.
Cardiac:
Ischemia: No acute evidence of ischemia. Cont'd. ASA. Not on
bbl, ace, or statin as she could not tolerate asa for GI reasons
and had not had HTN. Held on BB and ACE given low BP at this
hospitalization. Given severity of CAD and hx of LMCA PCI in '[**23**]
the goal was to avoid further Neosynephrine.
.
Pump: Unknown EF, but thought to be low given multiple ischemic
events and CABG. Euvolemic. Daily lasix was held given low spbs.
.
Rhythm: Sinus on tele at this hospitalization, though there is a
known h/o Afib. NO anticoagulation -- thought to be b/c of
falls. Cont'd. ASA. Tele.
.
Valve: H/o AS, severe per note. Preload dependent - this may
have played into her low BP post-procedure. She had a stable
loud SEM over her RUSB.
.
Parkinson's Disease: Cont'd. sinemet/requip and the patient did
quite well. Masked facies were prominent and there were
occasional choreoathetoid movements, however she had very little
tremor and only mild bradykinesia during this hospitalization.
She was able to ambulate with the assistance of a walker.
.
Depression: Celexa/remeron were continued.
.
Groin hematoma: The pt developed a small groin hematoma after
her procedure that was marked and was not found to be expanding.
THe fellow examined her hematoma and she was followed
clinically. HCT dropped from 41-30 from [**12-23**] - [**1-3**], though the
[**Location (un) 1131**] from [**12-23**] was likely spurious as her baseline was
generally in the low 30's.
.
PPX: SQ hep tid, zantac were initiated and continued throughout
the hospitalization.
.
Full code
.
Social: Before discharge, patient informed RN that she felt
verbally abused by her husband at home and that they no longer
communicate very much. She denied any physical harm. Niece is
involved in her care and well being.
.
PAtient was AAOx3, communicative and ambulatory and taking PO on
discharge.
Discussed discharge with Dr. [**First Name (STitle) **] who agrees with the plan. He
requests that he be called regarding her blood pressures and to
be informed regarding any significant events that come up. His #
is [**Telephone/Fax (1) 920**].
Medications on Admission:
Meds at home: Lasix 80 qd, ditropan 10 tid, imdur 60 qd, mvi,
cal/D, sinemet 25/100 qid and sinemet CR 25/100 qhs, remeron 15
qd, zantac 150 qd, feso4 325, kdur 20 qd, plavix 75, asa 325
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
4. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig:
One (1) Tablet PO HS (at bedtime).
5. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO QAM
(once a day (in the morning)).
6. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Carotid Artery Stenosis (Left)
Discharge Condition:
AAOx3
Communicating appropriately
No chest pain, or shortness of breath.
Ambulatory w/ aid of walker
Discharge Instructions:
Please keep blood pressure between 120-160. Please increase her
beta blocker for tighter blood pressure control (keep HR>50).
Would avoid vasodilators such as imdur and norvasc.
.
Please call Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 920**] with daily blood
pressure readings.
.
Please call your primary care physician or Dr. [**First Name (STitle) **] in the
event that you experience any chest pain, shortness of breath,
any new changes in vision or new weakness. Also, if there are
any other concerning symptoms, please call or go to the
emergency room.
Followup Instructions:
You have the following premade appointments.
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-3-11**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2127-3-11**] 2:00
.
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-7-29**]
1:30
Completed by:[**2127-1-7**]
ICD9 Codes: 4241, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4284
} | Medical Text: Admission Date: [**2147-4-7**] Discharge Date: [**2147-4-14**]
Date of Birth: [**2072-7-4**] Sex: F
Service: NEUROSURGERY
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
SAH
Major Surgical or Invasive Procedure:
Cerebral Angiogram with coiling of Left MCA aneurysm
Left hemicraniotomy
R frontal EVD
Cerebral Angiogram with angioplasty
History of Present Illness:
74f who was diagnosed with L MCA aneurysm one week ago.
Today had complaints of headache and became aphasic. Taken to
OSH
where her MS decreased and she was intubated. CT head showed SAH
and she was transferred to [**Hospital1 18**] for further evaluation. On
transport her left pupil became fixed and dilated. She received
3% NaCl. Her SBP was labile and noted to be 200 on transport.
Past Medical History:
HTN, COPD
Social History:
Positive Tobacco use, unknown amount
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 5 [**Doctor Last Name **]: IV GCS 3 E: 1 V: 1
Motor 1
T: 99.0 BP: 164/88 HR: 56 R 15 O2Sats 100%
Gen: Intubated. Not sedated. No eye opening. No commands. No
movement in upper or lower extremities to noxious.
HEENT: Pupils: On arrival L 8mm NR R 3mm reactive. 2nd exam
after
mannitol both pupils 3mm and reactive
Patient Passed at 1O:04 am on [**4-14**]
Pertinent Results:
[**4-7**] CXR: IMPRESSION:
1. Endotracheal tube in proper position.
2. Nasogastric tube with side port at the gastroesophageal
junction. Could be advanced several centimeters for proper
positioning.
[**4-7**] CTA Head: IMPRESSION:
1. Bilobed 11 x 7 mm aneurysm arising from the left M1/M2
junction, the
likely source of the large left frontal intraparenchymal
hematoma with
extensive neighboring subarachnoid and subdural blood products.
2. Moderate right word subfalcine herniation.
3. Moderate suprasellar and mild quadrigeminal cistern
effacement, concerning for early uncal/transtentorial
herniation.
4. Right frontal approach ventriculostomy catheter terminating
in the
approximate region of the third ventricle.
[**4-7**] Cerebral Angiogram: IMPRESSION: [**Known firstname **] [**Known lastname **] underwent
cerebral angiography, which revealed an aneurysm of the left
middle cerebral artery that was coiled subtotally. Since her
exam was poor, at some point, she will be brought back to finish
this if she makes a satisfactory recovery.
[**4-7**] CXR: An NG tube is present, the tip extends beneath the
diaphragm and overlies the lower mid abdomen, question within
distended stomach. The lung bases are grossly clear. The
sideport lies in the left mid abdomen, again, likely in a
distended stomach. Right upper quadrant surgical clips noted.
[**4-7**] CT Head: IMPRESSION:
1. Interval left frontal craniectomy with improved but
persistent rightward shift of normally midline structures and
mild effacement of the basal cisterns on the left.
2. Increased density of large left parenchymal and extensive
bilateral
subarachnoid hemorrhage, likely secondary to interval
administration of
contrast and additional extravasation.
3. External ventricular drain catheter terminates below the
left lateral
ventricle, with tip possibly outside the ventricular system.
[**4-8**] EEG: *** pending
[**4-8**] CT Head: IMPRESSION: Status post left frontal craniectomy
and ventriculostomy drain retraction, stable appearance of left
intraparenchymal and bilateral subarachnoid hemorrhage with mild
improvement of midline shift, but persisting sulcal and
ventricular effacement.
[**4-9**] EEG: ***pending
[**4-9**] CXR: FINDINGS: Endotracheal tube has been advanced
slightly, now terminating about 2.5 cm above the carina.
Central venous catheter has apparently been slightly withdrawn
since previous study with tip now at or just below the
cavoatrial junction. Cardiomediastinal contours are within
normal limits. Appearance of the lungs is essentially unchanged
except for slight obscuration of a small portion of the
peripheral right hemidiaphragm. It is uncertain whether this
represents a focal area of right basilar atelectasis or
consolidation, or if it reflects a newly developed small right
pleural effusion. Attention to this area on followup radiograph
may be helpful in this regard.
[**4-9**] CT Head: IMPRESSION: Status post left frontal craniectomy
and ventriculostomy with persistent large parenchymal and
subarachnoid hemorrhage causing increased hmass effect. The tip
of the EVD in the frontal [**Doctor Last Name 534**] of the left lateral ventricle,
which is being compressed by adjacent mass effect.
[**4-10**] EEG: ***pending
[**4-10**] Echo: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Doppler parameters are
indeterminate for left ventricular diastolic function. There is
no ventricular septal defect. 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. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. indeterminate diastolic function. No pathologic
valvular abnormalities.
[**4-10**] CXR: FINDINGS: As compared to the previous radiograph,
there is no relevant change. Monitoring and support devices are
constant. No change in appearance of the lung parenchyma and
the cardiac silhouette. A previously seen blunting of the
lateral aspect of the right diaphragmatic contour is no longer
present.
[**4-11**] EEG: IMPRESSION: This is an abnormal continuous ICU
monitoring study because of severe diffuse encephalopathy and
interhemispheric asymmetry
suggesting greater left hemisphere pathology and particularly
greater
left mid to posterior temporal pathology. There continues to be
multifocal independent interictal epileptic activity
predominantly over
the right central and temporal regions with rare discharges over
the
left hemisphere. Compared to the prior day's recording, there is
worsening encephalopathy and worsening left temporal cerebral
dysfunction noted in this recording.
[**4-11**] CXR: FINDINGS: In comparison with study of [**4-10**], there is
poor definition of the hemidiaphragms, especially on the right,
consistent with small layering effusions and compressive
atelectasis at the bases. No evidence of vascular congestion.
The tip of the endotracheal tube measures approximately 4.8 cm
above the carina. Nasogastric tube and left central catheter
are unchanged in position.
[**4-11**] CTA: IMPRESSION:
1. Minimal vasospasm of the M1 segment of the left MCA proximal
to the coil. The distal opercular branches are patent. There
is no vascular occlusion.
2. Stable intraparenchymal and subarachnoid hemorrhage
involving the left
temporal and frontal lobes with no change in the mass effect
from the prior
study. No evidence of herniation.
[**4-12**] EEG: IMPRESSION: This is an abnormal continuous ICU
monitoring study because of a severe diffuse encephalopathy with
a burst and burst suppressive pattern and asymmetric attenuation
of voltage over the left temporal region and, to a lesser
degree, left central region. There were no clear electrographic
seizures and only a few potential interictal
discharges identified.
[**4-12**] CXR: The ET tube tip is 4.3 cm above the carina. The NG
tube tip is in the stomach. Heart size and mediastinum are
unremarkable. There is small amount of bilateral pleural
effusion, unchanged since the prior study with no evidence of
interval development of pneumothorax or pulmonary edema. Right
midline tip is at the level of mid portion of right subclavian
artery.
[**4-12**] CT Head: Little change in comparison to prior study from
the day before with stable appearance of large left
fronto-temporal intraparenchymal hemorrhage and foci of
subarachnoid hemorrhage with continued rightward mass effect.
Continued followup is recommended.
[**4-13**] CXR: As compared to the previous radiograph, there is no
relevant
change. The monitoring and support devices are constant.
Normal size of the cardiac silhouette. No overt pulmonary
edema. No larger pleural effusions. No evidence of pneumonia.
No pneumothorax.
[**4-13**] CT/CTA Head: 1. Unchanged intraparenchymal and
subarachnoid hemorrhage involving the left temporal and frontal
lobes as described in detail above, with similar pattern of mass
effect and edema. There is no evidence of herniation or new
areas of hemorrhage.
2. Interval improvement in the vasospasm involving the M1
segment of the left middle cerebral artery as described in
detail above, there is no vascular occlusion, the examination is
partially limited due to streak artifact and coiled material,
obscuring the vascular anatomical details, however, the distal
opercular branches are patent.
Brief Hospital Course:
This is a 74 year old female who was diagnosed with a Left MCA
aneurysm one week ago.
The patient presented [**2147-4-7**] with complaints of headache and
became aphasic.She initially presented to an Outside hospital
where her Mental statusS decreased and she was intubated. A CT
head showed Subarachnoid hemorhage and she was transferred to
[**Hospital1 18**] for further evaluation. On transport her left pupil became
fixed and dilated. She received 3% NaCl. Her SBP was labile and
noted to be 200 on transport. The patient was admitted on
[**2147-4-7**] to the intensive care unit. [**Unit Number **] gram Mannitol was given
a external ventricular drain placed in Emergency department.\
On [**4-8**], The External Ventricular Drain pulled back 1cm and the
EVD was patent and still draining. The patient was given a 500cc
IV bolus for hypotension. Following the IV bolus the SBP in
90s.
On [**4-9**], The external ventricualr drain dropped to 10 to
increase cerebral perfusion. Intercranial pressures were
elevated at 22-24. Teh drain was not draining. A NCHCT was
performed which was consistent with increase in mass effect,
ventricular compression and midline shift.
On [**4-10**], The EVD was open at 10 ICP 8-12. The patient was
paralyzed and cooled to decrease ICPs.The patient's pupils were
reactive- there was no movement in the extremities given
sedation and parylytic medication. In the afternoon the patient
was rewarmed given the normal ICPs. A family meeting was held
with the two daughters to review images and update the family on
the patients status.
On [**4-11**], patient remained on paralyzed overnight into the AM.
Pupils were 2 and reactive. CTA of her head was done which
showed mild narrowing of the M1, but all vessels were patent.
TCDs also show no vasospasm. Her ICPs were stable at 15. EEG
read shows worsening encephalopathy, but no further seizure
activity.
On [**4-12**] her neurological exam was stable. Upon further review of
her CTA and in comparison with her TCD's, it was decided to
undergo cerebral angiography for closer assessment for
vasospasm. There was vessel narrowing noted in the left MCA
therefore angioplasty was performed without complication. IVF's
were increased and she was given 2 units of PRBC's for a HCT of
23.
on [**4-13**] patient started developing increased intracranial
pressures, her ICPs were in the high 20s. her sedation was
increased and she was cooled and placed on paralytics. TCDs
revealed mild to moderated spasm in the right MCA; to counter
pervent further spasm she was started on a presser to elevate
her blood pressure to the 150s. Head CT was performed and
stable. She was noted to have a likely cushings response when
her heart rate began dropping into the 40's. She also had
increased urine output which was concerning for D.I.
At about 9pm neurosurgery was called to the patient's bedside
per the families request. A discussion was held and questions
regarding the patient's current medical status and outcome were
asked. The patient's 2 daughters and son were present and
decided to make her CMO at this time. This was discussed with
Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 59718**]. It was decided that we would rewarm
her to 35 degrees and then shut off the paralytics. When the
paralytics wore off and she was >36 degrees she was extubated.
Patient passed at 10:04 am on [**4-14**].
Medications on Admission:
unknown
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
L MCA aneurysm
subarachnoid hemorrhae
intraventricular hemorrhage
cerebral vasospasm
anemia requiring transfusion
respiratory failure
dysphagia
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2147-4-14**]
ICD9 Codes: 2762, 4589, 496, 2859, 431, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4285
} | Medical Text: Admission Date: [**2105-1-6**] Discharge Date: [**2105-1-15**]
Service: SURGERY
Allergies:
Nasonex / Ibuprofen / Aspirin / Aspartame / Bufexamac /
Celecoxib / Floctafenine
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
abdominal pain / incarcerated Spigelian hernia
Major Surgical or Invasive Procedure:
exlap, 30 cm small bowel resection
History of Present Illness:
Pt is 85 y/o F with h/o Crohn's disease, right hemicolectomy in
[**2095**] for colon cancer, CAD, afib who presents with abd pain
concerning for ischemic bowel. Pt initially presented to OSH
one week ago with complaints of chest pain and was ruled out for
MI. Pt developed some RUQ abd pain a few days into her
admission, but her abd pain acutely worsened 2 days ago and was
associated with nausea and vomiting. Her abdomen was also noted
to be tympanitic. She had a NG tube placed for her symptoms,
which was subsequently pulled. KUB initially was nonspecific.
She had a repeat KUB yesterday which showed some dilated small
bowel loops and WBC count increased to 25 with 26% bands. On
admission it was noted that her Cr had increased to 3.4 and
urine output decreased. Her abd pain continued to worsen and pt
was noted to have severe tenderness on right side on exam with
rebound tenderness and guarding. NGT was placed again today
with 1 liter output. Pt was ordered for CT scan but apparently
pt refused study because of claustrophobia. For concern for
need for operation, pt was
transferred to [**Hospital1 18**] for further management.
Past Medical History:
CAD s/p angioplasty
Afib
htn
COPD
asthma
gallstones
diverticulosis
Crohn's
Colon ca s/p right hemicolectomy
hysterectomy
nephrectomy
hernia repair
Social History:
No ETOH or smoking. Pt lives by herself.
Family History:
Breast cancer and CVA.
Physical Exam:
AVSS
General: A&O x3, NAD
CV: RRR
Chest: CTAB
Abd: S/NT/ND; incision with small amt peri-incisional erythema,
improved from previous
Ext: WWP
Pertinent Results:
[**2105-1-12**] 06:24AM BLOOD WBC-7.9 RBC-3.80* Hgb-10.5* Hct-32.5*
MCV-86 MCH-27.5 MCHC-32.2 RDW-13.7 Plt Ct-202
[**2105-1-11**] 05:05AM BLOOD WBC-10.5 RBC-4.05* Hgb-11.2* Hct-34.4*
MCV-85 MCH-27.7 MCHC-32.7 RDW-13.7 Plt Ct-228
[**2105-1-10**] 09:03PM BLOOD WBC-10.5 RBC-4.15* Hgb-11.5* Hct-35.4*
MCV-85 MCH-27.7 MCHC-32.5 RDW-13.9 Plt Ct-233
[**2105-1-6**] 04:54PM BLOOD WBC-24.7*# RBC-4.96 Hgb-14.1 Hct-40.0
MCV-81* MCH-28.4 MCHC-35.2* RDW-13.6 Plt Ct-323
[**2105-1-10**] 05:30PM BLOOD PT-13.6* PTT-33.6 INR(PT)-1.2*
[**2105-1-14**] 07:20AM BLOOD Glucose-98 UreaN-26* Creat-0.8 Na-139
K-3.9 Cl-103 HCO3-26 AnGap-14
[**2105-1-13**] 06:40AM BLOOD Glucose-96 UreaN-30* Na-144 K-3.6 Cl-107
HCO3-33* AnGap-8
[**2105-1-6**] 04:54PM BLOOD Glucose-138* UreaN-87* Creat-4.0*# Na-139
K-4.7 Cl-93* HCO3-32 AnGap-19
[**2105-1-7**] 02:09AM BLOOD ALT-17 AST-23 CK(CPK)-37 AlkPhos-72
TotBili-0.7
[**2105-1-6**] 10:54PM BLOOD ALT-17 AST-22 CK(CPK)-31 AlkPhos-65
Amylase-61 TotBili-0.7
[**2105-1-11**] 11:51AM BLOOD CK(CPK)-29
[**2105-1-11**] 05:05AM BLOOD CK(CPK)-31
[**2105-1-10**] 09:03PM BLOOD CK(CPK)-29
[**2105-1-11**] 11:51AM BLOOD CK-MB-2 cTropnT-<0.01
[**2105-1-11**] 05:05AM BLOOD CK-MB-2 cTropnT-LESS THAN
[**2105-1-10**] 09:03PM BLOOD CK-MB-2 cTropnT-<0.01
[**2105-1-14**] 07:20AM BLOOD Calcium-7.9* Phos-3.2
[**2105-1-13**] 06:40AM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.4 Mg-2.1
Iron-27*
[**2105-1-12**] 06:24AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.2
[**2105-1-13**] 06:40AM BLOOD calTIBC-235* Ferritn-238* TRF-181*
[**2105-1-13**] 06:40AM BLOOD Triglyc-162*
[**2105-1-7**] 02:09AM BLOOD Digoxin-2.0
.
Echo [**6-12**]: normal EF, moderate TR, mod pulm htxn.
.
DIAGNOSIS:
Small intestine; resections (A-O):
Full thickness mucosal necrosis with acute inflammation and
associated transmural edema and hemorrhage (see comment).
Serosal acute inflammation.
Serosal adhesions.
ADDENDUM:
No fungal organisms are identified on a GMS stain.
Four reactive lymph nodes are identified in the submitted
mesenteric fa
Clinical: 85 year old woman with peritonitis. Exploratory
laparotomy, lysis of adhesions and small bowel resection
.
Brief Hospital Course:
Ms. [**Known lastname 47639**] was admitted on [**1-6**] to the ICU for managment of
abdominal pain which was concerning for ischemic bowel. Due to
claustrophobia, patient was unable to undergo CT scan, however
her exam and history were highly concerning for ischemic bowel
and after discussion with the patient and family, it was decided
to go ahead with surgery. She underwent an exploratory
laparotomy and lysis of adhesions on the day of admission, and
at that time she was found to have an incarcerated Spigelian
hernia with necrotic small bowel. The necrotic bowel was
resected and patient was managed postoperatively in the ICU.
Initially she required ventilatory support and low-dose
levophed. She was treated empirically with vancomycin and zosyn
peri-operatively. Creatinine was elevated to 4 perioperatively
but decreased with IV fluids.
On [**2105-1-8**], patient was extubated and out of bed to a chair.
Her WBC count was 12 and she was afebrile. She was in atrial
fibrillation but rate controlled.
On [**2105-1-9**], she was transferred from the ICU to the floor and
TPN was started.
On [**2105-1-10**], she conitinued to auto-diurese. Her pulse oximetry
decreased to 88% on room air and she was re-started on 2L O2 by
NC. She complained of left-sided chest pain, similar to the
type she has at home for which she normally takes SL
nitroglycerin. She was given SL nitro x2 and refused IV
morphine, stating her pain was better. EKG showed Afib, CXR
showed no acute change, and cardiac enzymes were negative x3
over the next 24 hours.
On [**2105-1-11**], she was re-started on her home pain medications and
the O2 was weaned succesfully to room air.
On [**2105-1-12**], a picc line was placed for continued TPN, patient
reported passing flatus, and diet was started on clears and
advanced to regular diet.
On [**2105-1-13**], patient was tolerating a regular diet. Her
abdominal incision was noted to be mildly erythematous, and she
was started on cipro and flagyl empirically.
On [**2105-1-14**], patient was doing well, out of bed to chair. TPN
was discontinued in the morning and she was screened for rehab.
The incisional erythema was stable/decreased from the previous
day, and the inferior aspect of the wound was opened [**3-9**]
centimeters and a small amount of serosanguinous fluid was
expressed and sent for culture.
On [**2105-1-15**], patient's blood sugars stable overnight off of TPN
for 24hrs. Surgical status continues to be stable. Abdominal
incision continues with Moist saline packing with decreased
erythema. Contact Dr.[**Name2 (NI) 12822**] office with concerns regarding
incision. She will continue with PO Cipro/Flagyl for another 8
days. PO intake has been adequate. Continue to monitor PO intake
at Rehab.
Medications on Admission:
amilodipine-benazepril 5/20mg 1 tab PO daily
aspirin 81mg PO daily
digoxin 250mcg PO daily
lasix 40 mg daily
imodium 2mg PO BID
toprol 25 mg [**Hospital1 **]
ursodiol 300 mg daily
prilosec 20 mg daily
immodium prn
MVI 1 tab PO daily
vit B6 50mg PO daily
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Oaks Long Term Care Facility - [**Location (un) 5503**]
Discharge Diagnosis:
incarcerated Spigellian hernia, necrotic small bowel, status
post exploratory laparotomy, 30 cm small bowel resection
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 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.
TPN Orders:
-Check you blood sugars 4 times per day, at the same time each
day.
-Treat with insulin injections as indicated.
-Check serum sodium levels at rehab and adjust TPN as needed;
sodium levels were borderline high during this admission.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) 1924**] to get your staples removed
in [**2-6**] Please call his office for an appointment: [**Telephone/Fax (1) 7508**].
2. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 9674**] in 1
week OR as needed.
.
Wound cultures are pending at time of discharge.
Completed by:[**2105-1-15**]
ICD9 Codes: 5845, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4286
} | Medical Text: Admission Date: [**2115-6-27**] Discharge Date: [**2115-7-7**]
Date of Birth: [**2115-6-27**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: This is a 32 [**5-31**] week twin
gestation, 1535 gm male, twin II, delivered preterm due to
premature rupture of membranes and preterm labor. Mother is
a 40-year-old gravida 3, para now 2. Prenatal labs are O+,
antibody negative, hepatitis B negative, RPR non reactive,
rubella non immune, GBS unknown. This pregnancy resulted via
utero insemination. Pregnancy was complicated with this twin
being the smaller of the two, then premature rupture of
membranes 24 hours prior to delivery treated with intrapartum
antibiotic prophylaxis, no Betamethasone. Cesarean section
due to progressive preterm labor with twin I in breech
presentation. This twin emerged with spontaneous cry,
required only blow by O2 and routine care. Apgars were 7 at
one minute and 8 at five minutes. He was transferred to NICU
due to prematurity.
PHYSICAL EXAMINATION: Normal except for respiratory rate in
the mid 60's, weight was 4935 gm, 20th percentile, head
circumference 28.5 cm, 13th percentile, length 42.5 cm, 35th
percentile. The patient had mild intercostal retractions,
intermittent grunting, breath sounds were clear, slightly
decreased at the bases. The patient had slight pallor and
sluggish perfusion but otherwise normal for gestational age.
Red reflex was seen bilaterally, anterior fontanel was soft,
open and flat. Heart exam revealed regular rate and rhythm
without murmur. Abdominal exam was normal with three vessel
cord. Testes were descended bilaterally.
HOSPITAL COURSE:
1. Respiratory: The patient has been in room air since
admission. Initial minimal respiratory distress resolved
spontaneously and patient has not needed any support. The
patient has not exhibited any signs of apnea of prematurity.
Saturation monitor had been discontinued on [**7-3**].
2. Cardiovascular: The patient has been cardiovascularly
stable without signs of persistent ductus arteriosus.
3. Fluids, Electrolytes & Nutrition: The patient was
initially started on intravenous fluids and advanced on
enteral feeds. The patient had some slight distention of his
abdomen initially while not having had passed meconium yet.
After passing meconium with a glycerine suppository,
abdominal girth receded and patient advanced normally to full
feeds. The patient is currently on breast milk and premature
Enfamil 26 at 150 cc/kg/day po and PG. Patient will feed [**12-26**]
feeds a day. Patient's electrolytes and Dextrose sticks were
entirely normal. Discharge weight = 1625 gms.
4. Heme: The patient was treated with phototherapy for two
days because of mild hyperbilirubinemia. Maximum bilirubin
was 6.3 on day of life #4. Subsequent rebound bilirubin
initially was 4.6 on [**7-2**] and is now 7.1 on [**7-4**].
5. Infectious Disease: The patient was treated with
Ampicillin and Gentamycin for 48 hours to rule out sepsis.
Cultures have been negative.
CONDITION ON DISCHARGE: His physical exam is entirely
benign. His chest is clear. Heart sounds are normal without
a murmur. His abdomen is soft and non distended. His
neurologic exam is age appropriate and normal.
DISPOSITION: [**Doctor Last Name **] will be transferred to [**Hospital **] Hospital
for further care.
Pediatrician will be Dr. [**First Name (STitle) **] at [**Hospital 22361**] Pediatrics.
CARE RECOMMENDATIONS: Continue feeds and breast milk,
premature Enfamil 26 calories per hour, 150 cc/kg/day and
advance caloric intake as needed. Currently patient is
receiving breast milk.
DISCHARGE MEDICATIONS: Ferrinsol 0.15 cc po qday
State newborn screen has been sent, last [**2115-7-6**]. Patient
still needs hearing screen and car seat screen. No
immunizations have been given.
DISCHARGE DIAGNOSIS:
1. Prematurity at 32 6/7 weeks.
2. Twin gestation.
3. Mild hyperbilirubinemia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (STitle) 42633**]
MEDQUIST36
D: [**2115-7-4**] 16:06
T: [**2115-7-4**] 18:52
JOB#: [**Job Number 42815**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4287
} | Medical Text: Admission Date: [**2151-5-25**] Discharge Date: [**2151-6-24**]
Date of Birth: [**2101-2-27**] Sex: M
Service: MEDICINE
Allergies:
Nafcillin / Zosyn
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Right abdominal pain, Left lower leg cellulitis
Major Surgical or Invasive Procedure:
PICC line placement
Incision and Drainage of left ankle infection - [**6-9**]
History of Present Illness:
Patient is a 50 yo male with hx of alcohol abuse,hepatitis C
diagnosed three years ago presented to an OSH for evaluation of
a swollen left leg. Patient presents with jaundice and
abdominal distension which he states started three weeks ago. He
was sent for CTA to rule out PE and also an abdominal CT to
further evaluate his cause of jaundice and abdominal distension.
At the OSH, he was found to have perforated duodenal ulcer on
CT scan from outside hospital. Patient transferred to [**Hospital1 18**] for
further evaluation and treatment Patient denies any recent
trauma to his left lower extremity and states that he has
noticed the the edema starting 10 days prior. He denies any
fevers or chills. He denies any nausea, vomiting or abdominal
pain. He has had regular bowel habits and tolerating a regular
diet. No difficulty swallowing or pain with swallowing. He
denies any shortness of breath or chest pain.
Past Medical History:
GERD
HTN
Gout
CAD
PSH:
Cervical laminectomy
Social History:
+ Tobacco
+ ETOH - 6-9 beers/day
Family History:
Father Hx MRSA
Physical Exam:
ADMISSION EXAM:
Vitals: T 100.1 103 116/60 20 100% 4L
Gen: NAD, Awake, Alert Ox3, jaundiced
HEENT: Scleral icterus, mucosa moist
CVS: Tachycardic, S1&S2
Pulm: CTA BL
Abd: Soft, greatly distended, nontender, tympanic, no guarding,
no rebound, Caput Medusa
Ext: BL LE edema with left LE greater then right. Left lower
extremity with erythema at planter surface. Tender to
palpation. Palpable pulses BL DP.
.
DISCHARGE EXAM:
Vitals: O2 sat 98%RA
Lungs: Mild crackles at bases
CVS: 3/6 systolic murmur
EXT: [**3-18**]+ pitting edema b/l
Pertinent Results:
Admission Labs:
[**2151-5-25**] 04:53AM BLOOD WBC-9.4 RBC-3.35* Hgb-11.1* Hct-31.2*
MCV-93 MCH-33.2* MCHC-35.7* RDW-16.9* Plt Ct-45*
[**2151-5-25**] 05:05PM BLOOD WBC-7.9 RBC-3.15* Hgb-10.6* Hct-29.5*
MCV-94 MCH-33.7* MCHC-36.0* RDW-17.1* Plt Ct-39*
[**2151-5-25**] 04:53AM BLOOD PT-20.2* PTT-37.8* INR(PT)-1.8*
[**2151-5-25**] 04:53AM BLOOD Glucose-114* UreaN-31* Creat-1.1 Na-131*
K-4.4 Cl-102 HCO3-21* AnGap-12
[**2151-5-25**] 04:53AM BLOOD ALT-78* AST-133* AlkPhos-182*
TotBili-10.1* DirBili-6.7* IndBili-3.4
[**2151-5-25**] 04:53AM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.5 Mg-1.9
[**2151-5-25**] 05:05PM BLOOD Calcium-7.8* Phos-3.2 Mg-1.9 Iron-128
[**2151-6-5**] 06:11AM BLOOD VitB12-GREATER TH Folate-12.7
[**2151-5-25**] 05:05PM BLOOD calTIBC-163* Ferritn-582* TRF-125*
[**2151-5-25**] 05:05PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2151-5-25**] 05:05PM BLOOD Smooth-POSITIVE *
.
Ceruloplasmin 32
IMMUNOGLOBULIN G SUBCLASS 1 1310 H 382-929 mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 327 241-700 mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 98 22-178 mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 119.0 H 4.0-86.0 mg/dL
IMMUNOGLOBULIN G, SERUM 1700 H [**Telephone/Fax (1) **] mg/dL
.
HCV GENOTYPE, LIPA 1a
.
IMAGING:
LENI [**2151-5-25**]:
IMPRESSION: No deep vein thrombosis in bilateral lower
extremities. Left
calf edema.
.
RUQ U/S [**2151-5-25**]:
IMPRESSION:
1. Enlarged heterogeneous macronodular liver consistent with
history of
hepatitis/cirrhosis.
2. Significant gallbladder wall edema in a nondistended
gallbladder may be
suggestive of acute on chronic hepatitis. Diagnostic
cosnideraitons may
include acalculous cholecystitis, but that is felt much less
likely.
3. Splenomegaly.
4. Patent portal and hepatic veins as well as superior
mesenteric vein and
inferior vena cava.
.
[**2151-6-2**]:
IMPRESSION:
1. Distended gallbladder with gallbladder wall edema,
nonspecific in the
setting of liver disease and perihepatic ascites, but could be
compatible
with cholecystitis. Of note there was a probable gallstone seen
on CT that
was not visualized on this examination. Clinical correlation
recommended and a HIDA scan may be performed for further
clarification if indicated.
2. Marked splenomegaly.
3. Cirrhotic liver with perihepatic ascites.
.
CT A/P [**2151-5-25**]:
IMPRESSION:
1. No findings of perforated duodenal ulcer identified.
2. Cirrhotic liver with sequelae of portal hypertension
including
intra-abdominal collateral vessels, splenomegaly, and ascites.
Within the
limits of this single phase examination, no concerning hepatic
lesion is
noted.
3. Small gallstone with marked third spacing of the gallbladder
wall likely related to underlying hepatic dysfunction and low
albumin. If there remains a high clinical concern for acute
cholecystitis, suggest correlation with a HIDA scan.
.
MRI [**2151-5-30**]:
IMPRESSION:
1. Abnormal bone marrow signal with some cortical disruption
within the
distal posterolateral tibia with adjacent abnormal bone marrow
signal within the fibula, this is concerning for osteomyelitis.
2. Adjacent fluid collection, which may be infected. Note MRI is
insensitive to distinguish between infected and noninfected
fluid.
3. Small tibiotalar and subtalar joint effusions. Note again MRI
is
sensitive to distinguish between infected and noninfected fluid.
4. Reactive edema within the talus and calcaneus.
5. Subcutaneous edema, which may represent cellulitis.
6. Tenosynovitis of the flexor tendons as described above.
7. Tendinosis and/or split tear of the peroneus tendons, as
above.
.
MICROBIOLOGY:
Blood Culture, Routine (Final [**2151-6-11**]):
STAPH AUREUS COAG +.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2151-6-2**] 12:20 pm JOINT FLUID Site: ANKLE
LEFT ANKLE JOINT FLUID.
GRAM STAIN (Final [**2151-6-4**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2151-6-3**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FLUID CULTURE (Final [**2151-6-5**]):
Reported to and read back by [**Doctor Last Name **] [**Doctor Last Name **] 9-0929 [**2151-6-3**]
1:40PM.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**2151-6-5**] 3:00 pm JOINT FLUID Source: left ankle.
GRAM STAIN (Final [**2151-6-5**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2151-6-8**]):
Reported to and read back by DR. [**Last Name (STitle) **], J. [**2151-6-6**] 12:30PM.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 320-5091K [**2151-6-2**].
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2151-6-8**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary
.
[**2151-6-9**] 1:24 pm ABSCESS
GRAM STAIN (Final [**2151-6-9**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2151-6-12**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Blood cx [**Date range (1) 89282**] - negative
C dificile PCR negative
.
DISCHARGE LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2151-6-24**] 05:39 2.5* 2.24* 7.7* 21.3* 95 34.2* 35.9* 17.4*
35*
[**2151-6-24**] 05:39 ANC
1275*
Gluc UreaN Creat Na K Cl HCO3 AnGap
[**2151-6-24**] 05:39 111*1 30* 2.0* 134 3.3 100 26 11
ALT AST AlkPhos TotBili
[**2151-6-24**] 05:39 19 52* 93 8.0*
Brief Hospital Course:
Surgical course:
.
The patient was initially admitted to the Hepatobiliary Surgical
Service for evaluation and treatment of "perforated duodenal
ulcer" noted at OSH CT scan. Repeat admission CT demonstrated no
concern for free air or duodenal perforation. Admission
examination was concerning for LLE swelling and cellulitis.
.
Admission CT demonstrated no evidence of perforated duodenal
ulcer, but did demonstrate an edematous GB consistent with
cirrhosis. Hepatology consultation obtained given history of
liver failure. LFTs trended upward, which demonstrated concern
for liver failure. He was then transferred to the Medicine
service
.
Medicine course:
.
# Alcoholic hepatitis: Clinical picture and laboratory results
believed to be consistent with alcoholic hepatitis. The patient
had a discriminant function that peaked > 100, however steroids
were not given (received 1 dose of prednisone) as there was
concern regarding worsening infection (see below). The patient
was treated with supportive care while his other issues were
managed. He was able to maintain adequate nutrition through POs
and did not require placement of an NG or Dobhoff tube.
Bilirubin and INR were trending down at the time of discharge
from a peak of 47 and 3.7 to 8.0 and 2.3 respectively.
.
# Left ankle septic joint and tibial osteomyelitis: The patient
had positive admission blood cultures for MSSA. He was
initially started on nafcillin, but this was transitioned to
vancomycin for broadened coverage. He had an MRI that was
concerning for left tibial osteomyelitis and on further review
by radiology, appeared to have surrounding fluid pockets that
were contiguous with the joint space, concerning for a septic
joint. IR was able to aspirate the joint on [**6-2**] which grew
MSSA. Orthopedics peformed a bedside aspiration 3 days later
which also grew MSSA, while the patient was on vancomycin.
Because of persistenly positive cultures, and concern that
infection was driving worsening liver failure, the patient was
taken to the OR on [**6-9**] for left ankle incision and drainage.
He tolerated the procedure well, although had significant post
operative bleeding while his coagulopathy was resolving. He was
scheduled to complete a 6 week course of vancomycin from the
date of I&D. On [**6-21**], the patient was transitioned from
vancomycin to cefazolin out of concern for vancomycin-induced
leucopenia. He will complete his course of cefazolin on [**7-21**]. The
patient will be followed by Infectious Disease as an outpatient.
.
# Acute kidney injury secondary to allergic interstitial
nephritis and acute tubular necrosis: The patient's creatinine
rose from 1.0 to 2.7. Renal was consulted and felt this initial
insult was secondary to AIN as he had numerous WBC casts in the
urine sediment. The offending [**Doctor Last Name 360**] was believed to be pip-tazo
or nafcillin. Once both drugs had been stopped, his creatinine
plateaued at 2.4 for several days, until a second acute rise to
a peak of 3.3. This was felt to be secondary to ATN as he had
cellular debris and a few granular casts in his urine sediment.
The patient was making very adequate urine throughout his
hospitalization and dialysis was never indicated. His
creatinine at discharge was 2.0.
.
# Anemia: The patient had a drop in hematocrit to 19 early
during hospitalization. An EGD showed non-bleeding Grade I
varices with portal gastropathy but no active bleeding. He had
guaiac positive brown stool. It was felt that his anemia was
secondary to oozing from ankle wound and renal failure. He was
supported with blood products to maintain his Hct > 21.
.
# Leukopenia: The patient's WBC downtrended in the setting of
ongoing vancomycin use. His ANC nadir was roughly 800. He was
placed on neutropenic precautions and diet temporarily. His
vancomycin was transitioned to cefazolin in this setting, as his
leukopenia was deemed vancomycin-induced. His ANC at the time of
discharge was uptrending, and greater than 1000.
.
# Volume Overload: Patient retained significant fluid in the
setting of liver failure and volume resusitation. After
stabilization, he was aggressively diuresed with lasix and
spironolactone. His doses were titrated to lasix 80 mg daily and
spironolactone 25 mg daily with stable creatinine and serum
sodium.
.
Transitional Issues:
- Please transfuse RBCs to maintain HCT>21.
- Please draw the following labs weekly and fax to Infectious
Disease R.N.s at ([**Telephone/Fax (1) 1353**]: CBC with diff, BUN, Cr, LFTs,
ESR, CRP.
- Patient will follow-up in ID, Hepatology, and [**Hospital **]
clinic as an outpatient.
Medications on Admission:
Percocet
Atenolol
Prilosec
Colchicine
Lasix
Indomethacin
ASA 81 mg
Discharge Medications:
1. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. cefazolin 10 gram Recon Soln Sig: Two (2) gram Recon Soln
Injection Q12H (every 12 hours) for 27 days: Please continue
through [**2151-7-21**].
13. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Outpatient Lab Work
Please draw the following labs weekly and fax to Infectious
Disease R.N.s at ([**Telephone/Fax (1) 1353**]: CBC with diff, BUN, Cr, LFTs,
ESR, CRP.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Primary Diagnosis:
- Septic left ankle joint
- Osteomylitis (left tibia)
- Acute Interstitial Nephritis
- Acute Tubular Necrosis
- Anemia
- Leukopenia
- Alcoholic Hepatitis
.
Secondary Diagnosis:
- Alcohol-Induced Cirrhosis
- Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with an
infection in your left ankle joint and an infection in your
blood. During your hospital stay, you also developed damage to
your kidneys, which has slowly improved over the last week. You
were given water pills in order to remove excess fluid from your
body.
.
Please discontinue the following medications after discharge:
- Colchicine
- Indomethacin
- Aspirin
.
Please adhere to the medication list provided. Should you
experience any symptoms that concern you after discharge from
the hospital, please return to the Emergency Room or call your
liver doctor.
Followup Instructions:
Dr.[**Name (NI) 948**] office will contact you regarding a follow-up
appointment for your liver disease. Please follow up with the
Infectious Disease specialists and orthopedic surgeons at the
following time and place:
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2151-7-5**] at 9:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2151-7-19**] at 10:00 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: ORTHOPEDICS
When: WEDNESDAY [**2151-6-30**] at 9:30 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: ORTHOPEDICS
When: WEDNESDAY [**2151-6-30**] at 9:50 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5845, 7907, 2761, 2851, 5715, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4288
} | Medical Text: Admission Date: [**2150-2-9**] Discharge Date: [**2150-2-11**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
EU Critical [**Doctor Last Name **] ([**Numeric Identifier 101896**]) aka Ms. [**Known lastname 71492**] ([**Numeric Identifier 101897**]) is a
[**Age over 90 **]
year-old woman with a history of a fib (coumadin discontinued),
remote right parietal +/- right cerebellar stroke, and
Waldenstrom's macroglobulinemia who presented following a period
of unresponsiveness.
.
According to reports, the patient was last known well around 4pm
on the day of evaluation. After enjoying lunch with her family,
she became "unresponsive." Observers noted right eye deviation
before what sounds like horizontal nystagmus. EMS was called.
Apparently concerned the abnormal eye movements represented
seizure, the patient was given ativan 2 mg IV x 1. Blood
glucose
was 118. To protect her airway, the patient was given succ. and
then intubated at the scene. She was then transported to the
[**Hospital1 18**] for further evaluation and care.
Past Medical History:
Atrial fibrillation, no longer on Coumadin
Stroke with left sided deficit
Chronic kidney disease, stage III/IV, baseline Cr 1.5-1.8
Anemia of chronic disease
Systolic congestive heart failure, EF 45%
Waldenstrom Macroglobulinemia
Social History:
She lives at home and son is in the house. He is a lawyer. She
has 2 daughters, one in [**Name (NI) 6624**] and one in [**Name (NI) 311**]. No alcohol or
current smoking. She was an Opera singer for more than 30 years
with the [**Location (un) 86**] pops. She played piano before her stroke. She
now uses one hand to play the piano.
Family History:
Not related to her fall.
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: T: nr P: 86 R: 18 BP: 148/87 SaO2: 100% intub
General: intubated sedated --> prop held for ten minutes
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
intubated
Cardiac: irreg irreg rhythm, normal S1 and S2.
Pulmonary: coarse breath sounds to auscultation bilaterally ant.
Abdomen: Round Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: does not open eyes to loud voice, sternal
rub
Cranial Nerves:
* I: Olfaction not evaluated.
* II: R 2.5--> 2mm, L 2.25--> 2 cm
* III, IV, VI: gaze conjugate; eyes stay midline with doll's eye
maneuver
* V, VII: corneals intact bilat
* VII: face grossly symmetric
* IX, X: gag intact
Motor:
* Tone: increased in LUE
Strength:
* Left Upper Extremity: withdraws purposefully from noxious
* Right Upper Extremity: extends into stimulus
* Left Lower Extremity: withdraws purposefully from noxious
* Right Lower Extremity: withdraws purposefully from noxious
Reflexes:
* Left: 2+ throughout Biceps, Triceps, Bracheoradialis, brisk
Patellar, 1+ Achilles
* Right: brisk thoughout Biceps, Triceps, Bracheoradialis,
Patellar, 1+ Achilles
* Babinski:mute bilaterally
Sensation:
* intact to noxious in all limbs
Pertinent Results:
[**2150-2-9**] 10:09PM GLUCOSE-249* UREA N-43* CREAT-1.7* SODIUM-136
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-21* ANION GAP-24*
[**2150-2-9**] 10:09PM ALT(SGPT)-14 AST(SGOT)-37 ALK PHOS-60 TOT
BILI-0.9
[**2150-2-9**] 10:09PM CK-MB-3 cTropnT-<0.01
[**2150-2-9**] 10:09PM ALBUMIN-3.5 CALCIUM-10.0 PHOSPHATE-3.8
MAGNESIUM-2.4 CHOLEST-119
[**2150-2-9**] 10:09PM %HbA1c-6.7* eAG-146*
[**2150-2-9**] 10:09PM TRIGLYCER-62 HDL CHOL-55 CHOL/HDL-2.2
LDL(CALC)-52
[**2150-2-9**] 10:09PM WBC-7.4 RBC-3.99* HGB-9.6* HCT-30.7* MCV-77*
MCH-24.1* MCHC-31.3 RDW-19.3*
[**2150-2-9**] 10:09PM PLT COUNT-133*
[**2150-2-9**] 05:58PM URINE HOURS-RANDOM
[**2150-2-9**] 05:58PM URINE HOURS-RANDOM
[**2150-2-9**] 05:58PM URINE GR HOLD-HOLD
[**2150-2-9**] 05:58PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-2-9**] 05:58PM TYPE-ART PO2-393* PCO2-27* PH-7.55* TOTAL
CO2-24 BASE XS-3
[**2150-2-9**] 05:58PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2150-2-9**] 05:58PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2150-2-9**] 05:58PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2150-2-9**] 04:36PM GLUCOSE-149* LACTATE-2.9* NA+-142 K+-4.0
CL--103 TCO2-26
[**2150-2-9**] 04:35PM UREA N-39* CREAT-1.6*
[**2150-2-9**] 04:35PM estGFR-Using this
[**2150-2-9**] 04:35PM LIPASE-82*
[**2150-2-9**] 04:35PM CALCIUM-10.3 PHOSPHATE-3.6 MAGNESIUM-2.5
[**2150-2-9**] 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-2-9**] 04:35PM WBC-6.1 RBC-3.57* HGB-8.9* HCT-27.2* MCV-76*
MCH-25.0* MCHC-32.8 RDW-20.1*
[**2150-2-9**] 04:35PM PT-15.4* PTT-24.5 INR(PT)-1.3*
[**2150-2-9**] 04:35PM PLT COUNT-180
[**2150-2-9**] 04:35PM PLT COUNT-180
[**2150-2-9**] 04:35PM FIBRINOGE-212
[**Known lastname **],[**Known firstname **] [**Age over 90 101898**] F 92 [**2058-1-23**]
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2150-2-9**] 6:34 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**2150-2-9**] 6:34 PM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS; CT BRAIN
PERFUSION Clip # [**Clip Number (Radiology) 101899**]
Reason: ? cva, basilar thrombosis
Contrast: OPTIRAY Amt: 110
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **]F w. unresponsiveness, intubated at scene w.
unresponsiveness, h/o CVA. pt is
receivinb nac and bicarb for kidney protection. please do
perfusion imaging as
well.
REASON FOR THIS EXAMINATION:
? cva, basilar thrombosis
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: JKSd MON [**2150-2-9**] 7:47 PM
1. thrombus of left MCA and ACA with corresponding large infarct
of the
entire left MCA and ACA territory. No mismatch present on
perfusion between
CBV and CBF to suggest a penumbra. basilar artery patent. no
acute hemorrhage.
Final Report
EXAMINATION: CTA head and neck with CT perfusion of the brain.
INDICATION: Unresponsive.
COMPARISON: [**2150-2-9**] non-contrast head CT.
TECHNIQUE: Initially, non-contrast head CT was performed.
Subsequently,
contrast was administered intravenously and serial axial images
through the
head and neck were obtained in the arterial phase. CT perfusion
was also
performed of the brain as per protocol.
FINDINGS:
NON-CONTRAST HEAD CT:
There is a large infarction involving the left MCA and ACA
territories with
loss of [**Doctor Last Name 352**]-white matter differentiation, and diffuse edematous
changes with
effacement of adjacent sulci and of the left lateral ventricle.
In addition,
there is right parietal encephalomalacia, compatible with remote
infarct.
There is no evidence of hemorrhage.
CTA NECK:
The aortic arch has mild calcific arteriosclerosis with no
stenosis of the
great vessel origins. The right brachiocephalic, left common
carotid and left
subclavian have separate origins off the arch.
The bilateral common, external, and cervical right internal
carotid arteries
have regions of minimal calcific arteriosclerosis, but no
flow-limiting
stenosis. The vertebral arteries have no flow-limiting stenosis.
There is
mild calcific arteriosclerosis of the left vertebral artery
origin. The left
vertebral artery is dominant. The proximal left internal carotid
artery is
unremarkable. There is mild tapering of the left high cervical
internal
carotid artery.
CTA HEAD:
There is a thin linear filling defect within the petrous and
remaining
intracranial left internal carotid artery. This extends through
the carotid
siphons, the supraclinoid left carotid. The lumen of the
communicating segment
then quickly tapers with low-density filling defect extending
from the left
lateral wall, and occluding this vessel just proximal to its
bifurcation and
just distal to the left posterior communicating artery origin
which is patent.
The left MCA and ACA are occluded from their origin with
minimal, faint
peripheral filling of M2 and M3 branches.
The right intracranial carotid has mild calcific
arteriosclerosis, with no
evidence of flow-limiting disease. The right anterior
communicating artery
and branches are patent. No anterior communicating artery is
identified.
The posterior circulation is unremarkable.
The examination is otherwise significant for left greater than
right maxillary
sinus mucosal thickening; the left-sided maxillary thickening is
contiguous
with a carious left maxillary premolar. In addition, there is
patchy
opacification of the left mastoid air cells and degenerative
osseous changes.
There is mild right greater than left pleural/parenchymal
pulmonary scarring
and mild mediastinal adenopathy, partially visualized. There are
heterogeneous thyroid nodules with calcifications as well. An
endotracheal
tube terminates in the mid thoracic trachea.An esophageal tube
is partially
visualized.
CT PERFUSION:
There is markedly increased mean transit time and decreased
blood flow and
decreased blood volume within the left MCA and ACA territories,
with no
evidence of significant penumbra.
IMPRESSION:
1. Dissection of the left internal carotid artery at the
craniocervical
junction. The dissection flap extends through the petrous
carotid and carotid
siphon, and leads to occlusion of the left MCA and ACA and
distal left
internal carotid artery just proximal to its bifurcation. It is
difficult to
determine which is the true and false lumen. The left posterior
communicating
artery is patent and arises just proximal to the occlusion.
2. No other flow-limiting stenosis.
3. Associated infarction of the left MCA and ACA territories
with no evidence
of significant penumbra.
4. Chronic right parietal lobe infarct.
Brief Hospital Course:
Ms. [**Known lastname 71492**] is a [**Age over 90 **] year-old woman with a history of a fib
(coumadin discontinued), remote right parietal +/- right
cerebellar stroke, and Waldenstrom's macroglobulinemia who
presented following a period of unresponsiveness and was found
to
have evidence of occlusion of the distal left ICA, left ACA and
MCA with
corresponding regions of stroke on CT/CTA brain. CTP
demonstrated no
appreciable penumbra in the left MCA and ACA region. Although
the official radiology read of the CTA was left ICA dissection
starting in the left petrous canal and extending to the distal
left ICA as well as the MCA and ACA, given her history of atrial
fibrillation, the Neurology team thought that cardioembolism as
a result of afib was the most probable diagnosis.
The morning following her admission to [**Hospital1 18**], the patient's
situation was discussed with the son. [**Name (NI) **] was told that she had a
devastating stroke that had caused complete ischemia of the left
ACA and MCA territories. This stroke severity is associated with
a very high morbidity and mortality. Even if she survived this
event, she would have global aphasia, be unable to move or feel
the right side of her body, have loss of vision in a right
homonymous hemianopsia pattern. She would require a tracheostomy
and a PEG tube. She would require 24/7 nursing care. He agreed
that she should be DNR. He wanted to keep her intubated until
her family could arrive from Europe to say goodbye to her.
The following day she had difficulty maintaining her pressures
and pressors were initiated. The following morning her son was
attempted to be notified multiple times. She went asystolic.
With a DNR order, she was not resusitated and she expired.
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
hold for loose stools.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
6. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO twice a day.
7. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
Disp:*100 ML(s)* Refills:*2*
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
stroke
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2150-2-12**]
ICD9 Codes: 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4289
} | Medical Text: Admission Date: [**2161-7-5**] Discharge Date: [**2161-7-8**]
Date of Birth: [**2098-9-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Substernal Chest pain, ST elevation MI, CAD
Major Surgical or Invasive Procedure:
[**2161-7-5**] Cardiac Catheterization
[**2161-7-5**] Emergency CABG x 3 (LIMA->LAD, SVG->Ramus, SVG->OM)
History of Present Illness:
Mr. [**Known lastname 35763**] is a 62 year old male with a histroy of
hyperlipidemia who presented to the emergency room on [**2161-7-8**]
with substernal chest pain and ST elevation. Cardiac
catheterization showed 90% ostial LAD70% mid, 60% diagonal, 80%
ramus. Echocardiogram showed moderate hypokinesis and severe
apical hypokinesis with EF 50%. An IABP was inserted and he was
evaluated for CABG.
Past Medical History:
Hyperlipidemia.
Myocardial infarction
Social History:
Non contributory.
Family History:
Gransfather with CAD, CVA multiple family members.
Physical Exam:
Admission physical exam was unremarkable. On discharge physical
exam he was afebrile, BP 116/64, HR 83 and regular, respiratory
rate 20, he was 91% saturated on room air. He was neurologically
intact. His lungs were clear to ausculatation bilaterally. On
cardiovascular exam, he had S1 s2 with no murmurs rubs or
gallops. His midsternal incision was clean dry and intact with
no redness swelling or drainage. His abdomen was slightly
distended. He had 1+ peripheral edema. His left lower extremity
SVG incision were clean dry and intact however ecchymotic.
Pertinent Results:
[**2161-7-8**] 06:50AM BLOOD WBC-8.1 RBC-3.22* Hgb-8.8* Hct-26.3*
MCV-82 MCH-27.2 MCHC-33.4 RDW-13.6 Plt Ct-117*
[**2161-7-8**] 06:50AM BLOOD Glucose-120* UreaN-14 Creat-1.0 Na-136
K-4.0 Cl-100 HCO3-29 AnGap-11
[**2161-7-5**] 01:01AM WBC-7.4 RBC-5.40 HGB-14.9 HCT-44.5 MCV-82
MCH-27.6 MCHC-33.5 RDW-13.9
[**2161-7-5**] 01:01AM GLUCOSE-149* UREA N-27* CREAT-1.0 SODIUM-138
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16
[**2161-7-5**] 03:00AM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-63
AMYLASE-57 TOT BILI-0.6 DIR BILI-0.1 INDIR BIL-0.5
[**2161-7-8**] 06:50AM BLOOD WBC-8.1 RBC-3.22* Hgb-8.8* Hct-26.3*
MCV-82 MCH-27.2 MCHC-33.4 RDW-13.6 Plt Ct-117*
[**2161-7-8**] 06:50AM BLOOD Glucose-120* UreaN-14 Creat-1.0 Na-136
K-4.0 Cl-100 HCO3-29 AnGap-11
[**2161-7-5**] Cardiac Catheterization
1. Selective coronary angiography demonstrated three
vessel coronary artery disease in this left dominant
circulation. The
LMCA was without angiographically apparent flow limiting diseae.
The LAD
had a 90% ostial stenosis followed by a 70% mid-vessel stenosis.
The D1
had a 60% stenosis. The LCX was a large dominant vessel without
flow
limiting disease through the AV groove or OM branches. The ramus
intermedius was a moderate-sized vessel with 80% stenosis. The
RCA was a
non-dominant vessel with a 60% stenosis at the origin.
2. Resting hemodyanamics from right heart catheterization
demonstrated
elevated right and left sided filling pressures (RVEDP=18mmHg
and mean
PCWP=23mmHg). Cardiac output and index were mildly depressed at
4.4
L/min and 2.2 L/min/m2.
3. Left ventriculography not performed to reduce contrast load.
4. Successful placement of intra-aortic ballon pump via the
right
femoral artery.
[**2161-7-5**] CXR
No evidence of acute cardiopulmonary process. Mediastinal
contour within normal limits.
[**2161-7-7**] CXR
Left apical pneumothorax status post removal of thoracic
catheter.
[**2161-7-6**] ECHO
The left ventricular cavity size is normal. Resting regional
wall motion
abnormalities include anteroseptal/anterior/apical
akinesis/hypokinesis (views suboptimal). No definite apical
thrombus seen but cannot exclude. The mitral valve leaflets are
mildly thickened. No mitral regurgitation is seen. There is a
trivial pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 35763**] was admitted to the [**Hospital1 18**] on [**2161-7-5**] for further
management of his myocardial infarction. A cardiac
catheterization was performed which revealed severe three vessel
disease and an intra-aortic balloon pump was placed. Due to the
severity of his disease, the cardiac surgical service was
consulted for surgical revascularization and Mr. [**Known lastname 35763**] was
worked-up in the usual preoperative manner. On [**2161-7-5**], Mr.
[**Known lastname 35763**] was taken to the operating room where he underwent
coronary artery bypass grafting to three vessels.
Postoperatively he was taken to the cardiac surgical intensive
care unit. On postoperative day one, Mr. [**Known lastname 35763**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. His intra-aortic
balloon pump was weaned and removed without complication. He was
then transferred to the step down unit for further recovery. Mr.
[**Known lastname 35763**] was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. His epicardial pacing wires
and chest tubes were removed per protocol. Mr. [**Known lastname 35763**] continued
to make steady progress and was discharged to his home on
postoperative day three. He will follow-up with Dr. [**Last Name (STitle) **], his
cardiologist and his primary care physician as an outpatient.
Medications on Admission:
None.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*14 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Care Group
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Good.
Discharge Instructions:
Shower daily, wash incision with mild soap and water, pat dry.
No baths.
No lifting more than 10 pounds, no driving until follow up
appointment or after if taking pain medication.
Call with weight gain more than 2 pounds ion one day or five
pounds in one week, redness or drainage from incision or
temperature greater than 101.5.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Primary Care [**Provider Number **] weeks
Cardiologist 2-3 weeks
Completed by:[**2161-7-8**]
ICD9 Codes: 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4290
} | Medical Text: Admission Date: [**2103-8-12**] Discharge Date: [**2103-8-20**]
Date of Birth: [**2047-8-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
56 year old male with h/o EtOH abuse/narcotic dependence, CAD
s/p MI, HTN initially transferred from [**Hospital3 **] to
[**Hospital1 18**] [**2103-8-12**] for concern of AAA rupture vs ischemic bowel. The
pt reports 2-3 days of diffuse abdominal pain prior to
admission, associated with N/V (no hemetemesis), [**10-15**] unable to
describe character, exacerbating/relieving factors. (+)
anorexia. No diarrhea, BRBPR, fevers, chills, chest pain,
shortness of breath. His brother visited him, noted he was "not
acting right" and was diaphoretic and called EMS -> [**Hospital1 63695**]. There, he was noted to be bradycardic (HR 40s) for
which he received 0.5 mg atropine X 1. He was hypertensive with
sbp 180s and a nitro gtt was started. He was noted to be
acidotic (7.062/72.1/100) with acute renal failure (Cr 5.3) and
CK 3000. Reportedly, his NG lavage revealed ~ 100 cc maroon
blood and his rectal exam showed gross blood. He received 2u
PRBC and was emergently intubated and transfered to [**Hospital1 18**] for
further management. Given reports that he had fallen 2 days
earlier (the patient does not recall this event), the patient
was evaluated by trauma surgery. He underwent extensive CT
imaging (head, neck, chest, abdominal, pelvis), which was most
notable for ileal thickening. He was extubated this a.m., and,
given no clear surgical cause was found, he is being transferred
to medicine for further management.
Past Medical History:
PMHx:
1) CAD: h/o MI
2) Narcotic dependence
3) h/o cluster headaches
4) HTN
5) s/p appendectomy
6) s/p knee surgery
7) h/o left hip dislocation s/p closed reduction [**2-10**]
8) ? cancer: diagnosed in [**State 108**], told he had 4 months to live.
Social History:
Pt reports drinks ~ 1 drink/month, however per his brother he is
a heavy drinker. Denies other drug use. (+) tobacco [**2-8**] ppd X 40
yrs. He lives alone on disability.
Family History:
3 brothers, mother, father with DM and CAD. Mother died at age
67 yrs of MI, father died at 77 yrs of MI, brother had MI in his
40s
Physical Exam:
PE:
Gen:awake, in NAD, restless in bed
HEENT: no cervical LAD, no JVD appreciated
Cardiac: RRR, no MRG
Pulm: CTAB in all lung fields, no WRR
Abd: non-tender, non-distended, soft, + BS throughout
Ext: no C/C/E in bilateral LE
Neuro: oriented x 1 only, awake, answers questions, but confused
Pertinent Results:
[**8-12**] CT chest/abd/pelvis without contrast: Right hilar LAD, small
bilateral pleural effusion, no focal lungs consolidation,
thickening in distal ileum (infectious vs ischemic), limited
oral contrast reaching bowel, although no clear evidence of
obstruction, small amt of free fluid around liver/spleen.
.
[**8-12**] Head CT: No ICH, fracture
.
[**8-12**] CT C-spine: mild degenerative changes in mid cervical spine
w/o fracture
.
[**8-12**] CXR: no acute cardiopulmonary abnormality.
EKG on admission [**8-12**]- TWI and 1 mm depressions in II, III, and
aVF
EKG on [**8-13**]- TWI and ST depressions resolved, NSR, normal
intervals
Brief Hospital Course:
1) GI bleeding: given report of (+) lavage, concern for UGI
process. Potential UGI sources include PUD, varices, gastritis,
[**Doctor First Name 329**]-[**Doctor Last Name **] tear, gastroenteritis. Also some reports of rectal
bleeding at OSH (though guiac neg to date here), could be c/w
hemmorrhoid, polyp, colon CA, ischemic bowel, diverticuli, IBD.
- 2 large bore IVs
- transfuse for hct > 30 given hx CAD, hct stable over
admission, no signs of active bleeding, no transfusion necessary
- daily hct check
- GI consult --> they will performed EGD and Colonoscopy --> EGD
revealed duodenitis and gastritis. A colonoscopy revealed a
hyperplastic polyp 20
cm from the anal verge
- guaiced all stools- negative
.
2) Pneumonia- RLL PNA on CXR, fever resolved, satting well on RA
on the floor. Pt's hypoxia also probably has a component of
Emphysema
- Albuterol and Atrovent Nebs PRN
- Levofloxacin, Flagyl PO Day 4 -> discharged on 1 more week
Levo, 10 days Flagyl
- Advair started for component of COPD
.
3) Anisocoria- probably long-standing from old injury- pt. has
no sx of HA, normal Neuro exam
- monitor pupils, monitor for signs of HA, changes in Neuro exam
-> no changes over admission
.
4) EtOH Withdrawal
- Diazepam tapered and then d/ced for auto-taper, pt. did
exhibit any further signs of withdrawal on the floor
- Thiamine, Folate
.
5) Acute Renal Failure- resolved with IVF, most likely [**2-7**]
Rhabdomyolysis, Cr 4.4 on admission -> 0.6 in discharge
- Urine eos negative
- US Abd --> no hydronephrosis
- monitored lytes
.
6) Troponin Leak- most likely [**2-7**] demand ischemia
- held ASA until UGIB is investigated
- lipids WNL
- TTE --> LVEF > 55%, no WMA, no AR, trace MR
- continued metoprolol
.
7) C diff- may explain Abd pain on presentation, no diarrhea
over admission
- PO Flagyl day 4 -> discharged with 10 more days for 2 week
course
.
8) Prophy-
- Thiamine, Folate
- Hep SC
- Pantoprazole
.
9) Access- 2 large bore IVs
.
10) Code- full code
.
Discharge Disposition:
Home
Discharge Diagnosis:
C difficile colitis, Gastritis, Pneumonia, Acute Renal Failure
(resolved)
Discharge Condition:
Good- Acute renal failure has resolved, breathing comfortably on
room air, with no more episodes of upper or lower GI bleeding.
No fevers for 1 week.
Discharge Instructions:
Please take all medications as prescribed.
Please follow up with Dr. [**First Name (STitle) **] on [**2103-9-7**].
We gave you a prescription for Levaquin, which is an antibiotic
for Pneumonia. You should take it as directed for 7 more days.
We gave you a prescription for Flagyl, which is an antibiotic
for an infection in your intestine called C difficile colitis.
You should take it as directed for 10 more days.
Please continue your normal medications prescribed by Dr.
[**First Name (STitle) **], including your Atenolol, HCTZ and Accupril for your
blood pressure, and your Advair inhaler for your Emphysema.
Please call Dr [**First Name (STitle) **] or go to the ER if you have chest pain,
shortness of breath, cough up blood, have blood in your stool,
are making significantly less urine than usual, or have any
other symptoms that concern you.
Followup Instructions:
Please follow up with your Primary Care Doctor, Dr. [**First Name (STitle) **]. You
have an appointment scheduled with him on [**Last Name (LF) 2974**], [**9-7**]
at 1:30. You can call his office at [**Telephone/Fax (1) 63696**] if you need to
change the appointment. Dr. [**First Name (STitle) **] should check your Creatinine
to watch your kidney function and follow up on the results of
the biopsies the GI Doctors took of your stomach and your Colon.
Completed by:[**2103-9-10**]
ICD9 Codes: 0389, 5849, 2767, 5070, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4291
} | Medical Text: Admission Date: [**2139-12-12**] Discharge Date: [**2139-12-16**]
Date of Birth: [**2067-12-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Imipenem
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Mr. [**Known lastname **] presents for evaluation of persistent pneumonia
and the possibility of a bronchoesophageal fistula.
Major Surgical or Invasive Procedure:
[**2139-12-15**] - flexible bronchoscopy
[**2139-12-16**] - Flexible bronchoscopy; bronchography to evaluate
for a fistula; esophagogastroduodenoscopy
History of Present Illness:
Mr. [**Name13 (STitle) 75989**] is an unfortunate 71-year-old institutionalized
patient who several decades ago underwent the distal
esophagectomy and proximal gastrectomy with reconstruction low
in the left chest. He was recently transferred to this
institution for management of what appears to be a mediastinal
fluid collection with possible communications with both the
airway and GI tract. He has had
a recent [**8-14**] unit upper GI bleed. He was brought to the
operating room today by Dr. [**Last Name (STitle) **] to define communication of the
left distal mainstem bronchus to the mediastinum. Dr. [**Last Name (STitle) **]
requested my assistance in the operating room to
identify whether this communication also involved the stomach.
Past Medical History:
PMH: GERD, chronic aspiration, paraesophageal hernia,
hypothyroidism, HTN, Depression, hepatitis, hearing loss, C-diff
PSH: Gastrectomy, partial esophagectomy w/gastric pull through
and pyloroplasty, CCY
Social History:
non contributory
Family History:
non contributory
Physical Exam:
See physical chart, patient expired while in the hospital
Pertinent Results:
CT Chest [**2139-12-12**] - Heterogeneous left thorax fluid collection
and air extending laterally to the pleural surface could be
compatible with a bronchogastric fistula possibly extending to
the pleural space. Fluid collection noted at the level of the
distal tail of the pancreas could represent a pseudocyst from
remote pancreatitis.
Brief Hospital Course:
The patient was admitted to the ICU on [**2139-12-12**] for r/o MI,
massive GI bleed, recurrent pneumonia, started on a protonix
drip, empiric vanc/zosyn/gentamicin, started on dopamine, right
central line placed, intubated for airway protection and started
on IV fluids.
[**12-13**] - tube feeds started, transfused one unit of RBC
[**12-15**] - d/c vancomycin, continued mechanical ventilation, abx,
tube feeds,
[**12-16**] - underwent the above procedure where the patient began
having massive gastrointestinal bleeding from the site of the
esophageal ulcer. At this point, the flexible bronchoscope was
withdrawn and attempts were made to control the GI bleeding
with ice-cold saline. Due to the large amount of the bleed,
visualization through the endoscope was rendered difficult and
the scope was withdrawn. Attempts were made to pack the
esophagus to control the bleeding. The patient became
hypotensive on the operating table and required IV fluids and
blood products for resuscitation. Intravenous vasopressors were
started to maintain the blood pressure. At this point,
the decision was made to transfer the patient to the intensive
care unit to continue resuscitative measures. Surgical options
for control of the GI bleed were discussed,
but the opinion was that there were no clear surgical options
available at that point. The patient was then transferred to
the intensive care unit on IV fluids, blood products, and the
intravenous vasopressors. The patient's family was contact[**Name (NI) **]
from the operating room to update them about the critical
condition that the patient was in. The patient eventually
succombed to the bleeding and expired.
Medications on Admission:
unknown
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
massive GI bleed, MI
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
ICD9 Codes: 5070, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4292
} | Medical Text: Admission Date: [**2113-5-27**] Discharge Date: [**2113-6-2**]
Date of Birth: [**2050-12-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
IABP
History of Present Illness:
62 y/o man with PMH significant for sarcoidosis, HTN, and
hyperlipidemia admitted from the cath lab after treatment of a
ST elevation MI. Pt has been experiencing upper back pain for
approximately three weeks prior to admission. He attributed this
to muscle strain from moving in [**Month (only) 547**]. He had been treating this
at home with a heating pad, flexaril, and NSAIDs with relief of
the discomfort. However, on the evening of [**5-26**], the pain was
more severe over his bilateral shoulder blades and radiating
around on the left side. It was refractory to the treatments he
had been using for his back pain. The pt described it as a
"cramping". Significantly, the pain was associated with feelins
of weakness, nausea, and diaphoresis which was new for him. Pt
called EMS and when they arrived his BP was 107/75 with a HR of
80. He rated his pain a six at that time. He was transported to
[**Hospital3 934**] Hospital for further care. There he received
ASA, lopressor, nitro drip, heparin drip, and morphine. Cardiac
enzymes had not yet returned but ECG was concerning for
hyperacute T waves in V4 and a concern at the OSH for ST
elevation in V1-V3. Pt was transferred to the [**Hospital1 18**] ED for
further care. In the ED, the pt's VS were 98/64 ---> 117/80 80
20 100% 4L NC. ECG was very concerning with ST elevations in V3
and V4.
.
Pt was transferred to the cath lab for intervention. There, he
was found to have a 60% proximal ramus occlusion, 50% proximal
RCA occlusion, and a 100% proximal LAD occlusion. He had PCI to
the proximal LAD witha 3.5 by 2.8 cypher stent. Following the
stenting, the pt became hypotensive to the 80s with increased
CP. He then had a vagal episode with a decrease in his SBP to
the 60s and HR to the 40s. Pt was given atropine at that time
with good response. Then, there was placement of a balloon pump
and he was started on levophed. He also had transient worsening
of his CP. At that time, Pt's BP stabalized on this regimen and
he is currently CP free. He was transported to the CCU for
further care. Pt's hemodynamics were significant for a cardiac
output of [**5-15**] and an cardiac index of 2.67. Other measurements
included: PCW- 30; RA- 24.
.
On arrival to the CCU, the pt was pain free and not nauseated.
He reports that he has overall been feeling well at home except
for the intermittent back pain. He does not do much outside
exercise during cold weather as it adversely affects his
breathing with the sarcoidosis. However, he can walk several
blocks at baseline without difficulty. He denies any CP.
Past Medical History:
1. [**Name (NI) 66919**] Pt is on chronic prednisone for his sarcoidosis.
He rpeorts that he was diagnosed in [**2110**] and started on steroids
at that time. He has been on prednisone 5 mg daily for the past
couple of years.
2. Hypertension
3. Hyperlipidemia
4. Psoriasis
5. S/P removal of nasal polyp on the right
Social History:
Pt is married and lives with his wife. They have three children.
The pt is retired from working as a [**Social Security Number 66920**]social security worker. No
ETOH, tobacco, or drugs. He has never smoked.
Family History:
[**Name (NI) 1094**] father had CHF and a MI in his early 60s. His mother had
lymphoma and angina in her 80s. His sister is 71 and was treated
for an unknown type of cancer three years ago.
Physical Exam:
103/61 101 24 96% 4L NC
Augmented systole- 92 Augmented diastole- 129
Gen- Pleasant man resting comfortabley in bed. Balloon pump in
place through the right groin.
HEENT- NC AT. EOMI. Anicteric sclera. Mildly dry mucous
membranes.
Cardiac- RRR. S1 S2. Balloon pump sounds auscultated.
Pulm- Bilateral scattered rales anteriorly and laterally.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- Cool. No c/c/e. 1+ DP pulses bilaterally.
Nuero- Alert and oriented. CN II-XII intact.
Pertinent Results:
LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2113-6-2**] 06:00AM 9.0 4.33* 12.8* 36.8* 85 29.6 34.8 14.6
291
[**2113-6-1**] 06:00AM 9.9 4.34* 12.9* 36.8* 85 29.7 35.0 14.4
298
[**2113-5-31**] 05:54AM 9.5 4.30* 12.7* 36.1* 84 29.5 35.2* 14.2
254
[**2113-5-30**] 06:07AM 9.1 4.50* 13.4* 38.3* 85 29.7 34.9 14.1
239
[**2113-5-29**] 04:13AM 9.0 4.40* 12.9* 37.4* 85 29.4 34.5 14.0
195
[**2113-5-28**] 05:12AM 10.7 4.62 13.4* 39.2* 85 29.1 34.3 13.9
242
[**2113-5-27**] 08:30PM 14.3 40.5 35.3* 285
[**2113-5-27**] 03:00AM 13.6* 5.02 14.7 42.5 85 29.3 34.6 13.7
346
.
PT PTT Plt Ct INR(PT)
[**2113-6-2**] 01:00PM 21.8* 69.9* 2.1
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2113-6-2**] 06:00AM 109* 16 1.1 140 4.2 104 26 14
.
CK(CPK) AlkPhos Amylase TotBili DirBili
[**2113-5-29**] 04:13AM 376*
[**2113-5-28**] 05:12AM 1375*
[**2113-5-27**] 08:30PM 2606*
[**2113-5-27**] 10:41AM 5689*
[**2113-5-27**] 03:00AM 135
.
CK-MB MB Indx cTropnT
[**2113-5-29**] 04:13AM 19* 5.1 3.26
[**2113-5-28**] 05:12AM 122* 8.9* 4.43
[**2113-5-27**] 08:30PM 269* 10.3* 8.29*
[**2113-5-27**] 10:41AM 23.51*
[**2113-5-27**] 03:00AM 0.23*
[**2113-5-27**] 03:00AM 16* 11.9*
.
ECG: Sinus rhythm at 82 beats per minute. Left axis deviation.
First degree AV delay with RBBB. Approximate [**Street Address(2) 1766**] elevation
in V3 and V4.
.
Cath:
R heart - **PRESSURES
RIGHT ATRIUM {a/v/m} 26/29/24
RIGHT VENTRICLE {s/ed} 61/24
PULMONARY ARTERY {s/d/m} 54/23/38
PULMONARY WEDGE {a/v/m} 38/35/30
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 46
CARD. OP/IND FICK {l/mn/m2} 5.1/2.7
**RESISTANCES
PULMONARY VASC. RESISTANCE 126
.
L heart - right dominant system - 2VD
LAD - proximal TO after the takeoff from the left main. (no
collaterals)
Ramus - 60% lesion in the proximal portion
RCA - 40% lesion in the proximal portion
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated two vessel disease. The LAD demonstrated a total
occlusion
in the proximal portion of the vessel just after the takeoff
from the
left main. Unfortunately there were no collaterals dupplying the
mid and
distal portion of the vessel. The LCX was a small nondominant
vessel
with no significant disease. The Ramus demonstrated a 60%
lesion in the
proximal portion of the vessel. The RCA demonstrated a 40%
lesion in
the proximal portion of the vessel.
2. Limited resting hemodynamics demonstrated markedly elevated
right
and left heart filling pressures (RA mean of 24 mm Hg; PCWP mean
of 30
mm Hg). He also demonstrated moderately severe pulmonary
hypertension
with a PA pressure of 54/23 mm Hg. The cardiac output/index
calculated
via the Fick method was 5.0 / 2.7 respectively.
3. LV ventriculography was deferred.
4. Successful PTCA and stenting of the LAD with a 3.5 x 28 mm
Cypher DES
(see PTCA comments).
5. Successful placement of an IABP.
.
.
[**2113-5-27**]: TTE: EF 20% - severe regional left ventricular systolic
dysfunction with near akinesis of the anterior septum, distal
2/3rds of the anterior wall, distal inferior wall, and apex. The
apex is mildly aneurysmal and descending aorta is dilated. No
masses or thrombi are seen in the left ventricle. The right
ventricular cavity is mildly dilated with severe focal
hypokinesis of the apical free wall. 1+ AR.
Brief Hospital Course:
62M with sarcoidosis on steroids, HTN, late presentation [**5-27**]
with large ant MI, occluded pLAD s/p stenting [**5-27**], echo with
antero/apical AK and developing aneurysm, distal RV HK.
Initially with very high filling pressures and on IABP, ECG with
RBBB with Q's in V1-4, [**Last Name (LF) 16990**], [**First Name3 (LF) **] PR, and developed sudden CHB
with hemodynamic compromise [**2113-5-30**] - recovered to 1:1
conduction.
[**2113-5-30**]: EnTrust DR [**Last Name (STitle) 3941**], programmed MVP. R waves were [**3-18**] at end
of case via device interrogation (7 by strip), thresholds ok and
leads ok by fluoro. Device check, CXR with leads appropriately
placed, vanco for 48 hrs, restarted Coumadin [**5-30**]
.
1. STEMI- Peak CK: 5689 MB: >500 Trop-*T*: 23.51
Pt presented with atypical symptoms of back pain but was found
to have a ST elevation MI. In the cath lab, his proximal LAD was
found to be 100% occluded and a cypher stent was placed. He was
continued on ASA, plavix, and high dose statin. Started on beta
blocker and ACE-i. His BB and ACE-I were titrated as BP
tolerated and sent home on Toprol XL 50mg and Lisinopril 5mg
daily.
.
2. Cardiogenic shock- Pt with decreased BP following stenting.
Concern that there was distal embolization in the apical vessel.
This was treated with low pressure balloon inflation and final
angiography showed TIMI 3 flow into a large septal and D1/2.
IABP successfully d/c'd [**5-30**]. He then developed CHB with
hypotension and bradycardia with successful [**Month/Year (2) 3941**] placement. His
low dose BB was continued. He was bridged to coumadin with Hep
gtt and sent home on Coumadin 5mg daily in setting of depressed
EF 25% and HK/AK walls. He was also started on Lasix 20mg daily
for a depressed EF.
.
3. [**Name (NI) 66919**] Pt with sarcoidosis and on chronic steroids at
home. Do not like to give high dose steroids in setting of acute
MI. However, pt was continued on his home dose of prednisone 5mg
daily
.
4. Pt was deconditioned post several days of lying in bed.
Physical therapy followed pt and was steady on feet for safe d/c
to home with PT services.
.
6. CODE: FULL
Medications on Admission:
1. Norvasc 5 mg daily
2. Lipitor 10 mg daily
3. Prednisone 5 mg daily
4. Advair discus
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed.
Disp:*20 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
STEMI
Cardiogenic Shock
Sarcoidosis
HTN
Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Follow up as per below.
Please seek medical attention immediately if you experience new
symptoms including shortness of breath, chest pain,
palpitations, fainting, numbness, weakness or any other
concerning symptoms.
Followup Instructions:
See Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 66920**] Monday [**6-5**] for an INR check
and an appointment at 1:15pm. [**State **]. [**Apartment Address(1) 40601**]
[**Location (un) **]
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2113-6-7**]
10:30
Please call [**Known firstname **] [**Last Name (NamePattern1) **] (Cardiology) for an appointment
within the next month ([**Telephone/Fax (1) 29517**].
Completed by:[**2113-6-4**]
ICD9 Codes: 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4293
} | Medical Text: Admission Date: [**2108-12-1**] Discharge Date: [**2108-12-7**]
Date of Birth: [**2047-9-9**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
hypotension/somnolence
Major Surgical or Invasive Procedure:
Placement of central venous line
History of Present Illness:
Mr. [**Known lastname 10983**] is a 61 year old male with past medical history
munchhausens syndrome, anti-social behaviour, possible PTSD who
frequently presents here to ED with hypotension and somnolence.
In the past pt was discovered to have been hording his blood
pressure medication (mainly clonidine) and taking it all at
once. Pt also admitted in the past with eating his clonidine
patch. In the past this had led to multiple ICU admissions, with
ARF and most recently MI as a consequence. This time patient
brought in to the hospital by EMS after being found poorly
responsive.
In the ED his initial vital signs were T 98, BP 120/60, HR 66,
RR 8, O2sat 99%4L. 100 mg hydrocortisone, started on levophed
for subsequent hypotension, kayexilate/insulin/glucose for
hyperkalemia, renal consult for ARF, Vanc/zosyn for possible
sepsis. Bedside FAST u/s was negative for bleeding. Narcane
produced agitation and agressive bahaviour, pt started on
empiric heparin drip for possible PE given history.
ROS not obtained as pt barely arousable.
Past Medical History:
- anti social behaviour leading to discharge from shelters,
- munchhausens syndrome
- s/p STEMI w/ BMS in LAD in [**10-1**], due to GI bleed stopped
plavix cont only aspiring
- Malignant Hypertension: thought to be secondary to medication
non-compliance, but had hypotension during recent admission in
[**10-31**] and BP meds were cut back. (most likely due to Clonidine
effect: overdose/ withdrawal)
- Pulmonary Embolus: Recurrent [**Month/Year (2) 11011**] s/p IVC filter , not on
coumadine due to non compliance
- Heroin abuse: methadone maintenance clinic [**Street Address(2) 11016**]
daily at 7AM (most recent daily dose on [**Month (only) 462**] 135 mg daily.
- Hepatitis B previous infection, now sAg negative
- Hepatitis C, undetectable HCV RNA [**3-29**]
- Chronic obstructive pulmonary disease
- Gastroesophageal reflux disease
- PTSD ([**Country 3992**] veteran)
- Anxiety / Depression
- Antisocial personality disorder
- Microcytic anemia
- Vitamin B12 deficiency
- Chronic kidney disease baseline Cr 1.5
Social History:
[**Country 3992**] veteran. Past heroin abuse, now on methadone. On
disability. Currently living at [**Doctor Last Name **] House.
Family History:
Father died of myocardial infarction at unknown age. Mother died
of pancreatic cancer.
Physical Exam:
VS: T 97.7, BP 112/77, HR 60, RR 18, O2sat 100% RA
GENERAL: caucasian male somnolent, withdraws to pain, resists
eye exam
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP flat
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. bradycardic with RR, and soft heart sounds. No mumur
appreciated though.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, with crackles at
the bilateral bases
ABDOMEN: +BS Soft, NT,ND. No HSM or tenderness.
EXTREMITIES: trace pitting edema bilateral LE.
SKIN: Several excoriations over his extremities and ecchymoses.
Pertinent Results:
Admission labs:
[**2108-12-1**] 01:00PM BLOOD WBC-4.5 RBC-3.04* Hgb-8.6* Hct-25.5*
MCV-84 MCH-28.3 MCHC-33.7 RDW-14.9 Plt Ct-190
[**2108-12-1**] 01:00PM BLOOD Neuts-62.9 Lymphs-24.5 Monos-3.8 Eos-8.1*
Baso-0.8
[**2108-12-1**] 01:00PM BLOOD PT-16.6* PTT-35.6* INR(PT)-1.5*
[**2108-12-1**] 01:00PM BLOOD Glucose-82 UreaN-53* Creat-3.7*# Na-133
K-6.2* Cl-97 HCO3-26 AnGap-16
[**2108-12-1**] 01:00PM BLOOD ALT-12 AST-20 CK(CPK)-468* AlkPhos-71
TotBili-0.4
[**2108-12-1**] 01:00PM BLOOD Lipase-18
[**2108-12-1**] 01:00PM BLOOD cTropnT-0.06*
[**2108-12-1**] 01:00PM BLOOD Calcium-8.5 Phos-6.2*# Mg-2.8*
[**2108-12-2**] 03:59AM BLOOD calTIBC-220* Ferritn-195 TRF-169*
[**2108-12-2**] 02:13PM BLOOD PTH-143*
[**2108-12-1**] CT Head: IMPRESSION: No evidence of acute intracranial
process seen including acute intracranial hemorrhage. Exam is
unchanged from multiple recent prior studies except to note
small locules of gas along the muscles of mastication on the
right, which are of uncertain clinical significance. If acute
infarction remains a concern, MRI would be recommeneded for more
sensitive evaluation.
[**2108-12-1**] CXR:
IMPRESSION: Mild cardiomegaly, with bibasilar atelectasis and
pulmonary
vascular prominance, likely accentuated due to low lung volumes.
No overt
heart failure.
[**2108-12-1**] Bilat Lower extremity ultrasound: IMPRESSION:
1. No evidence of DVT seen in either lower extremity.
2. Interval resolution of thrombosis involving the right common
femoral vein through the right upper calf veins, as seen on most
recent prior ultrasound of [**2108-10-28**].
3. Diffusely decreased respiratory variation in venous waveforms
again
suggestive of more proximal thrombosis.
[**2108-12-1**] Renal US: IMPRESSION: No evidence of hydronephrosis.
Allowing for patient motion, no definite stone or renal mass
seen. Diffusely increased renal echotexture again consistent
with medical renal disease.
[**2108-12-1**] CT abd/pelvis: IMPRESSION:
1. Bibasilar patchy pulmonary opacities, could be consistent
with aspiration, pneumonia, or atelectasis.
2. Cardiac enlargement, with small pericardial effusion.
3. No evidence of abdominal or pelvic hematoma.
4. Expansion and thickening of the IVC (inferior to the IVC
filter), common iliac veins, right external iliac vein, and
right common femoral vein are again consistent with chronic
thrombosis, with many collateral vessels noted along the
anterior abdominal wall.
5. Moderate-to-large amount of stool.
6. Small hyperdense lesions in the right kidney are unchanged,
possibly
representing hyperdense cysts. No evidence of hydronephrosis or
stone noted in the kidneys.
[**2108-12-3**] TTE: The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the distal segments and probable dyskinesis
of the apex. A left ventricular mass/thrombus cannot be
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets appear structurally normal
with good leaflet excursion. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The tricuspid regurgitation jet is
eccentric and may be underestimated. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2108-11-21**],
global LV systolic function is slightly better. The distal
segments remain hypokinetic. The degree of mitral regurgitation
has decreased. The LV thrombus seen on the echo of 10//[**3-31**] is
not seen on the current study.
Brief Hospital Course:
This is a homeless 61 year old male with a past medical history
of medication overdose with clonidine, repeat acute renal
failure and recent STEMI status post bare metal stent to LAD,
hypertension/hyotension, post-tramatic stress disorder, and
depression who presents with hypotension somnolence.
# Hypotension/somnolence: Symptoms consistent with and likely
due to Clonidine overdose (bradycardia, hypotension and
lethargy, miosis). This has occurred before in setting of
patient's Munchausen syndrome. Patient was monitered in the
intensive care unit, with supportive therapy and improvement of
his symptoms, and was stable enough to come to the regular floor
where his outpatient medications were re-started.
.
# Acute on chronic renal failure: Acute on chronic renal
failure, most likely due to hypotension in the setting of
medication overdose. Resolved with IV fluids and supportive
management. Renal was involved.
.
# Anemia: Guiac negative, remained stable.
.
# Chronic systolic congestive heart failure: Remained stable,
maintained outpatient medications.
.
# History of DVT/Recurrent Pulmonary Emboli, status post IVC
filter: Stable.
.
# Chronic Obstructive Airway Disease: Continued outpatient
therapy.
.
# Psychiatric disorder/Post-traumatic stress
disorder/Munchausen's: Social work was involved during hospital
course. Patient should seek outpatient follow up with
psychiatry.
.
# Gastroesophageal reflux disease: Continued outpatient prilosec
20 mg [**Hospital1 **].
Medications on Admission:
Tamsulosin 0.4 mg
Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device
Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS
Omeprazole 20 mg Capsule, [**Hospital1 **]
Gabapentin 300 mg [**Hospital1 **]
Lisinopril 5 mg
Metoprolol Succinate 25 mg Tablet Sustained Release
Methadone 135 mg PO daily ([**Street Address(1) 11017**] clinic)
Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler \
Duloxetine 60 mg Capsule, Delayed Release once a day.
Clonazepam 2 mg Tablet Sig: One Tablet PO three times a day.
Aspirin 81 mg Tablet
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Methadone 10 mg Tablet Sig: One [**Age over 90 10973**]y Five (135) mg
PO DAILY (Daily).
11. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Toxic ingestion
Secondary:
Muchausen's Syndrome
Coronary artery disease
[**Last Name (un) 11020**] systolic congestive heart failure
Discharge Condition:
Good. Patient with stable vital signs.
Discharge Instructions:
You were admitted with toxic ingestion of your outpatient
medications. You were monitered and managed supportively with
improvement in your symptoms.
Please take medications AS DIRECTED.
Please follow up with [**Last Name (un) 4314**] as directed.
Please contact physician if develop chest pain/pressure,
shortness of breath, fevers/chills, any other questions or
concerns.
Followup Instructions:
Please follow up with these previously scheduled [**Last Name (un) 4314**]:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2108-12-18**] 2:00
Provider: [**Name10 (NameIs) 11021**] [**Name11 (NameIs) 11022**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-12-27**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-12-27**] 3:00
ICD9 Codes: 5849, 2767, 4280, 5859, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4294
} | Medical Text: Admission Date: [**2177-11-24**] Discharge Date: [**2177-12-4**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
AMS / Hypotension
Major Surgical or Invasive Procedure:
Central Venous Catheterization
PICC placment
A-line placement
History of Present Illness:
88F with CHF (TR and MR), HTN, Afib and dyslipidemia was
unresponsive at Nursing home today. Found to be in septic shock.
.
Ms. [**Known lastname **] was admitted to [**Hospital1 18**] from [**Date range (1) 107001**] with subacute
complaints consistent with the ultimate findings of old MI and
acute CHF. During this admission, a 6 cm infrarenal AAA with
mural calcium and thrombus was detected and a TTE revealed an EF
of 30% and 2+MR with 3+TR. Had been living at a [**Hospital **] rehab
from [**10-29**] to [**11-14**]. There they continued her lasix-diuresis with
good effect, with a discharge weight of 161 lbs. She developed
afib that was controlled with digoxin and was in NSR on [**11-14**].
They deferred coumadin given noncompliance and hx of falls. No
summary of [**11-14**] to [**11-24**] is provided by the NH, who were also
unavailable for questioning on repeated phone calls.
In ED, triage vitals were: 101.1 111 77/49 20 . She had an
inferolat ST depressions; labs indicative of sepsis (WBC 23 with
11% bands and floridly positive UA), shock ([**Last Name (un) **] with Cr 2.2,
elevated liver enzymes, lactate 5.6) and cardiac compromise
(Troponin of 4.87 and BNP > 30,000). She received 5L of NS,
Vanc, Zosyn. Was started on Neo, Levo. She was intubated for
airway protection. A right IJ was placed. Of note, a CT scan was
ordered to evaluate her AAA and it confirmed pyelonephritis.
.
She came to the ICU where she received Azithromycin and steady
fluid boluses. An a-line was placed. Stress dose steroids were
started. Serial LR boluses and variable dose of 2 pressors
resulted in gradual urine output.
Past Medical History:
CHF, recent NSTEMI ([**10-22**])
PAF
AAA: found incidentally on CT [**10-25**], 6.2cm and asymptomatic
Hypertension
s/p cholecystectomy
s/p hysterectomy
Thyroid nodule, Adrenal nodules
Social History:
-Tobacco history: smoked 2ppd x 60yrs (120 pk yrs)-quit 10yrs
ago
-ETOH: denies
-Illicit drugs: denies
Lives in senior facility at [**Street Address(2) 107000**] in [**Location (un) **] on [**Location (un) **] apt with husband of 43 years. Walks with cane. Worked for
bank in past. No children. No stairs to walk, able to ambulate
around apartment without difficulty.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GEN: intubated, sedated, no posturing
HEENT: PERRL, weak but positive corneal reflex bilaterally,
anicteric, dryMM, op without lesions, no supraclavicular or
cervical lymphadenopathy, no jvd, no carotid bruits, no
thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout (anteriorly)
CV: Tachy w/RR, S1 and S2 wnl, soft systolic apical murmur
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 1+ pitting edema bilateral legs. Nonpalpable DP/PT
bilaterally but [**Doctor First Name **] warm/dry. Thready radial pulse bilaterally,
cool and clammy hands with dry/warm foreams.
SKIN: no rashes/no jaundice/no splinters
NEURO: sedated, intubated, as above
RECTAL: deferred
GU: foley in place with brown/red "sludgey" urine
Pertinent Results:
CBC
[**2177-11-24**] 09:28AM BLOOD WBC-23.2*# RBC-3.93* Hgb-12.0 Hct-35.9*
MCV-91 MCH-30.6 MCHC-33.5 RDW-15.3 Plt Ct-171
[**2177-11-24**] 02:46PM BLOOD WBC-33.1* RBC-3.68* Hgb-11.3* Hct-35.6*
MCV-97 MCH-30.8 MCHC-31.8 RDW-15.2 Plt Ct-194
[**2177-11-25**] 04:06AM BLOOD WBC-37.7* RBC-3.50* Hgb-10.7* Hct-32.7*
MCV-94 MCH-30.6 MCHC-32.7 RDW-15.4 Plt Ct-134*
[**2177-11-26**] 04:01AM BLOOD WBC-34.8* RBC-3.54* Hgb-11.1* Hct-33.0*
MCV-93 MCH-31.4 MCHC-33.7 RDW-15.2 Plt Ct-106*
[**2177-11-26**] 11:41AM BLOOD WBC-33.6* RBC-3.56* Hgb-10.8* Hct-32.8*
MCV-92 MCH-30.3 MCHC-33.0 RDW-15.5 Plt Ct-90*
[**2177-11-28**] 03:48AM BLOOD WBC-20.2* RBC-3.05* Hgb-9.5* Hct-27.4*
MCV-90 MCH-31.2 MCHC-34.8 RDW-15.5 Plt Ct-52*
[**2177-12-4**] 03:32AM BLOOD WBC-17.1* RBC-2.60* Hgb-8.3* Hct-23.9*
MCV-92 MCH-32.0 MCHC-34.8 RDW-16.2* Plt Ct-216
CHEM &
[**2177-11-24**] 09:28AM BLOOD Glucose-105* UreaN-34* Creat-2.2*# Na-143
K-3.6 Cl-105 HCO3-21* AnGap-21*
[**2177-11-24**] 02:46PM BLOOD Glucose-137* Na-145 K-3.5 Cl-113*
HCO3-18* AnGap-18
[**2177-11-24**] 09:47PM BLOOD Glucose-194* UreaN-28* Creat-2.1* Na-140
K-3.5 Cl-114* HCO3-12* AnGap-18
[**2177-12-1**] 02:41PM BLOOD Glucose-126* UreaN-115* Creat-3.8* Na-134
K-5.3* Cl-103 HCO3-18* AnGap-18
[**2177-12-2**] 03:42AM BLOOD Glucose-99 UreaN-126* Creat-4.4* Na-136
K-5.6* Cl-99 HCO3-19* AnGap-24*
[**2177-12-4**] 03:32AM BLOOD Glucose-137* UreaN-143* Creat-4.8*
Na-131* K-5.3* Cl-92* HCO3-22 AnGap-22*
Liver Enzyme
[**2177-11-24**] 09:28AM BLOOD ALT-51* AST-106* CK(CPK)-154 AlkPhos-129*
TotBili-1.6*
[**2177-11-28**] 03:48AM BLOOD ALT-66* AST-57*
[**2177-12-4**] 03:32AM BLOOD ALT-134* AST-251* LD(LDH)-486*
AlkPhos-417* Amylase-118* TotBili-0.7
Cardiac Enzymes
[**2177-11-24**] 09:28AM BLOOD CK-MB-10 MB Indx-6.5* proBNP-[**Numeric Identifier **]*
[**2177-11-24**] 09:28AM BLOOD cTropnT-4.87*
[**2177-11-24**] 02:46PM BLOOD CK-MB-15* MB Indx-7.1* cTropnT-5.79*
[**2177-11-24**] 09:44PM BLOOD CK-MB-20* MB Indx-9.0*
[**2177-11-25**] 04:06AM BLOOD CK-MB-20* MB Indx-11.9* cTropnT-4.57*
Sample of Blood Gases
[**2177-11-24**] 02:58PM BLOOD Type-CENTRAL VE FiO2-70 pO2-47* pCO2-47*
pH-7.20* calTCO2-19* Base XS--9
[**2177-11-24**] 05:01PM BLOOD Type-ART pO2-179* pCO2-34* pH-7.23*
calTCO2-15* Base XS--12
[**2177-11-24**] 07:30PM BLOOD Type-ART pO2-176* pCO2-32* pH-7.22*
calTCO2-14* Base XS--13
[**2177-12-3**] 05:13AM BLOOD Type-ART Temp-36.3 pO2-116* pCO2-39
pH-7.40 calTCO2-25 Base XS-0 Intubat-INTUBATED
[**2177-12-3**] 12:28PM BLOOD Type-MIX pO2-34* pCO2-55* pH-7.29*
calTCO2-28 Base XS--1
[**2177-12-3**] 04:47PM BLOOD Type-MIX Temp-36.8 pO2-36* pCO2-49*
pH-7.31* calTCO2-26 Base XS--2
Blood Culture, Routine (Final [**2177-11-27**]):
KLEBSIELLA OXYTOCA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Ms [**Known lastname **] was an 88 y/o woman with CHF, hx of recent NSTEMI and
PAF who presented from her nursing home with klebsiella
urosepsis and an NSTEMI. Her early-goal directed resuscitation
was vigorous and successful. However, she was 29 litres positive
therafter and within 3 days of her death, unable to eliminate
the fluid, unable to wean from the ventillator and progressively
pressor dependent. Presented with options for further care,
including CVVH, her husband and HCP chose to make her [**Name (NI) 3225**] in
accordance with her wishes.
Septic Shock from Klebsiella pyelonephritis.
Thrombocytopoenia of Sepsis
Ms [**Known lastname **] was aggressively rescusitated and treated for septic
shock using LR boluses, 2 initial pressors, and steroids. She
became independent of pressors but in the days before her death
developed a new pressor dependence of unclear source. She became
profoundly thrombocytopoenic during her recovery. HIT negative
and briefly on argatroban with a hem-onc consultation. It was
likely the Thrombocytopoenia of Sepsis, a negative prognostic
sign.
NSTEMI
CHF exacerbation
Ms [**Known lastname **] had a markedly elevated BNP as well as an NSTEMI on
arrival that likely occured in the setting of her febrile
illness. Nevertheless, she did tolerate the initial
resuscitation but could not ultimately handle the fluid overload
(below). She was treated with aspirin and statin.
Fluid overload
Ms [**Known lastname **] was aggressively fluid resuscitated and could not
eliminate the fluid after stabilization. Renal followed
throughout. Increasingly aggressive attempts at diuresis
including creative staggering of massive lasix and diuril
boluses, lasix drips and metolazone were ultimately ineffective.
Atrial Fibrillation
Hypotension in the final days was partially attributable to
rate. Cautious betablockade failed. Amiodarone drip was begun
with success vis-a-vis rate but not with regards to pressure.
Goals of care.
There was unclear documentation about the patient's goals of
care with some documents hinting at DNR/DNI and others not. Her
PCP was [**Name (NI) 653**] in the [**Name (NI) **] and suggested a full code. Her
husband was initially also in agreement with full code. Repeated
attempts were made to contact other providers without success.
Her husband, who later suggested that no more procedures ought
to be done and the nursing home social worker were involved in a
series of meetings wherein the ultimate decision of [**Name (NI) 3225**] was made
as her condition steadily worsened.
Medications on Admission:
1. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
2. docusate sodium 100 mg [**Hospital1 **]
3. furosemide 40 mg PO daily
4. Digoxin 0.125 mg qd
5. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. lisinopril 5mg qd.
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2177-12-4**]
ICD9 Codes: 5849, 2875, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4295
} | Medical Text: Admission Date: [**2188-7-25**] Discharge Date: [**2188-7-30**]
Date of Birth: [**2148-4-3**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for Pcom aneurysm clipping
Major Surgical or Invasive Procedure:
[**2188-7-25**] Open right-sided hemicraniotomy and Pcom aneurysm
clipping [**2188-7-25**] Diagnostic cerebral angiogram
History of Present Illness:
Ms. [**Known lastname 91495**] is a 40-year-old right-handed female with h/o
aneurysmal subarachnoid hemorrhage s/p Pcom aneurysm coiling
([**2187-11-6**]). Follow-up angiogram on [**2188-6-30**] revealed that
the aneurysm had recanalized at the base. Though this does not
pose any risk for rupture at this point, given patient's young
age this would have to be treated at some point. It was felt
that this would be best treated through an open craniotomy and
clipping as the aneurysm could be recanalized again and coiled.
Patient is therefore now electively admitted to undergo open
craniotomy and clipping of her PCom aneurysm.
Past Medical History:
Migraines
Depression
Hypercholesterolemia
Appendectomy
Tonsillectomy
Social History:
She works as a dental assistant and is currently laid off. She
quit smoking after subarachnoid hemorrhage and takes about four
glasses of wine a few times a week.
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAM PRIOR TO ADMISSION ([**2188-7-10**], per Dr. [**First Name (STitle) **] clinic
note):
Patient awake, alert, oriented x3. Her memory recent and remote
is good. Attention and concentration is appropriate. Language
and fund of knowledge is good. Cranial nerves were intact. Her
motor strength is [**5-10**] in all four
extremities. Gait and coordination were normal.
PHYSICAL EXAM ON DISCHARGE:
AVSS, NAD, AxOx4
symmetric chest rise, breathimg comfortably
incision on scalp, c/d/i
symmetric smile
CNII-XII intact
EOMI, PERRL
Strength/motor: LUE: 4+ D/B/Tr, 4-IO, LLE: 5 IS/Q/H/[**Last Name (un) 938**]/TA/GS,
RUE: 5 D/B/Tr/WF/WE/IO, RLE: 5 IL/Q/H/TA/[**Last Name (un) 938**]/GS
SITLT R U M Sa [**Doctor First Name **] SP DP Bilat
BL wwp, 2+cr, 2+dp/pt BL, 2+ R
Pertinent Results:
CEREBRAL ANGIOGRAM ([**2188-6-30**]):
-IMPRESSION: Previously coiled right posterior communicating
artery aneurysm has recanalized and the left internal carotid
artery posterior communicating segment aneurysm is unchanged.
POST-OP NONCONTRAST HEAD CT ([**2188-7-25**]):
1. Probable small amount of blood in the right sylvian fissure
s/p clipping of the right posterior communicating artery
aneurysm. Evaluation is limited by streak artifacts from the
clips and coils.
2. Mostly air-filled extraaxial collection underlying the right
craniotomy, with mild right frontal sulcal effacement, mild
ventricular effacement, and 3 mm leftward shift of midline
structres.
3. Apparent low density projecting over the right frontal lobe
may be related to artifacts from the overlying scalp staples.
Recommend close attention on follow up imaging to exclude the
possibility of edema.
NONCONTRAST HEAD CT ([**2188-7-26**]): Allowing for streak artifacts,
there is no evidence of new hemorrhage or edema. The extraaxial
collection underlying the right craniotomy has slightly
decreased in size.
CT Perfusion/CT Angiogram ([**2188-7-26**]):
Status post coiling and clipping of the right PCOM aneurysm, it
is difficult to assess for residual aneurysm at this location
due to artifact.
The remaining neck vasculature appears patent.
New hemorrhage in the right basal ganglion.
No large territorial perfusional defects on the CTP.
CT HEAD W/O CONTRAST [**2188-7-27**]
1. Stable right basal ganglia hemorrhage measuring 2.2 cm. No
new area of hemorrhage.
2. Stable 5-mm leftward shift of midline structures.
3. Post-surgical changes from right frontoparietal craniotomy.
Brief Hospital Course:
Patient was admitted to the hospital on [**7-25**]. That day she
underwent elective right craniotomy with clipping of right
posterior communicating artery aneurysm. Intraoperatively there
were no complications, but the right PComm did have to be partly
sacrificed with expectectation that collateral circulation would
provide perfusion. Post-op neuro exam was non-focal. Post-op
head CT showed minimal blood in right sylvian fissues s/p
aneurysm clipping as well as expected post-op changes; no
hemorrhage or edema. SBP was strictly controlled between
140-160mmHg postoperatively.
On HD #2 (POD #1) patient was noted to have decreased strength
([**2-10**]) in distal left lower extremity. Repeat head CT showed no
new hemorrhage or edema. However, as there was concern for
ischemia secondary to partial PComm sacrifice, but collaterals
were seen on angio that which showed there was adequate flow.
She was started on heparin drip and her SBP parameters were
increased to 160-180. Later that evening, patient was seen to
have new LUE weakness and lethargy. A stat head CT was performed
which showed a new R basal ganglia hemorrhage. Heparin was
discontinued and protamine was given. Her systolic blood
pressure parameters were lowered to 100-140 and IVF were also
decreased.
On [**7-27**], aspirin was stopped and repeat head CT showed stable
hemorrhage. On [**7-28**], her exam improved with LUE 4-/5 and LLE
5-/5. Pt was then transferred to the floor with continued
improvement in exam as depicted in final exam upon discharge
above. The patient made steady progress with PT and was deemed
safe to go home with physical therapy services. The patient at
time of discharge expressed readiness for discharge and all
questions were answered. The patient will require follow-up as
listed below for her medical conditions. She was discharged home
on [**2188-7-30**].
Medications on Admission:
ASA 325
Zantac qd
Topomax (dose unknown)
Zoloft (dose unknown)
Loratadine 10mg daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN pain
do not exceed 4 grams in 24 hours
2. Bisacodyl 10 mg PO/PR DAILY
3. Docusate Sodium 100 mg PO BID
4. Ibuprofen 400 mg PO Q8H:PRN Pain
5. LeVETiracetam 1000 mg PO BID
RX *Keppra 1,000 mg 1 tablet(s) by mouth twice a day Disp #*90
Tablet Refills:*0
6. Loratadine *NF* 5 mg Oral daily Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
7. Omeprazole 20 mg PO DAILY
8. Senna 1 TAB PO BID
9. Simvastatin 10 mg PO DAILY
home medication
10. Topiramate (Topamax) 25 mg PO QAM pain
home medication
11. Topiramate (Topamax) 50 mg PO QPM
home medication
12. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN headcahe
hold rr < 12
RX *Dilaudid 2 mg 1 tablet(s) by mouth Q4hr Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right Pcom aneurysm
Right BG hemorrhage
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:
Craniotomy for aneurysm clipping
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? **Your wound was closed with sutures/staples. You may wash
your hair only after sutures and/or staples have been removed.
?????? **Your wound was closed with dissolvable sutures, you must
keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? **You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? **You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101.5?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office at 10 days from your date of
surgery for removal of your staples/sutures. This appointment
can be made with the Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) **] [**Name Initial (PRE) 19158**].
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????**You may also have them removed at your rehab facility.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **] to be seen in 4 weeks.
??????You will not need a CT scan of the brain.
Completed by:[**2188-8-4**]
ICD9 Codes: 431, 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4296
} | Medical Text: Admission Date: [**2153-8-23**] Discharge Date: [**2153-9-2**]
Date of Birth: [**2083-6-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
ventricular fibrillation - cardiac arrest
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2153-8-23**]
Cornary artery bypass graft x2 (Left internal mammary artery >
Left anterior descending artery, saphenous vein graft >
Posterior descending artery) [**2153-8-11**]
History of Present Illness:
70 year old male transferred from [**Hospital3 3583**] for emergent
therapeutic catheterization. He was playing basketball yesterday
with some friends. [**Name (NI) **] after he was done playing, he sat on the
bench to rest and watch other players running by him. He then
felt slightly dizzy, and the other players appeared blurry and
fuzzy, and then he lost consciousness. He had no palpitations or
chest pain. He was later told by witnesses that he fell from the
bench, hit his head on the ground. He was found to be in VF
arrest, was out for about 2 minutes before the EMTs started CPR,
and he was shocked 3 tmes with AED before his pulses came back.
He woke up in the ambulance, confused about where he was and was
initially very combative. He arrived at [**Hospital3 3583**] awake
and alert and oriented in NSR.
Past Medical History:
Hypertension
metastatic renal cell CA to cerv. nodes [**2139**]
Elevated lipids
Chronic kidney disease
metastatic renal cell cardinoma (to cervical lymph nodes
[**2138**])
s/p neck [**Doctor First Name **]
Gout
Cataracts
s/p left nephrectomy
s/p cervical lymph node dissection [**2139**]
Social History:
He is a father of 2 adult daughters, 6 [**Name2 (NI) 18198**].
retired limo driver and cares for his grandchildren several days
a week
No alcohol.
Tobacco history: He smoked 2 packs a day for 40 years, quit at
the diagnosis of renal cell cancer.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. His mother died of cervical cancer. He
is estranged from his father.
Physical Exam:
VS: temperature not recorded. 120/60, 48, 20
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.
CARDIAC: bradycardic. PMI located in 5th intercostal space,
midclavicular line. RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
CATH SITES: c/d/i. Nontender to palpation.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Brief Hospital Course:
Transferred in for cardiac evaluation and underwent cardiac
catherization that revealed coronary artery disease.
Electrophysiology was consulted due to ventricular fibrillation.
Echocardiogram revealed decreased left ventricular function and
underwent preoperative workup for cardiac surgery. On [**8-28**] he
was brought to the operating room and underwent coronary artery
bypass graft surgery. See operative report for further details.
He received vancomycin for perioperative antibiotics. He was
transported to the intensive care unit for hemodynamic
management. Mr. [**Known lastname 18199**] was weaned and extubated from the
ventilator on the eve of POD 0. On POD#1 he was started on
betablockers, diuretics, and statin therapy and was transferred
from the ICU to the floor. His chest tubes and wires were
removed per protocol. He was evaluated and treated by physical
therapy and was cleared for discharge to home on POD#5.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth daily
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily
Metoprolol succinate - 25mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Primary diagnoses:
- Coronary artery disease
- Ventricular fibrillation
Secondary diagnoses:
- Hypertension
Discharge Condition:
Stable, afebrile, ambulating.
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] - please call to schedule
wound check as arranged by [**Hospital Ward Name 121**] 6 nurses [**Telephone/Fax (1) 170**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2154-2-12**] 4:30
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2153-9-11**] 9:20
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 18200**], MD (PCP) Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2153-9-12**] 1:45
Completed by:[**2153-9-2**]
ICD9 Codes: 4275, 5859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4297
} | Medical Text: Admission Date: [**2126-5-20**] Discharge Date: [**2126-5-23**]
Date of Birth: [**2049-3-11**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
STEMI, V fib arrest
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2126-5-20**] s/p stent to RCA
History of Present Illness:
77 yo [**Hospital1 100**]-speaking man with PMH significant for
hypercholesterolemia, ? CAD (no MI). Per daughter, patient
awoke "not right," had syncopal episdoe while lying in bed. Dtr
called EMS. When EMS arrived, patient was cool, clammy, and
diaphoretic. Initial BP 80/40. Upon arrival to ED, he
complained of hand pain. EKG showed huge STE inferiorly.
Patient given 4 baby aspirin, heparin gtt, plavix bolus.
Patient noted to suddenly be in VF. AED applied. Patient
shocked x2 with return of normal sinus rhythm. He was intubated
for airway protection and brought to cath lab. Cath showed
severe 3VD and his RCA was stented. He was transferred to the
CCU.
Past Medical History:
- Hypercholesterolemia
- Posterior decompression for cervical stenosis [**2119**]
- L retrobulbar bony growth
- episode of chest pain 7 years ago -- likely negative stress
test
Social History:
lives in [**Country **] with wife. Here visiting daughter and
son-in-law. Does not smoke, drink alcohol, or use illicit drugs.
Does not exercise [**1-9**] chronic back pain.
Family History:
Unknown
Physical Exam:
T 96.6, BP 127/38, HR 72, RR 18, SaO2 100% on PS 5/5 40% FIO2,
then 95% on shovel mask
GEN - NAD, A&Ox3 (post-extubation)
HEENT - L eye proptosis, R eye EOMI, pupil round, reactive
NECK - no JVD
HEART - nl s1s2, RRR, no mrg
LUNGS - CTAB anterolaterally
ABD - soft, NT, ND, NABS
EXT - no edema, 2+ DP pulses
Pertinent Results:
[**2126-5-23**] 06:56AM BLOOD WBC-8.1 RBC-3.33* Hgb-11.0* Hct-30.3*
MCV-91 MCH-33.0* MCHC-36.3* RDW-12.8 Plt Ct-186
[**2126-5-22**] 01:07AM BLOOD WBC-8.2 RBC-3.63* Hgb-11.5* Hct-33.4*
MCV-92 MCH-31.7 MCHC-34.4 RDW-13.4 Plt Ct-174
[**2126-5-20**] 09:15AM BLOOD Neuts-34.3* Bands-0 Lymphs-58.4*
Monos-5.6 Eos-1.1 Baso-0.6
[**2126-5-23**] 06:56AM BLOOD Plt Ct-186
[**2126-5-23**] 06:56AM BLOOD PT-13.2 PTT-41.5* INR(PT)-1.2
[**2126-5-20**] 09:15AM BLOOD PT-11.5 PTT-23.0 INR(PT)-0.9
[**2126-5-20**] 09:15AM BLOOD Plt Smr-NORMAL Plt Ct-232
[**2126-5-22**] 04:40PM BLOOD Fibrino-586*
[**2126-5-23**] 06:56AM BLOOD Glucose-86 UreaN-8 Creat-0.9 Na-141 K-3.8
Cl-107 HCO3-27 AnGap-11
[**2126-5-20**] 09:15AM BLOOD Glucose-105 UreaN-20 Creat-1.0 Na-140
K-4.1 Cl-105 HCO3-29 AnGap-10
[**2126-5-22**] 01:07AM BLOOD ALT-28 AST-61* CK(CPK)-645* AlkPhos-39
TotBili-0.5
[**2126-5-21**] 04:03AM BLOOD ALT-32 AST-94* LD(LDH)-346* CK(CPK)-1079*
AlkPhos-38* Amylase-49 TotBili-0.7
[**2126-5-20**] 05:08PM BLOOD CK(CPK)-694*
[**2126-5-20**] 09:15AM BLOOD CK(CPK)-66
[**2126-5-21**] 04:03AM BLOOD Lipase-22
[**2126-5-21**] 04:03AM BLOOD CK-MB-30* MB Indx-2.8
[**2126-5-20**] 05:08PM BLOOD CK-MB-78* MB Indx-11.2* cTropnT-1.88*
[**2126-5-20**] 09:15AM BLOOD cTropnT-0.02*
[**2126-5-23**] 06:56AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.9 Iron-PND
[**2126-5-20**] 09:15AM BLOOD Cholest-227*
[**2126-5-22**] 01:07AM BLOOD Hapto-145
[**2126-5-20**] 09:15AM BLOOD Triglyc-82 HDL-56 CHOL/HD-4.1
LDLcalc-155*
pre-cath EKG: NSR at 57 bpm, nl intervals, nl axis, 4 mm STE II,
III, F, 1-[**Street Address(2) 5366**] depression in aVL, I, V2, V3, V5, V6.
.
post-cath EKG: NSR at 63 bpm, nl axis, nl intervals, STE
resolved, TWI in III and TW flattening in F.
Cardiac Cath [**2126-5-20**]: LMCA 20% ostial, LAD total occlusion after
D1, D1 with diffuse 80%, LCX diffuse with serial 60-70% mid LCX
into large OM2, RCA 99% mid with thrombus, ulceration; R>L
collaterals to the LAD
- RCA lesion was stented
- RA 8, RV 24/7, PA 24/14, PCWP 16, CO 3.30 (Fick), CI 2.23
Echo: [**2126-5-20**]
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Resting
regional wall
motion abnormalities include inferior, septal and apical
hypokinesis (views suboptimal). Left ventricular ejection
fraction ?45%. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
Brief Hospital Course:
77 yo man with hypercholeterolemia s/p inferior STEMI and s/p
ventricular fibrillation arrest in ED converted to NSR.
1) CAD - Cardiac catheterization revealed severe 3 Vessel
Disease with thrombus in the RCA that was stented. He was on
integrillen for 18 hours post cath. He was started on aspirin,
plavix, lopressor, lipitor. He should remain on plavix for at
least 6 months. He would benefit from an ACE inhibitor to be
started as an outpatient. We did not start it here because his
blood pressure was somewhat low. We recommend further
revascularization either by CABG or PCI in the future. If his
anterior wall function is preserved he may have increased
benefit from CABG. It may be advisable to wait a few months to
allow the RCA stent to heal and ensure there is no acute
stenosis before taking him for CABG. We recommend repeat echo to
determine his anterior wall function.
2) Hypercholesterolemia: He was started on lipitor 80 mg QD. He
should have CK and liver function tests in 6 weeks.
3) Rhythm: Ventricular fibrillation arrest in setting of acute
inferior MI. He was shocked in the ER with return to NSR. He had
a few episodes of NSVT on telemtry which is to be expected post
MI. He does not need to have an ICD placed given the MI likely
caused his ventricular fibrillation.
4) Cardiac function: Echo on [**5-21**] after catheterization with EF
of ~45%. He also had hypokinesis of apex, septum, and inferior
wall. He does not need anticoagulation given his preserved EF.
5) Anemia - His hematocrit dropped during his hospital course.
He stabilized at 30. CT scan was obtained without evidence of
retroperitoneal bleed. We think he was dehydrated on admission
and now equilibrating.
Medications on Admission:
Aspirin
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*1*
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*7 Tablet(s)* Refills:*1*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*6*
6. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*6*
7. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO once
a day for 7 days.
Disp:*7 Tablet(s)* Refills:*1*
8. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day for 7 days.
Disp:*7 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute inferior myocardial infarction
Secondary diagnosis:
1. Hypercholesterolemia
2. Posterior decompression for cervical stenosis [**2119**]
3. L retrobulbar bony growth
4. episode of chest pain 7 years ago -- likely negative stress
test
Discharge Condition:
stable
Discharge Instructions:
Please call your primary care doctor or return to the emergency
department if you develop chest pain, shortness of breath, or
other worrisome symptom.
During your hospitalization, you underwent cardiac
catheterization and had a stent placed in the RCA. However, you
have diffuse disease in other arteries to your heart which will
likely need treatment in the future. We have given you all of
the records from this hospitalization so that you can receive
the rest of your care at home is [**Country **].
You also have prescritions for a one week supply (with one
refill) of aspirin, Plavix, Atenolol and Lipitor. It is very
important for you to take these medications daily for your heart
and the stent that was placed. Dr. [**Last Name (STitle) **] should send you these
medicines from [**Country **].
Followup Instructions:
Please follow up with your cardiologist on return to your home
country of [**Country **]. We have given you a copy of all records from
this hospitalization to take with you.
If you have any concerns, you can call [**Hospital6 733**],
[**Telephone/Fax (1) 250**]. You can ask for an appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1923**]. If she is not available, you can see a covering
doctor. Also, the number for the Cardiology Department (Dr.
[**Last Name (STitle) **] is [**Telephone/Fax (1) 2386**], if you have other concerns.
ICD9 Codes: 4275, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4298
} | Medical Text: Admission Date: [**2119-6-26**] Discharge Date: [**2119-7-17**]
Service: MEDICINE
Allergies:
Amoxicillin / Verapamil / Univasc
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Lower extremity swelling
Major Surgical or Invasive Procedure:
Right internal jugular line placement with replacment over a
guidewire
PICC line placement
History of Present Illness:
[**Age over 90 **] year old female with asthma, atrial fibrillation on
Dabigatran and s/p dual-chamber (RA-RV) PPM in [**5-31**],
hypertension, and heart failure with preserved EF (EF 55% on
[**2119-6-28**] TTE but normal E wave, low deceleration time 133 msec)
and moderate pulmonary hypertension by TTE (TR Gradient + RA =
PASP: 44 mm Hg) who presented to the ED with lower extremity
edema. She reported considerable problems with lower extremity
edema over the weeks preceding admission with an approximately
12-lb weight gain and [**2-23**] pillow orthopnea. She further reported
dyspnea on exertion but not at rest. She has also had two
admissions within the last six weeks for AF with RVR. She had
been doing reasonably well despite persistent lower extremity
edema until the day prior to admision when she tripped and was
unable to get herself off the floor for a few hours due to
weakness.
She denies having any shortness of breath, chest pain, dyspnea
on exertion or palpitations in association with this. She
denies striking her head. Her grandson eventually was able to
help her to her feet and she seemed well without confusion so no
additional assistance was pursued at that time. She did report
three days of persistent cough, intermittently productive of
whitish sputum but denied any fevers. The morning after her fall
(the morning of admission), her family decided to bring her in
for further evaluation given her persistent cough and leg
swelling.
Past Medical History:
-Coronary artery disease
-Paroxysmal atrial fibrillation on dabigatran with dual-chamber
PPM (RA/RV)
-Hypertension
-Hyperlipidemia
-Mild Aortic insufficiency
-Chronic kidney disease (stage III)
-Asthma
-Osteopenia
-Diverticulosis
-Gallstones
-Cataracts
-Internal hemorrhoids
-Allergic rhinitis
-Impaired glucose tolerance
-Breast cancer s/p RIND '[**94**]
-sp TABHSO for dysfunctional bleeding
Social History:
Retired book-keeper at a diamond merchant. She lives with her
sister, who is 14 years younger. Mobilizes with cane, exercise
tolerance 25 meters. Smoking/Tobacco: Never smoked. EtOH: none.
Illicits: none.
Family History:
Mother died from a myocardial infarction at 65 y/o but had T2DM,
PVD, and CHF. Father had Hodgkin's disease and laryngeal
carcinoma. Brother died from pancreatic cancer. Sister has CAD
c/b by MI x2 s/p PCI.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98, P 76, BP 90/51, RR 18
General: Mildly uncomfortable appearing female in NAD
HEENT: atraumatic, normocephalic, MMM, OP clear
Neck: supple, JVP not able to be assessed due to right sided CVL
with some surrounding blood
Lungs: Bilateral expiratory wheezes, mild respiratory distress
on speaking
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound, tenderness or guarding, no organomegaly
GU: Foley
Ext: warm, well perfused, 3+ edema in lower extremities to knee
bilaterally, left lower extremity with 4*4 area of ecchymoses
followed by nontender, slightly indurated red area that is
nontender
DISCHARGE PHYSICAL EXAM:
Gen: alert and resting in bed, pleasant, oriented x 4, NAD
CV: RRR (AV paced) with audible S1/S2, no murmurs or S3
Pulm: poor ae bilaterally due to kyphosis but clear without
rales or wheezes
Abd: soft, NT, ND
GU: no dysuria, no foley
Ext: 2+ radial pulses, 1+ DP pulses bilateral. 1+ bilateral
pitting edema in legs with L stasis dermatitis on the shin
Skin: dry skin throughout, worse on trunck and face with
flaking. Left lower back with 7x4 cm erythematous patch--non
raised, no tenderness or pruritis
Pertinent Results:
Admission Labs:
[**2119-6-26**] 12:30PM BLOOD WBC-13.4* RBC-4.10* Hgb-11.5* Hct-34.0*
MCV-83 MCH-28.1 MCHC-33.9 RDW-16.0* Plt Ct-265
[**2119-6-26**] 12:30PM BLOOD Neuts-83.8* Lymphs-10.9* Monos-4.5
Eos-0.6 Baso-0.2
[**2119-6-26**] 07:13PM BLOOD PT-32.9* PTT-83.2* INR(PT)-3.3*
[**2119-6-26**] 12:30PM BLOOD Glucose-107* UreaN-59* Creat-2.1* Na-130*
K-4.3 Cl-86* HCO3-28 AnGap-20
[**2119-6-26**] 08:15PM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1
.
Cardiac Labs:
[**2119-6-26**] 12:30PM BLOOD CK-MB-7 cTropnT-0.02* proBNP-8710*
[**2119-6-27**] 01:53AM BLOOD CK-MB-5 cTropnT-0.02*
[**2119-7-3**] 03:21AM BLOOD proBNP-[**Numeric Identifier 106093**]*
[**2119-7-9**] 06:30AM BLOOD proBNP-5233*
.
Thyroid Studies:
[**2119-7-10**] 07:00AM BLOOD TSH-6.9*
[**2119-7-11**] 04:15AM BLOOD T3-56* Free T4-1.3
.
EKGs:
1. [**2119-6-26**]: Ventricular paced rhythm with a seven-beat run of an
irregular intrinsic wide complex rhythm of uncertain mechanism
but may be atrial fibrillation. Intermittent atrial pacer
activity also appears to be present. Clinical correlation is
suggested. Since the previous tracing of [**2119-5-27**] uniform atrial
pacing has been replaced by rhythm as outlined.
2. [**2119-7-11**]: Atrial paced rhythm. Left ventricular hypertrophy.
Diffuse ST-T wave abnormalities are non-specific but cannot
exclude myocardial ischemia. Clinical correlation is suggested.
Since the previous tracing of [**2119-6-26**] atrial pacing is now
present throughout and ventricular pacing is not seen.
.
Tib/Fib XRay ([**2119-6-26**]): No acute fracture or dislocation in
either tibia or fibula.
.
Right Shoulder XRay ([**2119-6-26**]): No acute fracture or dislocation.
Findings suggestive of underlying rotator cuff disease.
.
Relevant CXR:
1. [**2119-6-26**]: Mild congestive heart failure with small bilateral
pleural effusions. Opacities within the lung bases may represent
atelectasis but infection or aspiration cannot be excluded.
2. [**2119-6-27**]: Bilateral pleural effusions blunt the pleural sinuses
and obliterate the diaphragmatic contours. They also conceal
major portions of the cardiac silhouette which undoubtedly
represents marked cardiac enlargement. The pulmonary vasculature
is congested with perivascular haze and hazy peripheral
densities in the mid lung field which have now increased in
comparison with the last study and suggest development of
pulmonary edema. No pneumothorax has developed. There is no
evidence of central airway occlusion and occlusion atelectasis
related to mucus airway plugging. Comparison is made with
multiple chest examinations obtained during the last week and
they disclose findings consistent with CHF, continues
progression of pulmonary congestion.
3. [**2119-7-5**]: There is no pulmonary edema or appreciable pulmonary
vascular engorgement. Bilateral pleural effusions,
moderate-to-large on the right and moderate on the left are
stable, obscuring cardiac silhouette, which is probably enlarged
but not changed in the interim. Right PIC line can be traced to
the upper right atrium. No pneumothorax.
.
TTE ([**2119-6-28**]):
Suboptimal image quality. The left atrium is moderately dilated.
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). There is
no ventricular septal defect. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-22**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2119-5-9**], the estimated PA systolic
pressure is lower.
.
TTE ([**2119-7-11**]):
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. IMPRESSION: Mild symmetric left ventricular hypertrophy
with normal global and regional biventricular systolic function.
Mild aortic and mitral regurgitation. Compared with the prior
study (images reviewed) of [**2119-6-28**], severity of tricuspid
regurgitation and degree of pulmonary hypertension have both
decreased.
.
Discharge Labs:
Creatinine 1.9
Potassium 4.7
Sodium 140
Brief Hospital Course:
[**Age over 90 **] y/o female with CAD, atrial fibrillation c/b tachy-brady
syndrome s/p PPM placement, CKD, asthma and heart failure with
preserved EF, who presented with cough, lower extremity edema
and hypotension. Patient was initially treated with
Norepinephrine for hypotension and diuresed on a Lasix drip,
with a loss of approximately 12 pounds. Chest radiography
revealed a possible infiltrate and the patient received 8 days
of antibiotics for a health-care associated pneumonia
(Vancomycin plus Zosyn, which was switched to Cefepime, and,
finally, Levofloxacin to complete the course). No definitive
cause of her initial hypotension was identified, though
interrogation of pacemaker early in her hospitalization revealed
several prolonged episodes of atrial tachycardia (one lasting
approximately 50 hours). Such episodes may have lead to a loss
of atrial kick with subsequent drop in cardiac output. Though
she was treated for an infection, the ICU team did not feel that
septic physiology was to blame for her presentation. Serum AM
cortisol of 26.4 argued against adrenal insufficiency. TSH was
elevated but did not indicate significant hypothyroidism (see
discussion below).
The patient was subsequently transfered to the inpatient
cardiology service to continue care for her hypotension and
acute on chronic kidney disease. Diuresis had been held for 48
hours prior to transfer. Diuresis was intermittently continued
on the cardiology service with little improvement in her
peripheral edema. Patient developed a persistent metabolic
alkalosis and her serum creatinine remained elevated at
approximately 2, up from a baseline of 1.5, which was concerning
for overdiuresis. Urine lytes were not helpful in assessing for
intravascular volume depletion (FEUrea ~ 43%, UNa 33). A TTE did
not reveal evidence of worsening cardiac function or valvular
disease but did reveal a near-normalization of pulmonary artery
pressures as well as loss of a TR gradient, which fit with a
clinical picture of overdiuresis. A diuretic regimen of
torsemide 20 mg PO daily was eventually restarted and patient
was discharged on this regimen.
Other Issues by Problem:
1. Atrial Fibrillation c/b Tachy-Brady Syndrome: Patient had
dual-chamber (RA/RV) [**Company 1543**] pacemaker placed on [**2119-5-26**] for
Tachy-Brady Syndrome. Pacemaker interrogation on admission
revealed frequent and prolonged episodes of atrial fibrillation.
Patient was continued on her Dabigatran throughout admission.
Her Amiodarone was dose reduced from 200 mg PO TID to 200 mg PO
daily as review of records indicated that she may have received
a load as high as 25 grams. She will need to take 200 mg
amiodarone daily for 10 days, then dose reduce to 100 mg daily
for maintenance. Metoprolol required dose reduction due to
hypotension and at discharge was prescribed as metoprolol
succinate (Toprol XL) 25 mg PO daily. Patient was continued on
dabigatran at the time of discharge.
2. Acute on Chronic Kidney Disease: Baseline creatinine in
recent months was ~ 1.5. Her serum creatinine peaked at
approximately 2. Urine lytes did not help in differentiating the
etiology (FEUrea ~ 43%, UNa 33) but other data suggested
overdiuresis. On discharge her Cr stabilzed in the range of
1.8-1.9 after several days of regular diet with oral fluids and
torsemide 20 mg PO daily to maintain treatment of lower
extremity edema.
3. Left Lower Extremity Erythema: Patient was treated for
cellulitis during a recent admission in [**5-1**]. At that time a
LLE US was without evidence of DVT to explain the asymmetry
between the LLE and RLE. She was evaluated for fracture in the
ED but imaging was negative. Her erythema gradually improved
throughout the hospitalization and at the time of discharge
looked like the chronic changes of stasis dermatitis.
4. Leukocytosis: Patient presented with WBC count of 13.4 with
neutrophil predominance though no bands or atypicals. WBCs
intermittently as high as 19.2. Blood cultures negative on
admission. UA negative on admission (no urine culture
performed). Cough and CXR suggestive of consoliation concerning
for HCAP, for which she received 8 days of appropriate
antibiotics. C. difficile toxin negative by EIA once. Patient
remained afebrile following transfer to the cardiology service.
Her leukocytosis resolved prior to discharge. Ultimately, it was
likely due to possible infection or stress response.
5. Metabolic Alkalosis: Patient developed elevated serum
bicarbonate (peak of 45) in setting of diuresis. She received
three days of Acetazolamide while diuresis was pursued. Her
serum bicarbonate at discharge was normalized. This was likely
due to volume contraction/overdiuresis.
6. Abnormal Thyroid Function Tests: Baseline TSH 1.5 prior to
initiation of Amiodarone. TSH on [**2119-7-10**] is 6.9. Elevated TSH
may reflect a consequence of significant iodine load from
Amiodarone though it is difficult to interpret in the setting of
an acute illness. T4 is within normal limits and T3 is reduced
which is more consistent with a sick euthyroid state in the
setting of an ICU stay. No treatment was initiated in the acute
setting, especially as TSH < 10, but TFTs should be closely
monitored following discharge.
7. Asthma: Patient initially managed with Levalbuterol however
was transitioned to salmeterol given concern for worsening
tachycardia and compromising hemodynamics.
8. Normocytic Anemia: Hematocrit 34 on admission and remained
stable in the low 30s.
9. Hyperglycemia/Impaired Glucose Tolerance: Patient was
maintained on a Humalog insulin sliding scale for hyperglycemic
correction though only required this very infrequently and did
not need to be continued at discharge.
10. Right Shoulder Pain: In ED patient complained of right
shoulder pain in the setting of a recent fall. Shoulder xray
revealed no fracture but did indicate chronic rotator cuff
disease.
Transition Issues:
1. Close monitoring of thyroid function tests as above
2. Close monitoring of creatinine and BUN as above. D/C Cr 1.9
3. Close monitoring of symptoms of diastolic heart failure. See
D/C physical exam.
4. Daily standing weight, if greater than 3lbs change, call Dr.
[**Last Name (STitle) **].
Ppx: The patient was maintained on SQ heparin throughout the
hospital course
Code status: Full code
Contact: [**Name (NI) **] (sister), H:[**Telephone/Fax (1) 106094**], C:[**Telephone/Fax (1) 106095**]
Lines: none
Access issues: difficult but possible with peripheral sticks
Dispo: extended stay rehab facility
Medications on Admission:
1. Dabigatran etexilate 75 mg PO twice a day.
2. Simvastatin 20 mg PO DAILY
3. Vitamin D 50,000 unit PO once a month.
4. Travoprost Z 0.004 % Drops : One ophthalmic at bedtime.
5. Psyllium powder once a day.
6. Furosemide 80 mg QAM, 40 mg QPM DAILY
7. Amiodarone 200 mg TID
8. Metoprolol succinate 100 mg PO daily
9. Acetaminophen 650 mg PO every six hours as needed for pain
Discharge Medications:
1. dabigatran etexilate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*30 Capsule(s)* Refills:*2*
2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
month.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for CHF: Hold for SBP < 95.
Disp:*30 Tablet(s)* Refills:*1*
8. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*50 ML(s)* Refills:*2*
9. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours): Inhale once in the
morning and once at night.
Disp:*60 Disk with Device(s)* Refills:*2*
10. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day:
For ten days, take 2 tablets each day in the morning. After ten
days decrease to one tablet each morning. Hold for SBP < 95 or
HR < 50.
Disp:*30 Tablet(s)* Refills:*2*
11. miconazole nitrate 2 % Powder Sig: One (1) Topical once a
day as needed: Apply once a day to area under breasts if moist
or painful.
Disp:*2 tubes* Refills:*2*
12. docusate sodium 50 mg Capsule Sig: [**1-22**] Capsules PO twice a
day as needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**] - [**Location 9583**]
Discharge Diagnosis:
Primary
1. Congestive Heart Failure
2. Hypotension (Low Blood Pressure)
3. Acute on Chronic Kidney Disease
4. Healthcare Associated Pneumonia
5. Atrial tachycardia
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:
1. You were admitted to [**Hospital1 18**] with low blood pressure and leg
swelling, likely due to heart failure. Fluid was removed with a
diuretic called Lasix but the amount of fluid that could be
taken off was limited by your blood pressure. You will need to
continue diuretics as an outpatient.
2. The following changes were made to your medications:
CHANGE Amiodarone 200 mg by mouth daily x 10 days. Patient is
scheduled to follow-up with Dr. [**Last Name (STitle) **] (PCP) in 10 days, and
amiodarone dose will be adjusted as necessary then.
START Torsemdie 20 mg daily
CHANGE Metoprolol succinate (Toprol XL) 25 mg daily
START Salmeterol disukus twice daily
STOP Furosemide (lasix)
3. It is very important that you keep the appointments with your
doctors including Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **].
Followup Instructions:
You will be discharged to a rehab facility.
1. Please keep your appointment with your primary car doctor,
Dr. [**Last Name (STitle) **] on [**2119-7-27**] at 1:30 pm. His phone number is [**Telephone/Fax (1) 7728**].
His address is: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**]
ICD9 Codes: 486, 5849, 2762, 4280, 4589, 4168, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4299
} | Medical Text: Admission Date: [**2113-5-30**] Discharge Date: [**2113-6-17**]
Date of Birth: Sex: M
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: This was a 25 year-old man who
fell from a 70 foot height, presumably as a suicide attempt.
He was brought to the Emergency Room in hemorrhagic shock.
He was emergently intubated there and vascular access was
obtained. He was found to have a grossly deformed bilateral
upper arms and right thigh. He was bleeding from the nose
and mouth. An abdominal ultrasound demonstrated free
intraperitoneal blood. He was in shock and was brought to
the Operating Room emergently. There an exploratory
laparotomy showed no significant intraabdominal injury. He
clearly had an unstable pelvic fracture. A G tube and
suprapubic tube were placed. He was then brought to the
angiography suite where extensive embolization of multiple
bleeding vessels was obtained in the pelvis. His abdomen had
been left open and covered with an esmarch bandage. He had
nasal packs placed due to ongoing bleeding. He had traction
device placed on the left tibia.
Postoperatively, the patient had an extremely complex course
and ultimately died after extensive efforts within the
Intensive Care Unit. He required delayed closure of the
abdominal wound with mesh on the third hospital day.
Following this he then developed peritoneal sepsis and
required multiple explorations at the bedside. He had
multiple episodes of intraperitoneal sepsis. He suffered
repeated episodes of hemorrhage and was found to have a
necrotic bowel. As indicated after a complex Intensive Care
Unit course complicated by anuria and a variety of other
complications the patient was made CMO and allowed to expire
with full involvement of the family.
DISCHARGE DIAGNOSIS:
Fall from height with multiple intraperitoneal injuries and
open pelvic fracture, intracranial injury.
DISCHARGE CONDITION: Deceased.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern4) 1779**]
MEDQUIST36
D: [**2113-10-15**] 08:03
T: [**2113-10-20**] 07:14
JOB#: [**Job Number 35470**]
ICD9 Codes: 5845 |
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