meta
dict | text
stringlengths 0
55.8k
|
|---|---|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4300
} | Medical Text: Admission Date: [**2198-2-1**] Discharge Date: [**2198-2-8**]
Date of Birth: [**2198-2-1**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**Known lastname 6633**] was the 4.335 kg product of a
term gestation born to a 27-year-old, G1, P0 mom.
PRENATAL SCREENS: Blood type A positive, antibody negative,
hepatitis surface antigen negative, RPR nonreactive, rubella
immune, and GBS positive. This pregnancy was uncomplicated.
Mother has a history of mild depression.
INTRAPARTUM: Sepsis risk factors include rupture of
membranes greater than 24 hours without treatment. Maternal
temperature spiked to a maximum of 101.4 degrees. Labor was
complicated by sustained elevated fetal heart rate. Mother
was treated with penicillin, then ampicillin and gentamicin
10 hours prior to delivery. Infant was delivered by stat
cesarean section due to nonreassuring fetal heart rate. Apgar
scores were 8 and 9 at 1 and 5 minutes, respectively. Infant
admitted to the newborn intensive care unit for sepsis
evaluation.
EXAMINATION: Birthweight 4.335 kg, length 21-cm, temperature
101.5 on admission. Normocephalic, atraumatic anterior
fontanel open, flat, Palate intact. Red reflex present
bilaterally. Skin brown and warm. Neck supple. Lungs clear
bilaterally. Cardiovascular regular rate and rhythm, no
murmur. Femoral pulses 2 plus bilaterally. Abdomen soft with
active bowel sounds, no masses or distention, large cord. GU:
Normal female external genitalia. Hips stable. Clavicles
intact. Spine midline. No sacral dimples. NEURO: Good tone,
normal suck, normal gag.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Jenialys
was being monitored during her sepsis evaluation course and
was noted to have desaturations to the mid-80s requiring
nasal cannula O2. She weaned from her nasal cannula from a
maximum of 150 mL/min down to 25 cc over the next 4 days. She
transitioned to room air on [**2198-2-5**]. Chest x-ray was
obtained initially which was within normal limits, and a
repeat chest x-ray was performed on [**2198-2-5**] which also
was within normal limits. Infant has been stable in room air
for the last 48 hours.
CARDIOVASCULAR: No issues.
FLUID AND ELECTROLYTES: She was initially started on 60
cc/kg/D of D10W. Enteral feedings were initiated on day of
life #1. Infant has been ad lib p.o. feeding and
breastfeeding, taking in adequate amounts. Her discharge
weight is 4135 grams.
GI: Bilirubin on [**2-4**] was 6.6/0.2.
HEMATOLOGY: Hematocrit on admission was 52.1. Infant had not
required any blood transfusions.
INFECTIOUS DISEASE: CBC and blood culture were obtained on
admission in light of maternal sepsis risk factors.
Antibiotics were initiated, and at 48 hours blood cultures
remained negative, and antibiotics were discontinued. A
lumbar puncture was obtained which was within normal limits,
had a white count of 1, red blood cell count of 1, 52 for
protein, and 40 for glucose. Infant has been otherwise
stable.
NEURO: Has been appropriate for gestational age.
SENSORY: Hearing screen was performed with automated auditory
brain stem responses, and the infant passed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**Hospital 1426**] Pediatrics, telephone
number is [**Telephone/Fax (1) 37802**].
CARE RECOMMENDATIONS:
1. Continue ad lib feeding Enfamil 20 calorie and breast
milk.
2. Medications: Not applicable.
3. Car seat position screening was performed for a 90-
minute, and the infant passed.
4. State newborn screens have been sent per protocol and
have been within normal limits.
5. Infant has received hepatitis B vaccine on [**2198-2-3**].
6. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria: 1) Born at less
than 32 weeks, 2) Born between 32 and 35 weeks with 2 of
the following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airways abnormalities,
or school-aged 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 first 24 months of the
child's life, immunization against influenza is
recommended for household contact and out-of-home
caregivers.
DISCHARGE DIAGNOSES: Premature infant with persistent oxygen
requirement, ?secondary to infection, rule out sepsis with
antibiotics.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2198-2-7**] 21:22:30
T: [**2198-2-7**] 22:40:09
Job#: [**Job Number 65772**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4301
} | Medical Text: Admission Date: [**2135-12-14**] Discharge Date: [**2135-12-19**]
Date of Birth: [**2077-10-14**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Augmentin / Phenobarbital / Morphine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Hypoglycemia, EtOH intoxication and possible seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58M h/o COPD, HCV, polysubstance abuse admitted to ICU for
hypoglycemia, EtOH intoxication, and possible seizure. The
patient reportedly was witnessed to have a 5 minute generalized
tonic-clonic seizure by bystanders followed by a fall with head
trauma. He has no known prior seizure history. When EMS arrived,
he was notably intoxicated and confused. He did not recall the
event but reports drinking 1 pint vodka the day of admission.
Last meal at 9am this morning. There was no incontinence or
tongue biting. C-collar placed and he was brought to the ED
where vitals were T;98 HR 92 BP 130/74. BAL 215. Initial FS 67
and given 1 amp D5W but repeats were lower so started on D10W
gtt with improvement to 101. Received banana bag. CT head, spine
plain films, and FAST negative. LP with 1 WBC, 0 RBC, normal
protein and glucose.
.
Of note, The patient is not diabetic and takes no
anti-hyperglycemics. Patient denies any prior episodes of
hypoglycemia or seizure. Recently finished a course of
prednisone for COPD flare. Does note 10 pound weight loss in
last month. ROS limited due to intoxication but otherwise
negative.
Past Medical History:
1. COPD- last flare requiring hospitalization in [**2135-6-24**].
Never intubated. Attributes to smoking and [**Doctor Last Name **] [**Location (un) **]
2. Allergic rhinitis
3. HCV- status unknown
4. PTSD/depression since age 20 when he returned from the
[**Country 3992**] war (requiring many hospitalizations at the VA)
5. Polysubstance abuse: drinks etoh and smokes crack - last used
[**Month (only) **] of this year
6. Right total knee replacement
7. Right carotid AV fistula
8. Multiple blood transfusion
Social History:
Smokes less than 1/2ppd tobacco. Hx heavy ETOH (vodka 1 pint)
states that does not drink frequently now, less than once a
week. Also with h/o crack cocaine use states that he last used
used in [**Month (only) **]. Denies IVDA. Per OMR, reports that his parents
were substance abusers and that his mother was physically
abusive. Pt is divorced. Moved to [**Location (un) 86**] from [**Location (un) 7349**] one year ago
to take care of his mother. After she passed away a few months
ago, he moved into a transitional houseing vet house in [**Location (un) **] [**Telephone/Fax (1) 102166**]. He is on SSDI for PTSD but he would
like to find work. Sees social worker/therapist at [**Hospital **] clinic in
[**Location (un) 5503**] named [**Name (NI) 24592**] [**Name (NI) **].
Family History:
Patient believes his mother may have had bipolar. Siblings with
panic attacks.
Physical Exam:
Physical Exam:
T 96 HR 91 BP 127/71 RR 17 SaO2 98% on 4L
General: WDWN, NAD
HEENT: NC, AT, pinpoint pupils, anicteric sclera, conjunctivae
pink
Neck: supple, trachea midline, no masses,
Cardiac: RRR, s1s2 normal, no m/r/g
Pulmonary: expiratory wheezes bilat, L>R
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses, no edema
Neuro: A&Ox3, speech clear and logical, CNII-XII grossly intact,
moves all extremities
Pertinent Results:
[**2135-12-14**] 04:10PM WBC-6.5 RBC-4.41* HGB-14.9 HCT-42.0 MCV-95
MCH-33.8* MCHC-35.5* RDW-14.6
[**2135-12-14**] 04:10PM ASA-NEG ETHANOL-215* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2135-12-14**] 04:10PM CALCIUM-9.3 PHOSPHATE-4.2# MAGNESIUM-2.2
[**2135-12-14**] 04:10PM CK-MB-3
[**2135-12-14**] 04:10PM cTropnT-<0.01
[**2135-12-14**] 04:10PM PT-12.8 PTT-25.0 INR(PT)-1.1
[**2135-12-14**] 04:10PM GLUCOSE-67* UREA N-17 CREAT-0.8 SODIUM-143
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-23 ANION GAP-21
[**2135-12-14**] 08:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2135-12-14**] 10:20PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0
LYMPHS-30 MONOS-0 MACROPHAG-70
[**2135-12-14**] 10:20PM CEREBROSPINAL FLUID (CSF) PROTEIN-46*
GLUCOSE-64
[**2135-12-14**] 10:59PM ALT(SGPT)-51* AST(SGOT)-46* CK(CPK)-124 ALK
PHOS-62 AMYLASE-51 TOT BILI-0.3
Brief Hospital Course:
58M h/o COPD, HCV, polysubstance abuse admitted to ICU for
hypoglycemia, EtOH intoxication, and possible seizure.
.
# Hypoglycemia: Likely due to starvation and EtOH leading to
decreased hepatic gluconeogenesis. Decreased carbohydrate intake
also reduces insulin and increases glucagon secretion. Anion-gap
17 but urine from ED notable for absence of ketones. Other
etiologies includes exogenous use of insulin, renal failure and
hypothyroidism. Patient denies use of insulin or any
anti-hyperglycemic drugs, renal function is within normal
limits. TSH was within normal range at 1.0. He was given D5NS
fluid and his blood glucose was followed; hypoglycemia did not
recur.
.
# EtOH intoxication/Withdrawal: He had an ETOH level of 215 on
presentation. he was monitored for evidence of etoh withdrawal;
this did not recur.
.
# Seizure: Unclear if actual seizure vs. acute intoxication. If
true seizure, possibly EtOH withdrawal vs. hypoglycemia vs.
other toxic-metabolic cause. No evidence brain mass or CNS
infection was noted on imaging or LP. EEG was normal.
.
# Head trauma: Imaging negative for fracture or bleed.
.
# COPD: stable on inhalers.
.
# PTSD/depression: Continued on trazodone and zoloft.
.
# pt. complained of rt. ankle pain at the site of his PIV which
had been there. No evidence of infection, plain films neg. for
fracture.
Medications on Admission:
Trazodone 150 mg PO HS
Sertraline 150 mg PO DAILY
Albuterol inhaler 1 puff Q4H prn
Combivent inhaler 2 puffs QID
Benadryl 50mg [**Hospital1 **] prn
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*0*
2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*1 Inhaler* Refills:*0*
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Hypoglycemia
Alcohol intoxication
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Return to the Emergency Department for:
Fevers
Lightheadedness
Seizure
Followup Instructions:
Call your primary doctor at the [**Location **] for an
appointment for within two weeks of leaving the hosptial:
[**Last Name (LF) 90404**],[**First Name3 (LF) **] J.
ICD9 Codes: 496, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4302
} | Medical Text: Admission Date: [**2156-6-25**] Discharge Date: [**2156-6-29**]
Date of Birth: [**2089-12-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional angina
Major Surgical or Invasive Procedure:
[**2156-6-25**] Coronary Artery Bypass Graft x4 (Left internal mammary
artery > left anterior descending, Saphenous vein graft >
diagonal, Saphenous vein graft > Obtuse marginal, Saphenous vein
graft > Distal right coronary artery)
History of Present Illness:
66 yomale with known CAD medically managed since [**2146**]. Referred
for pre-op cath prior to hernia repair as part of clearance for
surgery. Cath [**6-17**] revealed no MR, EF 70%, LM 70%, LAD 100%, CX
80%, RCA 90%. Referred for CABG.
Past Medical History:
CAD
HTN
elev. lipids
rheumatoid arthritis
umbilical hernia
right inguinal hernia
rheumatic fever as a child
PSH: LIH surgery, removal left hip bone spur
Social History:
works part-time
smokes 2 pipes per day for 40 years
lives with wife
no ETOH
no recr. drugs
Family History:
brother and sister with heart disease- unknown specifics
father died in late 70's of heart disease
Physical Exam:
HR 64 RR 20 right 172/87 left 155/93
6'8" 168# 99% RA sat
NAd lying in bed
PERRL with EOMI, MMM nl. bucosa
skin unremarkable
neck supple, no [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] bruits
CTAB
RRR no murmur
soft, NT, ND, + BS; reducible right hernia
warm, well-perfused, no edema or varicosities; arthritic hands
alert and oriented x 3, nonfocal neuro exam
2+ bil. fem/radials
1+ bil. DP/PTs
Pertinent Results:
[**2156-6-29**] 07:20AM BLOOD WBC-12.0* RBC-3.22* Hgb-11.2* Hct-31.5*
MCV-98 MCH-34.6* MCHC-35.4* RDW-14.1 Plt Ct-268#
[**2156-6-29**] 07:20AM BLOOD Plt Ct-268#
[**2156-6-29**] 07:20AM BLOOD Glucose-99 UreaN-18 Creat-0.7 Na-139
K-4.2 Cl-104 HCO3-27 AnGap-12
RADIOLOGY Final Report
CHEST (PA & LAT) [**2156-6-27**] 6:11 PM
CHEST (PA & LAT)
Reason: r/o ptx s/p ct's removed
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with
REASON FOR THIS EXAMINATION:
r/o ptx s/p ct's removed
CHEST
HISTORY: Pneumothorax post chest tube removal.
Two views. Comparison with [**2156-6-25**]. The patient is status post
median sternotomy and CABG as before. There is streaky bibasilar
density consistent with subsegmental atelectasis. The
costophrenic sulci are now blunted consistent with small pleural
effusions. The heart and mediastinal structures are unchanged.
An endotracheal tube, nasogastric tube, left chest tube,
Swan-Ganz catheter and mediastinal drains have been removed.
IMPRESSION: Status post CABG. Subsegmental atelectasis. Small
pleural effusions.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved
Cardiology Report ECHO Study Date of [**2156-6-25**]
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. Chest pain. Hypertension.
Mitral valve disease. Preoperative assessment.
Status: Inpatient
Date/Time: [**2156-6-25**] at 10:52
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size. Depressed LAA emptying velocity
(<0.2m/s) 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: Normal LV wall thickness. Normal LV cavity size.
Inferobasal
LV aneurysm. Mild regional LV systolic dysfunction. Low normal
LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
inferior apex -
hypo; apex - hypo; remaining LV segments contract normally.
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. Moderately thickened
aortic valve
leaflets. Mild AS (AoVA 1.2-1.9cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild thickening of mitral valve chordae.
Calcified tips of
papillary muscles. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient received antibiotic prophylaxis. The
TEE probe was
passed with assistance from the anesthesioology staff using a
laryngoscope.
The patient was under general anesthesia throughout the
procedure.
Conclusions:
PRE-CPB: 1. The left atrium is normal in size. The left atrial
appendage
emptying velocity is depressed (<0.2m/s). No thrombus is seen in
the left
atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. There is an inferobasal left ventricular
aneurysm. There is
mild regional left ventricular systolic dysfunction with
inferoseptal and
apical hypokinesis.. Overall left ventricular systolic function
is low normal
(LVEF 50-55%). The remaining left ventricular segments contract
normally.
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are
moderately thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2).
Trace aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
POST-CPB: On infusion of phenyephrine. Preserved biventricular
systolic
function. MR is mild. Aortic contours are preserved post
decannulation.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2156-6-25**] 13:28.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 41441**])
Brief Hospital Course:
Admitted [**6-25**] and underwent cabg x4 with Dr. [**Last Name (STitle) **].
Transferred to the CSRU in stable condition on titrated
phenylephrine and propofol drips.Extubated that evening and
transferred to the floor on POD #1 to begin increasing his
activity level. Beta blockade started and gentle diuresis begun.
Chest tubes and pacing wires removed on POD #2. Made excellent
progress and cleared for discharge to home with VNA services on
POD #4. Pt. is to make all follow up appts. as per discharge
instructions.
Medications on Admission:
toprol Xl 50 mg daily
lisinopril 10 mg daily
lipitor 10 mg daily
MVi one tab daily
celebrex 200 mg daily
ASA 81 mg daily
calcium 600 mg daily
niaspan 1700 mg daily
methotrexate
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO once a day for 10 days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Hypertension
Hyperlipidemia
Rheumatoid Arthritis
Rheumatic fever as child
umbilical and right inguinal hernias
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 [**Last Name (STitle) 4469**] in [**1-13**] week ([**Telephone/Fax (1) 4475**]) please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2156-6-29**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4303
} | Medical Text: Admission Date: [**2149-12-31**] Discharge Date: [**2150-1-7**]
Date of Birth: [**2087-9-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
admission for chemoembolization of hepatocellular carcinoma
Major Surgical or Invasive Procedure:
chemoembolization
transfusion of 3U of PRBC
RIJ central line placement
History of Present Illness:
62 year-old man with morbid obesity, alcoholic cirrhosis,
admitted for chemoembolization of his recently-diagnosed
hepatocellular carcinoma.
Mr. [**Known lastname **] has a long history of alcoholic cirrhosis with a
history of heavy
consumption (>80 grs/day) of alcohol use over the past 40 years.
In [**2145**], he developed decompensation with evidence of
encephalopathy, ascites and portal hypertension. Over the
subsequent 2 years, he had ongoing problems with advanced liver
disease including admissions for encephalopathy, ascites, lower
extremity edema, anemia and renal failure.
The patient has been followed since [**2-22**] by Dr. [**Last Name (STitle) **] for
alcohol related cirrhosis, and has been managed on Lasix,
Aldactone, lactulose and Inderal. Due to his morbid obesity, he
was not deemed a transplant candidate. Recently he has had a
decrease in his appetite and occasional nausea and vomiting.
While his AFP was not particularly high (7.0), his LFTs were
slightly abnormal with an alkaline phosphatase of 213, and
increase of his AST to 397 and ALT to 98. An ultrasound in
[**Month (only) 1096**] showed a large 13cm mass in the right lobe of the liver
of 13 cm. Biopsy of this mass was read as consistent with
hepatocellular carcinoma.
He was quickly referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who discussed with
him his options. Given that he was not a surgical candidate
with his cirrhosis and that he is not a transplant candidate,
his options were extremely limited.
Patient agreed on the recommendation of chemoembolization.
Prior to the procedure, patient reported no pain, nausea,
vomiting, new fatigue.
Vital signs remained stable throughout procedure. Embolization
of artery with gelfoam and chemotherapy (adriamycin). Also
received versed, fentanyl, papaverine, xanax, vistaril,
dilaudid, allopurinol, Unasyn, prochloperzine peri and post-op.
Post-procedure, patient report feeling slightly nauseous, but no
vomitting, fevers, chills, chest pain, shortness of breath,
abdominal pain.
Past Medical History:
-alcohol cirrhosis with encephalopathy and ascites, not a
transplant candidate due to his morbid obesity
-diverticulitis requiring hemicolectomy about 30 years ago
-morbid obesity
Social History:
Retired construction worker and singer.
He is married, but separated and lives alone.
Wife is still supportive and comes to help him.
He has good relationships with his three children.
He no longer drinks alcohol and does not smoke.
Family History:
no cancer
Physical Exam:
PE on admission
Vital signs: temp 96.5, BP 112/palp, HR 54, RR 18, O2sat 98% on
room air
weight 156.8 kg
Gen: middle-aged morbidly obese male in no acute distress
HEENT: mucous membranes slightly dry, obese neck- difficult to
assess veins, anicteric
Heart: distant heart sounds, regular rate and rhythm, unable to
appreciate murmurs, gallops, or rubs
Lungs: clear-to auscultation bilaterally anteriorly
Abdomen: obese, nontender
Extr: 1+ pitting edema bilaterally in lower extremity. warm,
[**11-23**]+ distal pulses
no groin hematoma
Neuro: alert and oriented x3
Pertinent Results:
[**2149-12-9**]
WBC 5.9 Hgb 14.6 Plt Ct 207 MCV 98
Hct 42.7
PT 14.5 INR 1.3 PTT 34.3
UreaN 15 Glucose 121
Creat 1.0
ALT 98 TotBili 1.4 IndBili 0.8 Albumin 2.8
AST 397 DirBili 0.6 GGT 145
AlkPhos 184
Amylase 69
Ferritn 1322
AFP 7.0
EKG: NSR @82bpm, left axis deviation, normal intervals,
flattened T waves in inferior leads.
CXR post procedure: clear
[**2150-1-1**] CT of ABD/PELVIS IMPRESSION:
1) Large right retroperitoneal hematoma extending from the right
groin and along the right flank. There is extensive tracking of
hemorrhage within the retroperitoneum to the mesenteric root.
This finding was discussed immediately with Dr. [**Last Name (STitle) **], who
was caring for the patient.
2) High density material within the right lobe of the liver,
opacifying mutliple tumor masses, consistent with
chemoembolization performed on same date. These findings are
consistent with the patient's known history of hepatocellular
carcinoma.
3) Persistent nephrograms within the kidneys, as well as
excreted contrast within the renal collecting systems. In the
setting of a noncontrast examination contrast given earlier in
the day, this finding could be related to acute tubular
necrosis.
4) No bowel obstruction or perforation.
5) Bilateral pleural effusions and bibasilar atelectasis.
Brief Hospital Course:
[**Date range (1) 49691**]
Post procedure the patient was transferred to the floor. At
approximately 22:15 the house officer was called to the bedside
because the patient was found to be more somnolent and confused
by the nursing staff. Vitals were checked at that time and the
patient was found to have a SBP of 74 by doppler. The patient
was immediately placed in Trendelenberg and given a 500cc bolus
of NS. A second peripheral IV was placed and a stat HCT was
drawn. The MICU team was called. HCT=>31.7 down from 41
pre-procedure. There was a high suspicion for retroperitoneal
bleed given the patient's hypotension in relationship to the
procedure. An ABD/PELVIC CT was done which revealed a large
right retroperitoneal hematoma extending from the right groin
and along the right flank. The patient was transferred to the
MICU and transfused 2U of PRBC. Vascular surgery was also
consulted who agreed with the plan of serial HCTs and medical as
opposed to surgical management at this time. A right IJ central
line was placed for access as well.
[**Date range (1) 28479**]
During the patient's MICU stay, he developed acute renal failure
with a creatinine increase from 1.1 to 2.0 as well as atrial
fibrillation, both thought to be related to his hypovolemia and
poor perfusion state [**12-24**] to his retroperitoneal bleed. His HCT
remained stable and he was transferred back to the floor.
[**1-6**]
A day after transfer, the patient developed a fever and was
empirically started on levofloxacin. A CXR, UA, blood and urine
cultures were obtained. The patient's respiratory status
continued to worsen and he became hypotensive likely [**12-24**] to an
overwhelming infection likely of intraabdominal origin from
necrosis of liver post-procedure or pulmonary source due to his
poor ventilatory status (body habitus and fluid overload). The
patient's overall prognosis and chance for recovery was very
poor. Discussion was held with the patient's family, medical
team, and primary oncologist and the patient's code status was
designated as DNR/DNI and he was made CMO. His infection was
treated with antibiotics and his pain was treated with IV
morphine. The patient expired on [**1-7**] from respiratory failure
and PEA arrest.
Medications on Admission:
propranolol 10mg PO BID
furosemide 40mg PO once daily
Aldactone 50mg PO once daily
MVI
folic acid
vitamin B1
milk thistle
ranitidine qpm
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
respiratory failure [**12-24**] overwhelming sepsis
alcoholic cirrhosis with hepatic encephalopathy and ascites
hepatocellular carcinoma
morbid obesity
s/p hemicolectomy
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
ICD9 Codes: 5849, 0389, 2851, 4280, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4304
} | Medical Text: Admission Date: [**2126-5-24**] Discharge Date: [**2126-5-25**]
Date of Birth: [**2062-10-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 29055**]
Chief Complaint:
presyncope / elective PVI
Major Surgical or Invasive Procedure:
pulmonary vein isolation
History of Present Illness:
63 year old man with history of paroxysmal atrial fibrillation
diagnosed in [**2117**], s/p 3+ CVs with recurrence of presyncopal
symptoms who is transferred to CCU s/p PVI earlier today in
setting of relative hypotension (SBP min 77mmHg) during the
procedure.
.
His PAF has been distressing to him since onset with symptoms of
dizziness, lightheadedness and feeling like he is going to fall
down and a sensation of the "jello heart." He has been in/out
of afib every couple of years, most of the time lasting several
days and requiring a CV. He was on Propafenone in the past,
however had signfiicant bradycardia and near syncope thus this
was stopped.
.
Over the last 2 months, he had 3 occurences of Afib. [**4-1**]
requiring DCCV and [**4-6**] lasting 3 days, undergoing Stress/ECHO
and then undergoing DCCV. His last episode was in early [**Month (only) 958**],
when he noted a feeling of lightheadedness and and then syncope
while shopping at Sears. LOC lasted ~ 45 seconds. He noted
history of dehydration and exhaustion prior to this episode.
This Afib episode lasted for 2.5 days and terminted on its own.
.
In addition he reports having symptoms of "atrial fibrillation"
while straining on the toilet and in setting of dehydration, but
not during exertion while wt. lifting. He denied episodes of
difficulty with language, weakness, clumsiness, numbness or
tingling or visual deficits. He has never had urinary retention
or balance difficulties. He was treated with ASA 325mg for Afib
utnil ~ 2 wks ago when he was started on Pradaxa.
.
Prior to PVI, he had undergone an evaluation including TTE
([**3-/2125**]) showing nl EF, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 13385**] of 3.8cm and a trileaflet
aortic valve with a small pericardial effusion w/o "evidence of
hemodynamic compromise." He had also undergone a adenosite
imaging stresss, which was normal.
.
Today, while undergoing PVI, had an episode of atrial
tachycardia with SBP to 77 from 90s, underwent DCCV x2, received
2.6L NS and has remained in SR after PVI. Given his low normal
BPs, he was admitted to CCU for monitoring. Pre-PVI EKG at 8am
was NSR at 65.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
In the CCU, patient feels comfortable and has no complaints. He
feels a little confused after having received Dilaudid in the
PACU. No CP, no SOB.
Past Medical History:
1. CARDIAC RISK FACTORS: None
2. CARDIAC HISTORY:
-CABG: NA
-PERCUTANEOUS CORONARY INTERVENTIONS: NA
-PACING/ICD: NA
- PAF s/p CV x 3+, s/p PVI.
.
3. OTHER PAST MEDICAL HISTORY:
- Tonsillectomy as a child.
- Multiple MSK surgeries (shoulder, knee)
Social History:
He is a retired teacher, quit 5 yrs ago, now substituting.
Lives at home with with his wife. 3 kids, one passed away from
cancer. He is a competitive water skier.
Family History:
Father's brother, grandfather and multiple cousins w/ Afib.
Both parents lived to mid 90s, no early CAD or cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
.
Physical Exam:
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI at apex. At 2 RICS there are a systolic and a
diastolic murmur each [**3-24**]. No S3.
RR, normal S1, S2. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Trace crackles
bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits. R groin site C/D/I,
no murmur.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP dopplerable.
Left: DP dopplerable.
Pertinent Results:
Labs at admission:
[**2126-5-24**] 08:57AM GLUCOSE-104* UREA N-23* CREAT-1.1 SODIUM-139
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
[**2126-5-24**] 08:57AM estGFR-Using this
[**2126-5-24**] 08:57AM WBC-4.6 RBC-3.63* HGB-11.7* HCT-32.8* MCV-90
MCH-32.1* MCHC-35.6* RDW-12.8
[**2126-5-24**] 08:57AM NEUTS-61.1 LYMPHS-26.0 MONOS-8.4 EOS-3.6
BASOS-0.8
[**2126-5-24**] 08:57AM PLT COUNT-315
[**2126-5-24**] 08:57AM PT-14.0* INR(PT)-1.2*
Imaging:
ECHO
[**2126-5-24**]
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The estimated pulmonary artery systolic pressure is normal.
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Small circumferential pericardial effusion without
echocardiographic signs of tamponade physiology.
ECHO
[**2126-5-24**]
The left atrium is elongated. The right atrium is moderately
dilated. A left-to-right shunt across the interatrial septum is
seen at rest. A small secundum atrial septal defect 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 ascending
aorta is mildly dilated. Trivial mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is a small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: Small circumferential pericardial effusion without
echo signs of tamponade. Small secundum ASD.
ECHO
[**2126-5-25**]
- Wet read : no increase in pericardial effusion; increase in TR
Brief Hospital Course:
63 year old man with history of paroxysmal atrial fibrillation
diagnosed in [**2117**], s/p 2 CVs with recurrence of presyncopal
symptoms who is transferred to CCU s/p PVI earlier today in
setting of relative hypotension (SBP min 77 mmHg) during the
procedure.
.
# PUMP: Nl LV and RV fx and EF. Small circumferential effusion
(note on prior TTE), no evidence of tamponade. Normotensive,
normal pulsus. Has systolic/diastolic murmur at 2 RICS likely
s/p procedure. He had stable heart rate and BP. Repeat ECHO did
not reveal worsening effusion, it did reveal slightly worsened
TR.
.
# RHYTHM: PAF s/p multiple CVs and now PVI. Currently in SR. We
restarted Pradaxa which he will continue at home. Pt was
instructed on the use of a "[**Doctor Last Name **] of heart" monitor. He will call
to make a f/u outpatient EP appointment
.
# Anemia. Normocytic. HD stable, HCT 32, no priors. Etiology
unclear.[**Name2 (NI) **] studies were sent but patient was discharged prior
to results, he should have outpatient follow up of this issue.
Medications on Admission:
Pradaxa 150mg [**Hospital1 **]
Vitamin C 1g daily
Glucosamine-Chondroit-VitC
Centrum Ultra Men
Fish Oil [**Telephone/Fax (1) 89797**] daily
Discharge Medications:
1. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
2. ascorbic acid 250 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Atrial Fibrillation
Secondary:
Pericardial effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital3 **] Medical Center for a PVI
procedure. During the procedure you had transient low blood
pressure. An echocardiogram also noted that you had an
accumulation of fluid around your heart. Given these two
findings, you were admitted to the Cardiac Intensive Care Unit
for close monitoring. Overnight your blood pressures were within
a normal range and your repeat echocardiogram did not show
worsening fluid accumulation around your heart.
You were discharged home with a heart monitor that you should
wear for 2 weeks.
No changes were made to your medications please continue to take
all your medications including Pradaxa.
Please call your doctor or return to the emergency room if you
have chest pressure or pain or feel lightheaded or dizzy.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 5448**], cardiologist.
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4305
} | Medical Text: Admission Date: [**2191-4-28**] Discharge Date: [**2191-5-7**]
Date of Birth: [**2115-7-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Latex / Monosodium Glutamate
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
[**4-29**] Coronary artery bypass grafting times three (LIMA to LAD,
SVG to Ramus, SVG to dLCx), mitral valve replacement (25mm
[**Company **] mosaic tissue)
History of Present Illness:
Ms. [**Known lastname **] is a 75 year old with a history chest discomfort,
shortness of breath, and an abnormal nuclear stress test
referred for cardiac cath. She was scheduled to undergo a
hemicolectomy due to tubulovillous adenoma, polyps, and
high-grade dysplasia found on colonoscopy at [**Hospital3 417**].
During her
anesthesia workup, the patient reported episodes of chest
discomfort and shortness of breath with exertion. She
subsequently had an abnormal stress test, so her hemicolectomy
was cancelled and she was referred for cardiac surgery
evaluation.
Past Medical History:
Coronary artery disease, silent myocardial infarction [**2186**],
hypertension, hypercholesterolemia, diabetes mellitis, colon
cancer, cataract surgery, s/p partial colectomy in [**2181**] for
colon cancer(recurrent now), appendectomy, hysterectomy,
bilateral arthroscopic knee surgery
Social History:
Ms. [**Known lastname **] lives with her son when in [**State 350**] and
alone when she lives in [**State 108**] for part of the year.
She quit smoking 25 years ago, but smoked 1 pack per day for 30
years.
Family History:
noncontributary
Physical Exam:
Pulse:52 Resp:13 O2 sat:98 RA
B/P Right:174/68 Left:170/66
Height:5'2" Weight:180 LBS
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [x], Dentures
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [x]
Heart: RRR [X] Irregular [] Murmur No
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None [X]
Neuro: Grossly intact
Pulses:
Femoral Right:+2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right:+2 Left:+2
Carotid Bruit Right:- Left:-
Pertinent Results:
[**2191-5-6**] 05:35AM BLOOD WBC-11.4* RBC-3.86* Hgb-11.1* Hct-32.4*
MCV-84 MCH-28.8 MCHC-34.3 RDW-14.9 Plt Ct-290
[**2191-5-6**] 05:35AM BLOOD Plt Ct-290
[**2191-5-6**] 05:35AM BLOOD Glucose-61* UreaN-13 Creat-0.7 Na-140
K-4.2 Cl-98 HCO3-33* AnGap-13
Brief Hospital Course:
On [**4-29**] Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a mitral valve replacement with
a 25 mm [**Company **] mosaic tissue valve and coronary artery bypass
grating times three (LIMA to LAD, SVG to RAMUS, SVG to d LCx).
She tolerated this procedure well and was transferred in
critical but stable condition to the surgical intensive care
unit. She was extubated and weaned from her pressors. She was
noted to be in a first degree heart block until she went into
atrial fibrillation and had a bradycardic episode, after which
she continued in a first degree block with a long PR interval.
The electrophysiology service was consulted and it was felt that
she would not need a permanent pacemaker. It was recommended
that beta blockers and amiodarone be held. Her chest tubes were
removed. She was transferred to the surgical step down floor.
She was gently diuresed. Physical therapy saw her in
consultation. By post-operative day six her temporary pacemaker
was discontinued and then her epicardial wires were removed on
the following day after she tolerated low dose atenolol and her
PR interval prolongation improved. She was discharged to home
on post-operative day eight.
Medications on Admission:
Atenolol 25 mg daily
Glyburide Micronized-Metformin 2.5 mg-500 mg Tablet 1 Tablet
daily
Valsartan [Diovan] 320mg daily
Aspirin 325 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*2*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
coronary artery disease
mitral regurgitation
silent myocardial infarction in [**2186**]
hypertension
hyperlipidemia
diabetes
colon cancer, s/p partial colectomy in 200
resent colonoscopy revealing polyps with high grade dysplasia
appendectomy
hysterectomy
bilateral arthroscopic knee surgery
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) **] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**])
please call for appointment
Dr [**Last Name (STitle) **] (cardiologist) in 1 week ([**Telephone/Fax (1) 8725**]) please call for
appointment
Please see your primary care physician [**Last Name (NamePattern4) **] [**12-28**] weeks
([**Telephone/Fax (1) 170**]) please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2191-5-7**]
ICD9 Codes: 4240, 9971, 412, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4306
} | Medical Text: Admission Date: [**2188-8-4**] Discharge Date: [**2188-8-13**]
Date of Birth: [**2112-8-8**] Sex: M
Service: UROLOGY
Allergies:
Ace Inhibitors
Attending:[**First Name8 (NamePattern2) 19908**]
Chief Complaint:
hematuria, frequency, nocturia
Major Surgical or Invasive Procedure:
Radical Cystectomy with ileal loop
History of Present Illness:
HPI: Mr. [**Known lastname 58053**] is a 75-year-old man with a history of
recurrent bladder cancer. According to Mr. [**Known lastname 58053**], this was
initially diagnosed in [**2172**] when he presented to the [**Location 58054**] with hematuria. Cystoscopy diagnosed localized
superficial bladder cancer, and he was treated with
intravesicular BCG. Then in [**2176**] he had recurrence noted on
screening cystoscopy, and at that time, he was treated with
intravesicular BCG and mitomycin C. This course was complicated
by severe UTI leading to urosepsis and hospitalization at the
[**Location 1268**] VA. He subsequently transferred his care to Dr.
[**Last Name (STitle) 43569**] at [**Hospital3 **] and had another episode of urosepsis in
[**2182**] or [**2183**]. He transferred care to [**Hospital6 58055**] where he underwent TURP in [**2184**]. It was soon after this
that he began to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**] for screening
cystoscopy and treatment for recurrent urinary tract infections.
He reports having had multiple cystoscopies with biopsies. On
[**2188-6-8**] he was admitted to the [**Hospital 882**] Hospital with
recurrent hematuria with clots, increased urinary frequency and
nocturia, and underwent cystoscopy on [**6-9**], which showed a
1.5-cm papillary tumor on the right anterior wall of the
bladder.
He then underwent transurethral resection on [**2188-6-10**]. The
biopsy showed a high-grade bladder transitional cell carcinoma
with smooth muscle invasion. He currently has a Foley catheter
in place. He denies having pelvic pain and admits to a small
amount of low back pain. Additionally, Mr. [**Known lastname 58053**] was admitted
to [**Hospital1 18**] in [**2187-12-27**] and to [**Hospital1 18**] [**Location (un) 620**] in [**2188-5-25**] with
decompensated diastolic heart failure. Today, he denies having
recurrent fevers, chills, night sweats or weight loss
Past Medical History:
-Bladder Carcinoma
-Diabetes Type II
-Hypertension
-Frequent UTI
-Pulmonary hypertension
-Diastolic congestive heart failure (EF>55% on [**2188-2-5**])
Social History:
Lives with his wife in [**Name (NI) 1411**], MA. Now retired. Occasional
alcohol use,
with distant history of tobacco use.
Family History:
Noncontributory.
Physical Exam:
Physical Examination: Weight 262.1 pounds, temperature 97.1,
pulse 68, blood pressure 108/70, respiratory rate 20, oxygen
saturation 100% on room air.
In general, comfortable, obese male in no acute distress, walks
with a cane.
HEENT: Pupils equally round and reactive to light. Sclerae
anicteric. Status post bilateral cataract surgery with right
pupillary scar. Oropharynx is clear without lesion or exudate.
Lymph: No cervical, supraclavicular, occipital, axillary, or
inguinal adenopathy.
Cardiovascular: PMI nondisplaced. Regular rate and rhythm with
I/VI systolic murmur.
Lungs: Clear to auscultation bilaterally. No crackles, rhonchi
or wheeze.
Abdomen: Obese, soft, nontender, nondistended without masses or
hepatosplenomegaly.
Extremities: Bilateral 1+ lower extremities edema. Foley bag
on
the right leg.
Skin: No rashes.
Neurologic: Alert and oriented x3. Cranial nerves II through
XII intact. Strength 5/5 throughout.
Pertinent Results:
[**2188-8-4**] 12:40PM WBC-8.4 RBC-3.89* HGB-9.9* HCT-30.0* MCV-77*
MCH-25.6* MCHC-33.2 RDW-15.7*
[**2188-8-4**] 12:40PM PT-14.8* PTT-27.6 INR(PT)-1.3*
[**2188-8-4**] 12:40PM ALT(SGPT)-12 AST(SGOT)-9 ALK PHOS-63 TOT
BILI-0.2
[**2188-8-4**] 12:40PM ALBUMIN-3.7 CALCIUM-9.2 PHOSPHATE-4.5
MAGNESIUM-2.3
[**2188-8-4**] 12:40PM GLUCOSE-113* UREA N-62* CREAT-2.5*#
SODIUM-136 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15
Brief Hospital Course:
75yM with recurrent Bladder CA admitted for cystectomy and ileal
conduit on [**2188-8-5**]. Patient went to the OR for Radical
cystoprostatectomy, ileal loop urinary
diversion, bilateral pelvic lymphadenectomy. He tolerated the
procedure well with no complications, but was transferred to the
ICU in guarded condition still intubated. He had a NGT, RIJ,
ETT, urostomy stents x 2, and a Right A-line in place upon
transfer. He did require pressors for the first day post-op in
order to maintain his arterial pressure. He was extubated
without complication on POD 1 and transitioned to a face mask.
He became hemodynamically stable and was weaned off of pressors.
He was then started on his home lopressor, ASA, and statins.
His A-line was d/ced at this time as well. His pain was
adequately controlled with a PCA pump.
The patient was transferred to the floor on POD3 in stable
condition. He continued to experience bouts of rapid A. Fib
which were usually symptomatic and were usually stimulated by
activity. His Lopressor was titrated accordingly and eventually
switched from IV to PO once he began taking PO. From a GI
standpoint he was slow to return his bowel function and
therefore was kept NPO with NGT in place until he had some
return of function. The NGT was then d/ced and he was begun on
sips and slowly advanced which he tolerated well. From a
GU/Renal standpoint, the patient was restarted on his home lasix
and had excellent diuresis from his ileal conduit without any
issues. He was seen by physical therapy who recommended that the
patient would need rehab s/p discharge.
Prior to discharge his PCA was d/ced and he was switched to
PO pain meds. His IJ was removed prior to discharge as this was
his only available IV access. His uretheral stents are to
remain in place for at least another 2-3 weeks.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
Injection TID (3 times a day).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain, temp>100.
5. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
6. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.
8. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
11. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
13. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection ASDIR (AS DIRECTED): please follow sliding
scale on flowsheet.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Bladder Cancer
Discharge Condition:
Stable
Discharge Instructions:
Call Urology office or go to your local Emergency Room if
1) Temp greater than 101
2) Nauseau and Vomitting for greater than 24 hours
3) Worsening Pain not relieved by Medications
4) Inability to Urinate
You may resume your home Medications
You may shower
Followup Instructions:
Call [**Hospital 159**] clinic at [**Telephone/Fax (1) 164**] for follow up appointment to
have staples removed within one week
ICD9 Codes: 4280, 4019, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4307
} | Medical Text: Admission Date: [**2158-4-27**] Discharge Date: [**2158-5-8**]
Date of Birth: [**2085-8-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2158-5-3**] - Urgent off-pump coronary artery bypass graft x4, left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to diagonal, obtuse marginal and posterior
descending arteries.
History of Present Illness:
Mr. [**Known lastname 26644**] is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 664**] 72 yo with known coronary disease,
s/p MI'[**41**] s/p PCI/stent, s/p PCI [**2155**] now with increasing
episodes of chest tightness and
shortness of breath with exertion with minimal walking or
bending over. He denies any history of chest pain. A stress
test in [**Month (only) 404**] revealed moderate ischemia in the inferior
posterior region with normal LV size and an EF of 52% with
inferior hypokinesis. He had a cardiac cath which showed EF
60%, 45%LM, 99% subtotal mid -distal RCA lesion with L-R
collaterals, 85%mLAD, diffuse 50-60%mLCx. He was transfered for
CABG.
Past Medical History:
coronary artery disease
s/p MI '[**41**]
s/p PTCA/stent '[**41**]
s/p PCI [**2155**]
hypertension
diabetes
chronic kidney disease
hyperlipidemia
anemia
benign prostatic hypertrophy
colon polyps
peptic ulcer disease-s/p bleed requiring 2uPRBC
spinal stenosis
COPB/chronic bronchitis/possible asbestosis
Social History:
Lives with: wife
Cigarettes: Smoked no [] yes [x] last cigarette [**2138**]
Hx:1-2ppd/many years
ETOH: [**2-21**] drinks/week [x]
Illicit drug use-no
Family History:
None noted
Physical Exam:
Pulse:79 Resp:14 O2 sat:98% on RA
B/P Right: 158/99
Height:5'9" Weight:243 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs fine rhonchi L base, otherwise clear
Heart: RRR [x] Irregular [] Murmur-none [] grade ______
Abdomen: Soft [x] obese, non-distended [x] non-tender [x] +BS
[x]
Extremities: Warm [x], well-perfused [x] Edema [] __
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2158-4-28**] Carotid Ultrasouond
Impression: Right ICA less than 40% stenosis. Left ICA less than
40% stenosis.
[**2158-5-3**] ECHO
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. Right
ventricular chamber size is normal. There are complex (>4mm)
atheroma in the ascending aorta. There are complex (>4mm)
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Moderate (2+)
mitral regurgitation is seen when BP>150, mild when BP @ 11O
systolic
Post OPCABGX4
Patient is on a neosynephrine drip at 0.6 mcg/kg/min
LV Function is preserved at 55%
No RWMA,the valvular exam is similar to prebypass with no change
Aorta is intact with no visible dissection flaps
Radiology Report CHEST (PORTABLE AP) Study Date of [**2158-5-7**] 8:44
AM
Final Report
Compared with [**2158-5-5**] at 11:41 a.m., the bilateral chest tubes
have been
pulled. There are low inspiratory volumes. No pneumothorax is
detected.
Patchy opacity at the left base again noted, slightly improved.
Blunting of the right greater than left costophrenic angles is
also grossly unchanged. Upper zone redistribution, without CHF.
Sternotomy wires and
cardiomediastinal prominence again noted, unchanged.
IMPRESSION: Interval removal of chest tubes. No pneumothorax is
detected.
Small R>L effusions are grossly unchanged.
Pre-op Labs:
[**2158-4-27**] 09:40PM PT-11.8 PTT-29.2 INR(PT)-1.1
[**2158-4-27**] 09:40PM PLT COUNT-217
[**2158-4-27**] 09:40PM WBC-5.5 RBC-3.73* HGB-11.3* HCT-34.1* MCV-91
MCH-30.4 MCHC-33.2 RDW-13.1
[**2158-4-27**] 09:40PM ALBUMIN-4.3 CALCIUM-9.1 PHOSPHATE-3.0
MAGNESIUM-2.2
[**2158-4-27**] 09:40PM LIPASE-47 %HbA1c-5.6 eAG-114
[**2158-4-27**] 09:40PM ALT(SGPT)-38 AST(SGOT)-32 ALK PHOS-24*
AMYLASE-75 TOT BILI-0.2
[**2158-4-27**] 09:40PM GLUCOSE-101* UREA N-24* CREAT-1.6* SODIUM-137
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
Discharge labs:
[**2158-5-8**] 03:45AM BLOOD WBC-5.7 RBC-3.08* Hgb-9.3* Hct-28.2*
MCV-92 MCH-30.2 MCHC-33.0 RDW-13.6 Plt Ct-237
[**2158-5-8**] 03:45AM BLOOD Plt Ct-237
[**2158-5-8**] 03:45AM BLOOD Glucose-109* UreaN-31* Creat-1.6* Na-134
K-4.0 Cl-96 HCO3-27 AnGap-15
Brief Hospital Course:
Mr. [**Known lastname 26644**] was admitted to the [**Hospital1 18**] on [**2158-4-27**] for
surgical management of his coronary artery disease. He was
worked-up in the usual preoperative manner including a carotid
duplex ultrasound which showed less then a 40% stenosis
bilaterally. Plavix was allowed to washout of his system. On
[**2158-5-3**], Mr. [**Known lastname 26644**] was taken to the operating room where
he underwent off pump coronary artery bypass grafting. Please
see operative note for details.
In summary he had:
1. Urgent off-pump coronary artery bypass graft x4, left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to diagonal, obtuse marginal and
posterior descending arteries.
2. Endoscopic harvesting of the long saphenous vein.
Postoperatively he was taken to the intensive care unit for
monitoring. He woke neurologically intact and was extubated.
Amiodarone was started for rapid atrial fibrillation. He
required close monitoring of his pulmonary status. After
aggressive diuresis and weaning from pressor support he was
transferred on postoperative day four to the step down unit for
further recovery. The remainder of his hospital stay was
uneventful, he worked with physical therapy and nursing to
increase his strength and mobility. On POD5 he was discharged
home with visiting nurses and home physical therapy.
Medications on Admission:
advair diskus 100-50 1 puff twice daily
omega 3 and omega6 fish oil 600mg twice daily
loratadine 10mg daily
prilosec 20mg every other day
rhinocort aqua 2 sprays both nostrils as needed
niacin 1000mg twice daily
lisinopril 20mg twice daily
plavix 75 mg daily
metformin 500mg twice daily-stopped [**4-20**] d/t elevated creat
zetia 10mg daily
metoprolol tartrate 75 mg twice daily
pravachol 20mg daily
fenofibrate micronized 200mg daily
Discharge Medications:
1. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for
10 days.
Disp:*20 Capsule(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
4. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
5. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*1*
6. 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:*1*
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
8. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily) for
3 months.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x5days then 400mg QD x1 wk then 200mg QD.
Disp:*60 Tablet(s)* Refills:*1*
11. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*1*
12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
13. metformin 500 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*1*
14. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
16. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 10
days.
Disp:*40 Tablet Extended Release(s)* Refills:*0*
17. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
18. Atrovent HFA 17 mcg/actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 7665**] Homecare Services
Discharge Diagnosis:
coronary artery disease
s/p MI '[**41**]
s/p PTCA/stent '[**41**]
s/p PCI [**2155**]
hypertension
diabetes
chronic kidney disease
hyperlipidemia
anemia
benign prostatic hypertrophy
colon polyps
peptic ulcer disease-s/p bleed requiring 2uPRBC
spinal stenosis
COPB/chronic bronchitis/possible asbestosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 2+ bilat
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for one month or while taking narcotics. Driving
will be discussed at follow up appointment with surgeon.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
WOUND CARE Clinic: Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2158-5-16**] 10:15
Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2158-6-6**] 1:00
Cardiologist: [**Doctor Last Name 5017**] [**2158-5-29**] at 3:45p
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 39676**],RULA [**Telephone/Fax (1) 39677**] in [**4-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2158-5-8**]
ICD9 Codes: 2875, 2859, 412, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4308
} | Medical Text: Admission Date: [**2113-1-29**] Discharge Date: [**2113-1-30**]
Date of Birth: [**2027-5-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 yo male with a history of severe AS, 3VD CAD, CHF, s/p recent
admission to [**Hospital1 18**] ([**2113-1-11**] to [**2113-1-21**]) for acute on chronic
systolic CHF, with multiple recent admissions to [**Hospital1 1516**] for severe
AS and acute on chronic systolic CHF. He has been evaluated for
AVR/CABG, but his multiple recent admissions have delayed his
surgery.
.
Prior to this, the patient has had multiple hospitalisations at
[**Hospital1 **] in [**Month (only) **]-[**2112-12-29**]. He was admitted in [**Month (only) **] s/p LOC w/ left
orbital fracture thoguht to be secondary to AVNRT s/p ablation,
was found to have aortic stenosis and 3 vessel CAD on Cath. He
was d/ced with eval for surgery, but developed GI bleeding from
a gastric ulcer. Upon discharge he developed aCHF exacerbation,
and readmitted to [**Hospital1 18**] where his course was complicated by C.
diff colitis.
.
Patient had been at [**Location (un) 1121**] [**Hospital3 **] where he was
noted to
have low blood pressures(SBP 80s, baseline 90s), was agitated
and had loose stools for 3 days. Patient also reported some
difficulty breathing for the past well. He denied any fever,
cough, abdominal pain, chest pain, palpitations. Rehab
hospitalists and family requested transfer to [**Hospital1 18**], but he was
noted to be hypotensive to SBP 65, so transported to nearest ED
at [**Hospital3 7362**]. He was thought to be septic with leukocytosis
and left shift, with question of pneumonia on CXR, anasarca and
pleural effusions. Also noted to be in ARF this morning with
empty bladder, minimal urine output, difficulty with foley
catheterisation. His labs were: WBC 13 on presentation, 15.6
today with 24% bands, H/H 12.2/36.1, Platelets: 210. Chem7
notable for BUN 79, Creatinne 4.7 (4.1 on [**1-29**]), up from a
baseline of around 2.8. CK 1118->1557; Troponin 2.12->3.13; BNP
3211, up from a baseline of 1750. INR 3.5, lactate 1.7.
Urinalysis negative. Urine lytes: K: 59.7, Creatinine: 98.4, BUN
479. At [**Hospital3 **], he reports that he has not passed stool
or gas for the last 2 days, his urine output has dropped. Today,
he also had an episode of vomiting brown fluid.
.
He was given 3+L fluids, started on vasopressin, dopamine,
levophed, now weaned down to dopamine 10 and levophed 10, PO
Vanc, IV Vanc and IV Zosyn. Minutes prior to scheduled transfer
to [**Hospital1 18**], the patient developed chest pain and was given
sublingual nitroglycerin. However, he became hypotensive and
transfer was temporarily suspended. He was then placed on
dopamine 15 + levophed 28 mcg/kg/min and transferred to [**Hospital1 18**].
Past Medical History:
Past Medical History:
- DMII
- HTN
- CVA (2 yrs ago, started on warfarin afterwards)
- CAD
- atrial fibrillation
- hx DVT [**2102**]
- severe aortic stenosis
- systolic CHF (EF 40-45% with global hypokinesis)
- syncope w/ left orbital fracture, thought to be [**3-2**] AVNRT, now
s/p ablation
Past Surgical History:
- s/p hip surgery
- s/p knee surgery
- s/p carpal tunnel syndrome
Social History:
Pt lives in rehab following recent d/c from [**Hospital1 18**] ([**2113-1-21**]).
Previosly lived in [**Location 13011**] w/ his wife. [**Name (NI) **] lives approximately
5
minutes away. Pt denies EtOH, has a distant history of EtOH
use. Non-smoker. No illicit drugs.
Family History:
Pt denies family history of CAD, cancers or DMII.
Physical Exam:
ADMISSION EXAM
VS: T= 98.2 BP=85/42HR=69 RR=30 O2 sat=84% 2L
GENERAL: NAD. Sleepy but rousable, speech slurred, left facial
droop.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Slow reacting pupils, pupils not constricting fully to bright
light.
NECK: Supple.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Rhonchorous.
ABDOMEN: Distended, fluid thrill+ve, shfting dullnes +ve, tender
to deep palpation, but no rebound, no guarding, no flank
bruising. Not peritonitic. No masses or organomegaly.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Barely palpable. All pulses dopplerable.
Pertinent Results:
ADMISSION LABS
[**2113-1-29**] 07:58PM BLOOD WBC-20.5*# RBC-3.82* Hgb-11.5* Hct-36.0*
MCV-94 MCH-30.1 MCHC-32.0 RDW-17.8* Plt Ct-249
[**2113-1-29**] 07:58PM BLOOD Neuts-86.1* Lymphs-11.3* Monos-2.2
Eos-0.1 Baso-0.2
[**2113-1-29**] 07:58PM BLOOD PT-48.8* PTT-44.3* INR(PT)-4.8*
[**2113-1-29**] 07:58PM BLOOD Glucose-175* UreaN-85* Creat-5.0*#
Na-129* K-5.5* Cl-93* HCO3-11* AnGap-31*
[**2113-1-29**] 07:58PM BLOOD ALT-25 AST-102* LD(LDH)-476*
CK(CPK)-1711* AlkPhos-102 Amylase-81 TotBili-1.4
[**2113-1-29**] 07:58PM BLOOD Albumin-2.6* Calcium-6.7* Phos-9.5*#
Mg-2.6
[**2113-1-29**] 08:15PM BLOOD Lactate-6.9*
[**2113-1-29**] 09:34PM BLOOD Lactate-7.2*
.
PERTINENT STUDIES
ECHO [**2113-1-29**]
Conclusions
There is moderate symmetric left ventricular hypertrophy. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is moderate to severe global
left ventricular hypokinesis (LVEF =25-30 %). The aortic valve
leaflets are severely thickened/deformed. The mitral valve
leaflets are mildly thickened. Moderate to severe (3+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension.
IMPRESSION: Moderate to severe global hypokinesis. Moderate to
severe mitral regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2113-1-14**],
LV function has decreased.
.
CXR [**2113-1-29**]
Although not labeled, this film is probably obtained supine. The
cardiac
silhouette is prominent, but similar to [**2113-1-11**]. There is hazy
opacity
diffusely through both lungs -- I suspect the presence of
bilateral layering effusions. There is probably underlying
collapse and/or consolidation, with suggestion of air
bronchograms in the right infrahilar region.
.
Clinical correlation to confirm that the film was obtained
supine is
recommended as it is difficult to assess the degree of aerated
lung on this film. If clinically indicated, an upright, lateral
and/or decubitus films could help to further assess the
underlying lung.
.
KUB [**2113-1-29**]
Brief Hospital Course:
85 yo male with history of critical AS, 3VD CAD, paroxysmal
atrial fibrillation on coumadin readmitted from rehab to OSH
with sepsis, colitis, acute on chronic renal failure,
exacerbation of congestive heart failure, and possible NSTEMI.
.
ACTIVE ISSUES
# Hypotension/Shock: Pt presented with shock, likely combined
septic and cardiogenic shock, with multisystem failure and
lactic acidosis. The septic component is likely secondary to GI
source given the recent C.diff infection. Surgery consult was
obtained shortly after admission to CCU. Pt's abdominal exam
worsened rapidly with distension and rebound tenderness. KUB
showed dilitation of bowel. Given his unstable hemodynamics,
surgery was deferred. Pt was treated with iv flagyl. The
cardiogenic component of his shock is based on elevation of
troponin to 3 at OSH. Given his known critical AS and three
vessel coronary artery disease (including left main), he has
little reserve for cardiac output. It is also possible that the
GI symptoms were secondary to ischemic bowel in the setting of
NSTEMI. Pt was transferred on pressors. He was treated with
maximum dose of levophed, dopamine and vassopressin while he was
at CCU. His blood pressure was maintained at 80s/40s with
reasonable mental status.
.
# End of life: [**Name (NI) 1094**] son came to the hospital and was notified of
the critical situation. The decision was made to withdraw care
and focus on comfort measures. Pressor was weaned, and morphine
gtt was started. Chaplain was called and service was provided
at the bedside. At 2AM on [**2113-1-30**], pt became unresponsive with
asystole on telemetry. There were no evidence of radial/carotid
pulses, pupilary reflex, or heart/lung sounds on exam. Pt was
declared dead. His sons [**Name (NI) **] and [**Name (NI) 25368**] came and saw pt after his
expiration. Family declined autopsy. Medical examiner was
called given the death occured within 24 hours of transfer, but
the case was waived. His PCP was notified.
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. rosuvastatin 40 mg po qd
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. lopressor 12.5 mg [**Hospital1 **]
6. Lidoderm 1 patch daily
7. Seroquel qhs
8. Zinc Sulfate 220 mg qd
9. Multivitamin 1 tablet qd
10. insulin humulin subq sliding scale
11. aldactone 12.5mg po
12. saliva substitute0.15-0.15% MM qd
13. warfarin O qd
14. Potassium chloride 40meq qd
15. vancomycin 250 mg PO qd
16. ascorbic acid 500mg PO
17. Lantus 2 untis subq qd
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
septic shock
cardiogenic shock
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 0389, 5849, 2762, 4241, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4309
} | Medical Text: Admission Date: [**2194-4-25**] Discharge Date: [**2194-5-7**]
Date of Birth: [**2150-11-9**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
left frontoparietal tumor
Major Surgical or Invasive Procedure:
[**4-25**] Left Craniotomy
History of Present Illness:
43-year-old gentleman who initially
presented with a dominant generalized tonic-clonic seizure.
Workup revealed a left frontal mass. The patient underwent
biopsy of this mass for tissue diagnosis. Pathology analysis
revealed gemiscytic astrocytoma (WHO II) without oligo
component.
Past Medical History:
None
Social History:
He lives alone and is unemployed. His mother is deceased. He has
a step father
- [**Name (NI) **] [**Name (NI) **] - who he would like making his decisions if he is
not able to make decisions for himself. He has a brother but
reports him as "not a nice person". The pts father lives on [**Location (un) **] but is aparently nonverbal due to esophageal CA. He stopped
smoking and drinking several months ago. He does not have a PCP.
Family History:
His mother is deceased. His father has esophageal CA.
Physical Exam:
O: T: af BP: 184/102 HR: 96 R 16 O2Sats100
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**5-18**] EOMis NCAT
Neck: Supple.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-17**] 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 [**6-19**] throughout. No pronator drift
Sensation: Intact to light touch.
Discharge exam:
PERRLA, EOMs full, VF full
Expressive aphasia with word finding difficulty. Naming and
Repetition intact.
Right-Sided Facial droop
Rightward tounge deviation
Motor: D B T Gr IP Q H AT [**Last Name (un) 938**] G
Right 1 3 5 5- 5 5 5 5- 3 5
Pertinent Results:
fMRI
The expected activation areas during the functional paradigms
were demonstrated, during the movement of the right hand, there
is no evidence of areas close to the left frontal neoplasm.
During the movement of the tongue and language paradigms, areas
of activation were demonstrated anterior to the mass lesion in
the frontal lobe
[**4-26**] MRI Brain: CONCLUSION: Preoperative localization for tumor
surgery. The cortical infiltration is compatible with a glioma.
The focus of enhancement suggests the lesion may be higher than
grade II.
[**4-25**] Head CT: IMPRESSION:
1. Status post left temporal tumor resection with pneumocephalus
and tiny
blood products post-surgical at the surgical bed.
2. Persistent vasogenic edema in the left frontotemporal region.
3. Mild interval worsening of hypodensity at the left frontal
white matter
near surgical bed, could be mild interval worsening edema;
however, cannot
exclude focal ischemia.
4. No large acute hemorrhage.
[**4-25**] MRI Brain (post op):IMPRESSION: Status post resection of
left temporal and posterior frontal mass. Small residual area of
enhancement at the superior aspect of the surgical cavity is
identified. No significant increase in edema is seen, but slow
diffusion is seen at the margin of the surgical cavity with a
small focus more deeper to the margin of the surgical cavity
which could be related to ischemia or could also be due to
postoperative change. No territorial infarcts are seen, however.
[**4-26**] Head CT: IMPRESSION:
No evidence of new hemorrhage. Increased parafalcine air likely
represents
redistribution of moderate pneumocephalus. Vasogenic edema and
blood products at the resection site appear stable. There is
persistent extension of hypodensity into the left frontal lobe,
which may represent vasogenic edema.
[**4-30**] CTA Chest:
1. Very extensive, acute pulmonary embolism with associated
pulmonary
arterial and right ventricular hypertension.
2. Incidental finding of left thyroid nodule, ultrasound
evaluation, when
clinically appropriate, is suggested.
[**4-30**] Lower Extremity Venous Ultrasound: No evidence of deep
venous thrombosis in bilateral lower extremity.
[**5-1**] Transthoracic echocardiogram: The left atrium is elongated.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size is normal with borderline normal free wall
function. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
[**5-1**] Ct Head: Stable appearance of the left parietal lobe
resection bed, with minimal post-surgical blood products and
surrounding frontoparietal edema. Stable minimal rightward
shift of midline structures and effacement of the left cerebral
hemispheric sulci. No new intracranial hemorrhage.
LABS:
[**2194-4-25**] 07:42PM GLUCOSE-157 UREA N-10 CREAT-0.9 SODIUM-141
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17
[**2194-4-25**] 07:42PM WBC-16.5* RBC-4.60 HGB-14.2 HCT-39.3* MCV-85
MCH-31.0 MCHC-36.3* RDW-12.9
[**2194-4-25**] 07:42PM PLT COUNT-190
[**2194-4-26**] INR - 1.1
[**2194-5-1**] PT - 14.4 PTT- 55.9 INR - 1.2
[**2194-5-2**] PT - 15.2 PTT- 81.1 INR - 1.3
[**2194-5-3**] PT - 30.5 PTT- 83.6 INR - 3.0
[**2194-5-4**] PT - 34.5 PTT- 30.0 INR - 3.5
[**2194-5-5**] PT - 31.7 PTT- 31.4 INR - 3.2
[**2194-5-6**] PT - 36.0 PTT- 32.6 INR - 3.7
[**2194-5-7**] PT - 33.7 PTT- 32.5 INR - 3.3
Brief Hospital Course:
Patient presented electively for a left sided craniotomy for
resection of mass on [**2194-4-25**]. Surgery was without complication
but upon awakening the patient was right hemiplegia. A CT was
performed immediately which showed no hemorrhage or obvious
infarct. An MRI was performed that night which demonstrated no
evidence of CVA. Over the ensuing days, the patient's neurologic
examination improved. The initial deficit was attributed to a
temporary supplemental area syndrome.
On [**4-29**] PT and OT were ordered for assistance with discharge
planning. They recommended rehab. The patient worked with case
management trying to make a plan with regards to his insurance.
On [**4-30**] the patient remained neurologically stable. While
ambulating with physical therapy in the afternoon the patient
became hypotensive with decreased oxygen saturations and
complained of anxiety. LENI's and a CTA were ordered to evaluate
for DVT and PE. CTA revealed multiple PEs in all segmental
arteries. A medicine consult was obtained and patient was
transferred to SDU. He was started on a heparin gtt with a bolus
of 3000 units and then 1800 units/hr for a goal PTT of 60-100. A
head CT was done to evaluate for hemorrhage before heparin was
initiated and showed stable postop findings. Echocardiogram and
EKG were ordered to evaluate for further clots and
abnormalities, results as decribed in Pertinent Results section.
Lower extremity dopplers were negative for DVT. He c/o
intermittent chest pain with deep inspiration, at times [**8-24**] and
described as a cramping pain.
On [**5-1**] he continued on the heparin gtt with close monitoring of
PTT and was trasitioned to Coumadin. He received his first dose
of Coumadin 5mg on [**5-1**], followed by 5mg on [**5-2**], and 3mg on
[**5-3**]. Heparin gtt was stopped on [**5-3**] when his INR reached 3.0.
Coumadin was held on [**5-4**] for an INR of 3.5 and resumed on [**5-5**]
at a dose of 2.5mg QHS. His Coumadin was held again on [**5-6**] for
an INR of 3.7 and [**5-7**] for an INR of 3.3. His INR is likely
impacted by the interaction between Dilantin and Coumadin and so
on [**5-7**] a transition to Keprra 100mg [**Hospital1 **] was started. Dilantin
will need to be tapered over 4 days to off. Dexamethasone taper
was also started on [**5-7**] with a plan for a 2 week taper to off.
The patient's right-sided strength improved during his hospital
stay and he worked with PT, OT and Speech Therapy.
At the time of discharge he was tolerating a regular diet,
ambulating with a walker, afebrile with stable vital signs.
Medications on Admission:
Keppra
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left frontoparietal Tumor
Global Aphasia - expressive aphasia
Dysarthria
Bilateral Pulmonary Emboli
Rash
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:
?????? Please taper Dilantin to off over 4 days and Continue on
Keppra 1000mg [**Hospital1 **] for Seizure prophylaxis. Follow INR closely
(daily) as Dilantin potentiates the effect of Coumadin and
impacts the INR.
- Check incision daily for signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You are tapering off of Dilantin and being transitioned to
Keppra 1000mg [**Hospital1 **] for seizure prevention. You should continue
the Keppra until intructed by Dr. [**First Name (STitle) **].
?????? You are on steroid medication which will taper to off over 2
weeks. 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:
??????You have dissolving sutures and may get your surgical site wet
10 days from your surgery. Followup as below in Brain [**Hospital 341**]
Clinic for a wound check.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2194-5-19**] at
9:30am. 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 not need an MRI of the brain.
Completed by:[**2194-5-7**]
ICD9 Codes: 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4310
} | Medical Text: Admission Date: [**2156-4-17**] Discharge Date: [**2156-4-19**]
Date of Birth: [**2108-9-27**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
TBI with Left parietal SAH, R parietal skull fx, R anterior
temporal SDH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 40230**] is a 47 yo Right handed man with no significant
past medical history. At 3pm today he was riding his motorcycle
out of his driveway. Per report of his friend [**Name (NI) **] (who was
going
to go riding with him) his bike started to tilt to one side, at
which point he tried to right it and the bike seemingly flipped
over. This occurred before he was able to get to the end of his
driveway (suggesting that he could not have been going that
fast). The patient's friend states that Mr. [**Known lastname 40230**] struck his
head upon falling off the bike. He was helmeted, but upon impact
the helmet flew off. The bike then rolled over him and he
eventually landed about 20 feet away from his initial fall with
the bike on top of him. His friend rushed to him to find him
unconscious. 911 was called and the patient seemingly remained
unsconscious for a period of [**10-2**] minutes (other notes put this
at less than 5 minutes). He then began to wake up but was
agitated and combative. His sensorium began to clear when he
arrived at an OSH, but he continued to be perseverative and
"confused." He had a head CT showing Left parietal SAH, R
parietal skull fx, R anterior temporal SDH and was subsequently
medflighted to [**Hospital1 18**].
I saw him at 7pm, at which point he was conversing fairly
clearly. He tells me that his last memory was pulling out of his
driveway with his bike and that his next memory was waking up in
the ED here. He reports a dull occipital headache, but denies
nausea, blurred vision or diplopia.
Past Medical History:
1. Hyperlipidemia
2. Irritable bowel
Social History:
Married. Works as an engineer for [**Company **]. No TOB. No
sig EtOH.
Family History:
Not contributory
Physical Exam:
Afebrile BP:127/83 HR 86 Resp:18 O2 Sat:98%
Gen: WD/WN, comfortable, NAD.
HEENT: R parietal lac
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Oriented to hospital, but not which one. Oriented
to [**2156-4-17**]. States president is [**Last Name (un) 2753**] and can say that
the
[**Male First Name (un) **] wedding occurred yesterday. Fluent speech. Repeats well
(beautiful butterfly, methodist minister) and follows three step
commands. Has difficulty with months of the year backwards
(begins to go forwards and requires prompts). Able to do 20 to 1
in 12 seconds. Registers 4 items, but only after multiple
trials.
At one minute he recalls [**2-20**] and at 5 minutes he gets [**2-20**] as
well, but cannot get the 4th.
Cranial Nerves:
I: Not tested
II: Pupils 4 to 2 mm bilaterally. No papilledema.
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. No drift. full strength throughout.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Discharge: AAO x 3, PERRL, EOM full, face symmetric
Motor and sensory intact
ambulating without issues
Pertinent Results:
CT HEAD W/O CONTRAST [**2156-4-17**]
1. Multifocal multicompartmental intracranial hemorrhage,
including diffuse left hemispheric subarachnoid hemorrhage, thin
left frontal subdural hematoma, and 7-mm anterior right middle
cranial fossa subdural hematoma, all not significantly changed.
2. Right frontoparietal subgaleal hematoma, with underlying
nondisplaced
right temporal bone fracture extending into the squamous
portion, as
characterized on prior study.
Brief Hospital Course:
47 y/o M s/p fall off motorcycle coming out of driveway.
Helmeted, but struck head and bike rolled over him. + LOC.
Patient was taken to ED where head CT revealed a L parietal SAH,
R temporal SDH, and R parietal skull fracture. He was admitted
to the neurosurgical service to ICU for further evaluation. On
[**4-18**], patient on examination was nonfocal. Repeat head CT was
stable and patient was transferred to the floor. He was
encouraged to be OOB and PT/OT was consulted. They recommended
home vs. rehab.
Now DOD, his VSS, neurologically stable, tolerating oral diet
and pain is well controlled. He is set for d/c home vs. rehab
in stable condition and will f/u with Dr. [**First Name (STitle) **] accordingly.
Medications on Admission:
simvastatin
ativan prn (for IBS)
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for headache.
2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
TBI
L parietal SAH
R temporal SDH
R parietal skull fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you have been discharged on Keppra (Levetiracetam),
you will not require blood work monitoring. Please continue fo
7 days.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Please follow-up with you PCP [**Last Name (NamePattern4) **]: sutures due to your trauma.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks with a Head CT without contrast
prior to your appt.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
Completed by:[**2156-4-19**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4311
} | Medical Text: Admission Date: [**2140-12-18**] Discharge Date: [**2140-12-23**]
Date of Birth: [**2087-11-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Worsening hypoxia, fever
Major Surgical or Invasive Procedure:
Central line placement
Emergent bronchoscopy
Thoracentesis
History of Present Illness:
HPI: 53 year old male with severe COPD, remote L CVA (residual R
sided weakness), DM, hypercarbic respiratory failure,
chronically vented was sent to ED because of worsening hypoxia.
.
Pt usually gets his care at [**Hospital1 112**]/BU but since no beds were
available, he was sent to [**Hospital1 18**] ED. He has been intubated at the
beginning of [**2140-10-10**], reportedly at [**Hospital3 **] for
hypercarbic respiratory failure in setting of severe COPD.
Before that he has been O2 dependent due to severe COPD, living
at a NH. At the OSH, he was found to have a RML and RLL collapse
and paratracaheal LAD as well as chronic right pleural
effusions. He also has questionable old granulomatous lung
disease with calcified hilar LAD. He eventually required
trach/PEG because of difficulties weaning from the vent. He
reportedly had twice a bronchoscopy done ruling out malignancy.
He was at rehab ([**Hospital 671**] [**Hospital 4094**] Hospital) since [**11-8**]. He has
been doing better until the middle of [**Month (only) **], when he was on
CPAP transiently.
.
However, since the end of [**Month (only) **], his respiratory status
worsened again and he remained on AC. He developed worsening O2
sats over the last 24h despite increasing FiO2 from 80% to 100%.
CXR from [**12-7**] showed R pleural effusion (old) and dense R lobe
opacity. He was also noted to have copious, greenish secretions
and low grade temps (99.9 on [**12-17**]). Has been on Vanc from [**12-1**]
to [**12-12**] and remained on flagyl since [**12-16**] (unclear reason for
abx per discussion with covering O/C physician at rehab). Per
rehab note, sputum from [**12-10**] with Pseudomonas sensitive only to
Gent, but felt to be colonizer. ABG in AM of [**12-18**] was 7.59/51/29
on AC with 90% FiO2, Tv 600, PEEP 10. Per handwritten note, also
CXR with increased interstitial markings in addition to chronic
effusions as above. Pt received 40mg Lasix IVx3 with good UOP
but without improvement in his respiratory status. Pt was
subsequently sent to [**Hospital1 18**].
.
In the ED, his VS were T96.9, HR 106, BP 90/49, RR14, O2 sats
86% on AC (satting initially in the 70s-80s on AC 100% FiO2,
500x14, PEEP of 5). An ABG was 7.41/86/48. HCO3 on chemistries
was 41. He improved rapidly with deep suctioning to sats in the
high 80s, then 90s. His CXR showed multilobar collapse of the
right lobe and near opacification of the left hemithorax. He was
positioned on the right with further improvement in his
respiratory status. Repeat ABG was 7.39/72/73. He remained
afebrile. UA was negative. Lactate was 1.9. WBC 10.2 with 79.6%
neutrophils, no bands (last WBC at rehab on [**12-15**] was 7.9). He
received one dose of Vanc, Levofloxacin and Flagyl for presumed
pneumonia as well as 5L IVF for transient SBPs in the low 90s.
Trop was 0.02. EKG without any acute ST changes. He is now being
admitted to the ICU for further management of his hypoxia.
.
On arrival to the ICU, he was satting 87-98% on AC FiO2 100%,
500x14, PEEP of 5.
Past Medical History:
Past Medical History:
- Chronic vent/trach/PEG for hypercarbic respiratory failure at
the beginning of [**2140-10-10**], ?reportedly due to COPD
exacerbation
- Severe COPD, home O2 dependent in the past
- Per rehab admission note, questionable old granulomatous lung
disease with calcified hilar LAD
- Remote L CVA with residual right sided weakness
- New onset generalized TC seizures on [**2140-11-5**] per rehab neuro
note, thought to be [**2-12**] post-CVA and metabolic abnormalities (on
transfer from rehab on Keppra, Depakote)
- Diabetes mellitus, on 16U Lantus at rehab and RISS
- Depression
- Schizophrenia, on effexor and risperdal
- Past h/o EtOH abuse
- GERD
.
PSH:
- Trach [**2140-11-2**]
- PEG [**2140-11-7**]
Social History:
Social History: Divorced. Former smoking. Has been at a NH prior
to recent admission and vent facility. Has been on home O2
before that for severe COPD.
Family History:
Family History: non-contributory
Physical Exam:
Physical Exam:
VS: Temp: 98.6 BP: 126/52 HR: 108 regular RR: 13 O2sat 87-95%
on AC FiO2 100%, 500x14, PEEP of 5
GEN: comfortable, NAD but lethargic
HEENT: PERRL, EOMI, anicteric, did not open his mouth despite
multiple requests and attempts to open
NECK: large neck, difficult to assess jvd, trach in place
RESP: coarse, rhoncherous BS over both lungs anteriorly, no
rales
CV: tachy but regular, S1 and S2 wnl, no m/r/g
ABD: obese, nd, sparse b/s, soft, nt, no masses, PEG tube in
place
EXT: no c/c/e, warm, 1+ DP pulses
SKIN: fungal appearing rash in groins/no jaundice
NEURO: Opening eyes. Seems lethargic. Not responding to
questions (at baseline nodding his head per rehab). Right sided
weakness at baseline.
Pertinent Results:
[**2140-12-18**] 11:14AM BLOOD WBC-10.2 RBC-3.24* Hgb-8.7* Hct-28.4*
MCV-88 MCH-26.9* MCHC-30.6* RDW-21.8* Plt Ct-493*
[**2140-12-18**] 09:53PM BLOOD WBC-12.3*# RBC-2.95*# Hgb-8.1*#
Hct-26.6*# MCV-90 MCH-27.4 MCHC-30.3* RDW-22.6* Plt Ct-547*
[**2140-12-23**] 03:22AM BLOOD WBC-7.1 RBC-2.77* Hgb-8.1* Hct-25.0*
MCV-90 MCH-29.1 MCHC-32.2 RDW-22.5* Plt Ct-491*
[**2140-12-18**] 11:14AM BLOOD PT-14.9* PTT-26.8 INR(PT)-1.3*
[**2140-12-18**] 11:14AM BLOOD Plt Ct-493*
[**2140-12-21**] 01:47AM BLOOD PT-14.6* PTT-27.4 INR(PT)-1.3*
[**2140-12-23**] 03:22AM BLOOD Plt Ct-491*
[**2140-12-18**] 09:53PM BLOOD Fibrino-856.8*
[**2140-12-18**] 09:53PM BLOOD FDP-10-40
[**2140-12-19**] 04:35AM BLOOD Fibrino-861*
[**2140-12-19**] 04:35AM BLOOD FDP-0-10
[**2140-12-18**] 11:14AM BLOOD Glucose-158* UreaN-11 Creat-0.4* Na-139
K-4.0 Cl-93* HCO3-41* AnGap-9
[**2140-12-23**] 03:22AM BLOOD Glucose-116* UreaN-6 Creat-0.3* Na-139
K-3.7 Cl-96 HCO3-43* AnGap-4*
[**2140-12-18**] 11:14AM BLOOD CK(CPK)-11*
[**2140-12-18**] 04:05PM BLOOD AST-13 LD(LDH)-141 AlkPhos-20*
TotBili-0.1
[**2140-12-18**] 11:14AM BLOOD cTropnT-0.02*
[**2140-12-18**] 04:05PM BLOOD Albumin-1.2* Calcium-5.1* Phos-2.9
Mg-1.3*
[**2140-12-21**] 01:47AM BLOOD Albumin-2.2* Calcium-8.1* Phos-3.7 Mg-2.2
[**2140-12-23**] 03:22AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.8
[**2140-12-18**] 09:53PM BLOOD Hapto-303*
[**2140-12-19**] 04:35AM BLOOD TSH-1.3
[**2140-12-23**] 03:22AM BLOOD Tobra-0.4*
[**2140-12-18**] 11:16AM BLOOD pO2-48* pCO2-86* pH-7.41 calTCO2-56* Base
XS-24
[**2140-12-22**] 03:34AM BLOOD Type-ART Temp-37.9 pO2-77* pCO2-67*
pH-7.41 calTCO2-44* Base XS-13
RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2140-12-18**] 8:56 PM
CHEST PORT. LINE PLACEMENT
Reason: eval line placement, r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with sepsis, L consolidation and R lobar
collapse w/ new right subclavian.
REASON FOR THIS EXAMINATION:
eval line placement, r/o ptx
AP CHEST 9:38 P.M. ON [**12-18**].
HISTORY: Sepsis, left lung consolidation and right lobar
collapse. Rule out pneumothorax.
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Consolidation throughout the left lung is probably severe, and
exaggerated by a large posteriorly layering left pleural
effusion. Moderate right pleural effusion and mild edema in the
right lung are new. Lower lobe collapse is unchanged. CT
scanning would probably be helpful to better characterize the
thoracic abnormalities that are present, including possibility
of extensive mediastinal adenopathy, possible pericardial
effusion and size of the cardiac silhouette, which is largely
obscured by abnormality in the left hemithorax.
One right subclavian line ends in the upper SVC, and
tracheostomy tube tip is in standard placement in the mid
trachea. No nasogastric tube seen.
Dr. [**Last Name (STitle) **] was paged to report these findings at the time of
dictation.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: MON [**2140-12-19**] 9:24 PM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2140-12-18**] 11:07 AM
CHEST (PORTABLE AP)
Reason: eval for PNA, Pulm effusion, CHF
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with hypoxia chronically vent dependent
REASON FOR THIS EXAMINATION:
eval for PNA, Pulm effusion, CHF
CLINICAL HISTORY: 53-year-old male, chronically vent dependent
with hypoxia. Evaluate for pneumonia, pulmonary effusion, CHF.
COMPARISON: None.
AP CHEST RADIOGRAPH: There is right sided volume loss as
evidenced by right sided deviation of the mediastinum. No
stigmata of lobar resection is seen so the pattern suggests
collapse of the right upper and middle lobes. There is a pleural
based opacity in the right apex suggesting locaulted effusion.
Marked elevation of the right hemidiaphragm is noted.
There is diffuse parenchymal opacity of the left lung. Lateral
pleural margins and the left hemidiaphragm are well defined
making underlying pleural effusion not likely as the quantity
necessary to produce subtotal opacity of a hemithorax would
result in such features.
A trachesotomy tube is present in standard position. Evaluation
of the mediastinal margins is limited by the baseline processes
described above. Overall, gross cardiomegaly is not suspected.
IMPRESSION:
1) Multilobar collapse of the right upper and middle lobes.
Suspect mucous plugging.
2) Loculated effusion in the right apex.
3) Diffuse parenchymal opacity of the left lung suspect for
multifocal infection. Pattern is atypical for edema given
signifcant asymmetry. The pattern is parenchymal and not pleural
in nature. Correlate clinically.
Dr. [**Last Name (STitle) **] was informed of the change in initial report at 5:30
pm on the date of study.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: SUN [**2140-12-18**] 5:21 PM
Sinus rhythm. Low voltage in the limb leads. QR complexes in
lead VI, miniature
R waves and deep S waves in lead V2 possibly reflecting anterior
wall
myocardial infarction, although full criteria are not satisfied.
Low voltage in
the limb leads, low normal voltage in the precordial leads.
TRACING #1
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2140-12-19**] 11:43 AM
CT CHEST W/CONTRAST
Reason: Please eval lung parenchyma for source of infection,
other p
[**Hospital 93**] MEDICAL CONDITION:
53 year old man on trach p/w sepsis, increased O2 requirements,
with R lung collapse and L diffuse patchiness, and bronch that
showed edema but minimal secretions.
REASON FOR THIS EXAMINATION:
Please eval lung parenchyma for source of infection, other
pathology
CONTRAINDICATIONS for IV CONTRAST: None.
COMMUTED TOMOGRAPHY OF THE CHEST WITH CONTRAST MATERIAL
INDICATION: Intubation, increased oxygen requirements.
Bronchoscopy showed edema but minimal secretions. Evaluation of
lung parenchyma for source of infection or other pathology.
TECHNIQUE: Volumetric CT acquisition over the entire thorax
after administration of contrast material from the apex through
the bases of the lungs. Multiplanar reconstructions.
FINDINGS: Previous CT examinations for comparison are not
available. There are bilateral pleural effusions with a width of
[**3-13**] cm. As a consequence, the dependent parts of both lungs are
atelectatic. The well-ventilated parts of the left and the right
lung show completely different findings. The left lung is
diffusely overlaid by ground glass opacities. Additionally, the
interlobular septa in the apical part of the left lung are
minimally thickened. There appears to be very subtle traction
bronchiectasis. Towards the basal aspect of the left lung, the
parenchyma reaches near normal attenuation values, but several
subtle peribronchial rounded opacities are seen. The right lung
shows multiple predominantly peripheral and peribronchial
ill-defined nodules that partly have a tree-in-[**Male First Name (un) 239**] appearance.
At several subpleural locations, these nodules confluate to
bigger areas of consolidation. At the apex of the left lung,
several tiny emphysematous lesions are seen. In the mediastinum,
several enlarged lymph nodes can be detected, the biggest of
which is over 2 cm in diameter. The mediastinal vessels are
unremarkable. No pericardial effusion.
IMPRESSION:
Bilateral pleural effusions with consecutive dependent
atelectasis. Rather recent potentially infectious peribronchial
lesions in the right lung, in part with a tree-in-[**Male First Name (un) 239**]
appearance. These lesions predominant in the lung periphery. The
periphery of the right lung, notably its ventral aspects, would
thus be an appropriate site for a potential repeat bronchoscopy.
Diffuse ground glass pattern in the left lung, with signs of
subtle fibrosis. These changes could correspond to an already
longer ongoing infectious process. The described pattern is not
characteristic for a specific pathogen; however, mycoplasma
pneumonia, or streptococcus, or CMV could be considered.
Moderately enlarged mediastinal lymph nodes.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: TUE [**2140-12-20**] 11:39 AM
ECHO:
Conclusions
Suboptimal image quality. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is probably preserved (LVEF
50-60%). The right ventricular cavity appears dilated. Right
ventricular systolic function appears depressed. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2140-12-21**] 4:51 PM
CHEST (PORTABLE AP)
Reason: Eval for L PTx
[**Hospital 93**] MEDICAL CONDITION:
53 year old man with left thoracentesis
REASON FOR THIS EXAMINATION:
Eval for L PTx
INDICATION: _____ of the left thoracocentesis.
COMPARISON: [**2140-12-21**].
FINDINGS: In comparison to [**2140-12-21**], there is a slight
improvement in so far, as the transparency of the left lower
lung areas has increased. No pneumothorax _____ of the left
thoracocentesis. Otherwise the radiograph is unchanged.
IMPRESSION: Improvement in comparison to [**2140-12-21**] with
increased transparency of the left lower lung. No pneumothorax.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2140-12-21**] 1:38 PM
CHEST (PORTABLE AP)
Reason: Please eval for pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
53 year old man s/p R attempted [**Female First Name (un) 576**].
REASON FOR THIS EXAMINATION:
Please eval for pneumothorax
HISTORY: Status post right attempted thoracentesis; to evaluate
for pneumothorax.
FINDINGS: In comparison with the study of [**12-18**], there is little
overall change. Diffuse consolidation throughout the left lung
is again appreciated, accentuated by the posterior layering of
pleural effusion. The opacification at the right base is
somewhat less prominent than on the previous study.
Tracheal tube remains in place and right subclavian catheter
extends to the lower portion of the SVC.
Specifically, no evidence of pneumothorax.
[**2140-12-22**] [**-7/4775**] PLEURAL FLUID
SPECIMEN DESCRIPTION: Received 1200ml cloudy clotted yellow
fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: 55 y/o male with respiratory failure, chronically
vented, heterogenous pulmonary infiltrates. Question
malignancy, infection.
REPORT TO: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Doctor Last Name **]
DIAGNOSIS: Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, histiocytes, lymphocytes and
neutrophils.
Brief Hospital Course:
Mr. [**Known lastname 40503**] was admitted to the MICU on [**12-18**] from the emergency
department after having slight improvement with suctioning and
starting Vancomycin/Levofloxacin and Flagyl for assumed
pneumonia. He received and emergent bronchoscopy showed only
mucous plugging in LLL and diffuse edematous mucosa. His PEEP
was increased to maintain his O2 on max FiO2. He was continued
on vancomycin and flagyl for HAP and received one dose of
gentamicin for his history of pseudomonas. He received
nebulizer treatments and was pan-cultured. Regarding his
hypotension and poor urine output, he received fluid boluses as
needed and subsequently a central line and levophed drip. L picc
line was removed. Patient also had sinus tach upon admission
which resolved with IVF. He was continued on his regular dose
of cardizem for history of afib. Hct was trended and received
1u PRBC on [**12-21**] to stabilize intravascular volume. Hct now
stabilized. Regarding his history of seizures, schizophrenia,
depression, diabetes, he was continued on his normal med regimen
unchanged. Also received one dose of fluconazole for skin rash.
Lactate trended down from 1.8 to 0.9. Received wound care for
skin ulcers.
CT scan results as noted above.
On [**12-20**] was restarted on gent for persistent hypotension. ID
consult recommended change of abx to tobramycin and meropenem
given pseudomonas on BAL. ECHO showed no depressed EF.
On [**12-21**] received 1u PRBC to stabilize intravasc volume. Good
hct response. Regarding low UOP, patient was started on lasix
drip to mobilize fluid. Diagnostic thoracentesis drained 1.2L
fluid. Not infected. Lasix drip subsequently turned off for
low bp's. Weaned from levophed. Subsequently restarted lasix
drip.
Respiratory status stabilized on pressure support 15/15 with 0.5
FiO2. Off of levophed. Good UOP on lasix drip. In anticipation
of DC, lasix drip stopped and transitioned to PO lasix dose.
Now stabilized for DC to rehab facility.
Medications on Admission:
Medications at rehab:
RISS
Lantus 16U daily
Atrovent nebs
Flovent [**Hospital1 **]
Lovenox 40 daily
Keppra 250 [**Hospital1 **]
colace
Nexium 40 daily
Lasix 40 daily
Trazodone 25 tid
Miralax 17 gm daily
Lactulose 30 [**Hospital1 **]
FA daily
Effexor 150 daily
Risperdal 2 qHS
Vitmains
Depakote sprinkles 875 q8h
Cardizem 60 qid
Albuterol q6h
Flagyl 500 IV q8hr
ferriecit 62.5mg M/W/F
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
2. Clotrimazole 1 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
5. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
6. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
7. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times a
day).
8. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
9. Venlafaxine 75 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times
a day).
10. Risperidone 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
11. Divalproex 125 mg Capsule, Sprinkle [**Last Name (STitle) **]: Seven (7) Capsule,
Sprinkle PO TID (3 times a day).
12. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed for wheezing, SOB.
13. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2
times a day).
14. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
15. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
16. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 4-6 Puffs Inhalation
Q4H (every 4 hours).
17. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Hospital1 **]:
2-4 puffs Inhalation 2-4 puffs [**Hospital1 **] ().
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
19. Diltiazem HCl 30 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a
day).
20. Furosemide 20 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2
times a day).
21. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
22. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
23. Meropenem 500 mg IV Q6H
Day 1 of 14 [**12-21**]
24. Tobramycin 300 mg IV Q24H Start: In am
Day 1 of 14 [**12-22**]
Insulin scale as printed and attached.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Ventilator Associated Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
You were treated in the intensive care unit for an infection in
your lungs. You improved and are being discharged to a
rehabilitation facility to complete your treatment and recovery.
Take all medicines as directed.
Re-evaluate for fever, low blood pressures, worsening oxygen
status.
Followup Instructions:
Needs to have subclavian central line removed on [**12-26**].
Antibiotics to be continued until [**1-3**]. Recommend keeping
patient negative on fluid balance and following bicarbonate
level. Also, given Tobramycin, please monitor patient's
Creatinine. If increases significantly (above 1) or urine
output drops, measure tobramycin level. Also of note, patient
has air leek on exam this am, exhalaling via mouth and able to
whisper. Current vent settings are CPAP/Pressure support, FiO2
0.5, pressure support 15/Peep 15.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2762, 5180, 5119, 496, 311, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4312
} | Medical Text: Admission Date: [**2168-8-28**] Discharge Date: [**2168-8-30**]
Date of Birth: [**2109-11-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
ETOH intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58M h/o SVT, CAD s/p stent, chronic EtOH abuse, depression and
anxiety presenting with EtOH intoxication. The patient reports
his was brought in after passing out after drinking [**12-1**] a bottle
of bourbon. He reports that he has been not drinking very
frequently because he is in a detox program but he was nervous
this week after seeing Dr [**Last Name (STitle) 724**] regarding a brain tumor that was
identified on his last admission. He was scheduled to have an
MRI next week to further evaluate the lesion and he was very
nervous about that. He reports prior to the day of admission,
he last drank 2 weeks ago. He does not get tremulous when he
does not drink. Denies SI/HI. + depression.
ROS: Denies headache, chest pain, palpitations, shortness of
breath, abdominal pain, urinary symptoms. + constipation today.
In the ED, the patient was found to be intoxicated and expressed
suicidal ideations to the resident. Inital vitals were 99.0 82
136/76 18 95%RA. Upon sobering up, the patient was seen by
psychiatry and denied SI's. He was persistently tachycardic and
hypertensive and required valium 5mg x 3, ativan 2mg x 2, and
metoprolol 50mg PO x 1. His HR remained elevated in the 130's
to 140's. He also received a MVI/thiamine 100mg/folic acid 1mg.
He was transfered to the ICU for closer monitoring for ETOH
withdrawal.
Past Medical History:
-- HTN
-- CAD s/p RCA stent in [**8-/2164**]
-- s/p closed fract tib/fib
-- SVT (AVRT v. AVNRT)
-- Chronic EtOH abuse (no h/o seizures; s/p detox 3 years ago,
referred to [**Hospital1 1680**] house partial hospitalization program [**5-5**])
-- Depression/anxiety ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 66064**] [**Numeric Identifier 100681**] @ [**Hospital1 1680**] JP;
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12528**] [**Telephone/Fax (1) 5260**])
-- Neurofibromatosis - dx on last admission
Social History:
Unemployed, living alone in [**Location (un) **] MA. Graduated from [**University/College 72402**]with a major in business, most recent work was as a
security guard. Originally from [**Hospital1 40198**] MA. No siblings or other
family. Denies illicit drugs. The patient has been drinking
chronically since the mid [**2150**]'s. He was sober from [**2157**]-[**2160**].
In addition, he was sober from [**Month (only) 116**] to [**2167-10-30**], but
relapsed after losing his job. He has had multiple blackouts,
but denies history of w/d seizure or DT's. He denies any
history of illicit drug use. He quit smoking 20 years ago, and
smoked [**4-3**] cigs/day at that time.
Family History:
Mother with depression and CAD.
Physical Exam:
T 97.2 BP 138/117 HR 121 RR19 O2 95%RA
General: comfortable, lying in bed, appears slightly dissheveled
HEENT: PERRL, poor dentition
Neck: soft, NT/ND
Cardiac: tachycardic
Pulmonary: CTA B/L
Abdomen: soft non-tender, non-distended, + bowel sounds
Extremities: no edema, mild tremor of the hands
Skin: numerous small subcutaneous nodules
Pertinent Results:
None
Brief Hospital Course:
The patient is a 58M h/o SVT, CAD s/p stent, chronic EtOH abuse,
depression and anxiety presenting with EtOH intoxication.
# EtOH intoxication/withdrawl: The patient is a chronic ETOH
abuser but has been in an outpatient treatment program. Prior
to the day of admission he had not had a drink in 2 weeks. He
was nervous about an upcoming MRI and drank heavily on the day
of admission. He was admitted to the ICU for concern of ETOH
withdrawl. The patient was tachycardic at the time of
admission, but after being placed on his home dose BB his rate
was well controlled. He was placed on valium TID and PRN based
on CIWA scale. He received MVI/thiamine and folic acid daily.
During his hospital course he did not require any CIWA coverage
and did not show any signs of withdrawl. His valium was quickly
tapered to [**Hospital1 **] and then daily. He was not discharged with any
benzos. Social work met with the patient to coordinate his
continued outpatient care. The patient was discharged directly
from the ICU.
# Tachycardia: The patient has a history of h/o SVT (AVRT vs.
AVNRT). His HR was in the 130s in ED, but was well controlled
in the ICU after being placed back on his home dose beta blocker
(metoprolol 50 TID). He was discharged on atenolol 100mg daily.
# Neurofibromatosis: The patient was diagnosed with
neurofibromatosis on his last admission earlier this month. He
was scheduled for an MRI [**8-30**] (day of discharge) on the [**Hospital Ward Name **] as part of a study protocol. The person in charge of the
protcol ended up canceling that appointment and they will call
the patient to reschedule. He will follow with Dr [**Last Name (STitle) 724**] in
clinic.
# Anxiety/Depression: He was continued on celexa.
Medications on Admission:
ASA 81 mg [**Last Name (un) **]
Celexa 20 mg qday
Atenolol
Lisinopril
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day:
Please take one pill daily. .
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
ETOH intoxication
ETOH withdrawl
Secondary Diagnosis:
Chronic EtOH abuse
HTN
CAD s/p RCA stent in [**8-/2164**]
s/p closed fract tib/fib
SVT (AVRT v. AVNRT)
Depression/anxiety
Neurofibromatosis
Discharge Condition:
Stable - Patient was ambulating, tolerating oral intake, and has
returned to his baseline condition.
Discharge Instructions:
You were admitted to the hospital with alcohol withdrawal. It
will be important for you to abstain from further alcohol use
and continue your program at [**Hospital1 1680**] House.
When you were in the hospital, we also increased your heart rate
medication to atenolol 100mg daily.
Followup Instructions:
Please follow-up with the following appointments:
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2168-8-31**]
1:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 815**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2168-9-1**]
2:30
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4313
} | Medical Text: Admission Date: [**2181-1-8**] Discharge Date: [**2181-1-12**]
Date of Birth: [**2104-8-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Xopenex
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
mitral regurgitation
Major Surgical or Invasive Procedure:
Mitral valve repair(33mm CE Physio ring) [**2181-1-8**]
History of Present Illness:
This 76 year old white female has known mitral valve prolapse
with regurgitation. She has been followed with serial
echocardiograms. Her exercise tolerance has been decreasing
recently and the regurgitation has increased. She underwent
catheterization that demonstrated no coronary disease and is
admitted now for elective valve surgery.
Past Medical History:
Asthma
hyperlipidemia
hypertension
remotge vertigo
h/o paroxysmal atrial fibrillation
peripheral neuropathy
Social History:
Race: Caucasian
Last Dental Exam: had a tooth extracted last week and faxed
dental clearance to office
Lives: Alone in [**Hospital1 **], MA. Widowed.
Occupation: Retired
Cigarettes: Never
ETOH: < 1 drink/week [] [**3-20**] drinks/week [x] >8 drinks/week []
Illicit drug use: Denies
Family History:
Family History: Denies premature coronary artery disease
Physical Exam:
PE on Admission:
Pulse: 62 Resp: 16 O2 sat: 98% room air
B/P Right: 140/65 Left: 130/77
Height: 5'5" Weight: 140 lbs
General: WDWN elderly female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [x] grade 3/6 systolic murmur
best heard along LLSB
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x]
Edema: None
Varicosities: None
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit: none
Pertinent Results:
[**2181-1-10**] 06:00AM BLOOD WBC-14.9* RBC-2.95* Hgb-9.2* Hct-27.7*
MCV-94 MCH-31.2 MCHC-33.3 RDW-14.5 Plt Ct-110*
[**2181-1-8**] 10:20AM BLOOD WBC-10.9# RBC-2.45*# Hgb-7.7*# Hct-23.0*#
MCV-94 MCH-31.4 MCHC-33.4 RDW-13.1 Plt Ct-149*
[**2181-1-8**] 11:33AM BLOOD PT-14.1* PTT-31.9 INR(PT)-1.2*
[**2181-1-8**] 10:20AM BLOOD PT-15.1* PTT-39.7* INR(PT)-1.3*
[**2181-1-10**] 06:00AM BLOOD Glucose-112* UreaN-18 Creat-0.8 Na-133
K-4.6 Cl-99 HCO3-29 AnGap-10
[**2181-1-8**] 11:33AM BLOOD UreaN-12 Creat-0.6 Na-141 K-4.3 Cl-112*
HCO3-23 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 90889**], [**Known firstname 2671**] [**Hospital1 18**] [**Numeric Identifier 90890**]
(Complete) Done [**2181-1-8**] at 9:02:42 AM 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: [**2104-8-20**]
Age (years): 76 F Hgt (in): 64
BP (mm Hg): 129/76 Wgt (lb): 140
HR (bpm): 57 BSA (m2): 1.68 m2
Indication: Mitral valve disease. Preoperative assessment.
Shortness of breath. Valvular heart disease. Intraoperative TEE
for mitral valve repair. Left ventricular function. Prosthetic
valve function. Right ventricular function. Valvular heart
disease.
ICD-9 Codes: 424.0, 786.05, 424.2
Test Information
Date/Time: [**2181-1-8**] at 09:02 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2011AW-:1 Machine: us6
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Left Ventricle - Stroke Volume: 51 ml/beat
Left Ventricle - Cardiac Output: 2.91 L/min
Left Ventricle - Cardiac Index: *1.73 >= 2.0 L/min/M2
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Arch: *3.1 cm <= 3.0 cm
Aorta - Descending Thoracic: *3.0 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 6 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 3 mm Hg
Aortic Valve - LVOT pk vel: 1.00 m/sec
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT diam: 1.9 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque. Normal aortic diameter at
the sinus level. Normal ascending aorta diameter. Mildly dilated
aortic arch. Mildly dilated descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Myxomatous mitral valve leaflets. Moderate/severe
MVP. Mitral leaflets fail to fully coapt. No MS. [**Name13 (STitle) 650**] (4+) MR.
TRICUSPID VALVE: Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient was under general anesthesia throughout the
procedure. No TEE related complications. The patient appears to
be in sinus rhythm. Results were personally reviewed with the MD
caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. The aortic arch
is mildly dilated. The descending thoracic aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are myxomatous. There is moderate/severe P2 leaflet
mitral valve prolapse. The mitral valve leaflets do not fully
coapt. Severe (4+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at
time of surgery.
POST-BYPASS: The patient is A paced. The patient is on no
inotropes. There is a well-seated mitral annuloplasty ring in
place. No mitral regurgitation is seen. No paravalvular leak is
seen. There is a mean gradient of 1 mmHg across the mitral valve
at a cardiac output of 3.4 L/min. No aortic regurgitation is
seen. The mean gradient through the LVOT and aortic valve is 4
mmHg. Tricuspid regurgitation is unchanged. The aorta is intact
post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2181-1-8**] 13:01
?????? [**2172**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Following same day admission she went to the Operating Room
where mitral repair was effected with a 33mm CE Physio ring with
Dr.[**Last Name (STitle) **]. Please refer to operative report for further
surgical details. She tolerated the procedure well and was
transferred tot he CVICU intubated and sedated. She awoke
neurologically intact and was weaned to extubation the afternoon
of surgery. She weaned off pressor support and Beta blocker and
diuretics were started. All lines and drains were discontinued
per protocol. Post-operative day one she was transferred to the
step down unit for further monitoring. Her chest tubes and
epicardial wires were removed. Physical Therapy was consulted
to evaluate her strength and mobility. Narcotics were
discontinued due to postoperative confusion which slowly
improved. The remainder of her postoperative course was
essentially uneventful. She continued to progress and on
post-operative day#4 she was discharged to home. All follow up
appointments were advised.
Medications on Admission:
Fluoxetine 20mg daily
ProAir HFA 90 2 puffs every 4 hours as needed
Diltiazem 120mg daily
Gabapentin 300mg daily
Aspirin 81mg daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 5 days.
Disp:*10 Tablet Extended Release(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
mitral regurgitation/mitral prolapse
s/p mitral valve repair
hyperlipidemia
asthma
hypertension
paroxysmal atrial fibrillation
h/o vertigo
peripheral neuropathy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Edema: None
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2-15**] at 1:00pm in the [**Hospital **]
Medical office building, [**Doctor First Name **] [**Hospital Unit Name **]
wound check on [**1-23**] at 10:30am in the [**Hospital **] Medical office
building, [**Doctor First Name **] [**Hospital Unit Name **]
Dr [**Last Name (STitle) 10543**] ([**Telephone/Fax (1) 4475**]) on [**2-1**] at 3:15pm
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2181-1-12**]
ICD9 Codes: 4240, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4314
} | Medical Text: Admission Date: [**2114-2-21**] Discharge Date: [**2114-2-22**]
Date of Birth: [**2054-2-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
bowel perforation
Major Surgical or Invasive Procedure:
chest tube placement, central line placement, arterial line
placement
History of Present Illness:
60 year old lady with complicated demyelinating disorder and
chronic abdominal pain presents with a week of lethargy,
decreased oral intake, abdominal pain and back pain. Patient
fell in her bathroom. EMS found her to have altered mental
status with finger stick of 35 and she received D25 without any
improvement in mental status. She was brought to [**Hospital1 18**] Emergnecy
Department. Code stroke was called in ED due to tonic-clonic
movement in right arm in ambulance. She was following commands
on arrival and complained of abdominal pain. She was found to
have a new LBBB. She has felt chills at home. No fevers at
home. Trauma panel were sent. Her labs were significant for WBC
24, Lactate 19 and AG 34. She became comatose and was intubated
for further studies. Bilateral femoral lines were attempted but
were unsuccessful. CT abdomen/pelvis had free air with concern
for duodenal perforation. RIJ was placed but patient desaturated
during the procedure. Empirically put in right chest tube due to
concern for pneumothorax, however patient started to drain blood
from the site. She received Vancomycin, Zosyn and IVF. She was
started on norepinephrine for blood pressure control. Surgical
consult was obtained in the Emergency Department. They
recommended that she was not an operative candidate and
recommended discussion regarding comfort measures only.
.
On arrival to the floor patient started dropping her BP as low
as SBP of 60s. She required on and off pressures including
levophed, neosynephrine and vasopressine. Initally she was able
to move all her extremities and open eyes. She was sedated for
the required procedures. Patient also was in significant
acidemia and required bicarbonate drip. Her hematocrit dropped
to 19 from 32. She transiently went into wide complex
tachycardia lasting many seconds which resolved on its own. She
was bleeding around and from the chest tube. She received 6 u
pRBCs, 3 u FFP, 7 L of IVF, 60 IV KCL, 60 po KCL, 4 grams of
calcium gluconate, 1 gram of meropenem during her initial
stabilization in ICU. Her poor prognosis was discussed with the
family including her husband and daughter.
Past Medical History:
Demyelinating disorder of unclear etiology, probable MS.
History of recurrent branch retinal vein occlusions ([**Month (only) 547**]
[**2106**] and [**2108-8-27**]).
History of posterior uveitis.
History of generalized tonic-clonic seizures in childhood.
Organic affective disorder with psychotic features.
Hypertension.
History of multiple miscarriages.
.
Social History:
Obtained from OMR notes:
She is married to her second husband (over 30
years). By history, her first husband was abusive. She has two
daughters, one young and one grown. She is not employed.
.
Family History:
No known neurological problems. There
is a history of hypertension and coronary artery disease.
Physical Exam:
Gen: sedated, in NAD
HEENT: PERRL, MMM
Heart: S1S2 RRR
Lungs: CTAB in ant lung fields, right sided chest tube was in
place
Abdomen: BS absent, becoming more distended
Ext: WWP, no edema
Neuro: spontaneously moved all 4 extremities prior to sedation
Pertinent Results:
[**2114-2-21**] 07:20AM BLOOD WBC-23.8* RBC-UNABLE TO Hgb-UNABLE TO
Hct-32* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO Plt Ct-312
[**2114-2-21**] 12:59PM BLOOD WBC-7.0# RBC-2.08*# Hgb-5.7*# Hct-19.4*#
MCV-93 MCH-27.3 MCHC-29.3* RDW-14.7 Plt Ct-173
[**2114-2-21**] 04:21PM BLOOD WBC-7.5 RBC-4.11*# Hgb-12.3# Hct-35.8*#
MCV-87 MCH-30.0 MCHC-34.4# RDW-14.7 Plt Ct-68*#
[**2114-2-21**] 08:43PM BLOOD WBC-4.0 RBC-3.14* Hgb-9.5* Hct-26.4*#
MCV-84 MCH-30.2 MCHC-36.0* RDW-15.3 Plt Ct-79*
[**2114-2-22**] 01:58AM BLOOD WBC-5.2 RBC-3.05* Hgb-9.3* Hct-25.2*
MCV-83 MCH-30.5 MCHC-37.0* RDW-15.3 Plt Ct-73*
[**2114-2-22**] 06:00AM BLOOD WBC-5.6 RBC-3.14* Hgb-9.4* Hct-27.2*
MCV-87 MCH-29.8 MCHC-34.4 RDW-14.9 Plt Ct-68*
[**2114-2-21**] 07:20AM BLOOD Neuts-60 Bands-20* Lymphs-14* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-1*
[**2114-2-22**] 06:00AM BLOOD Neuts-48* Bands-13* Lymphs-35 Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-14*
[**2114-2-21**] 07:20AM BLOOD PT-16.6* PTT-37.3* INR(PT)-1.5*
[**2114-2-21**] 04:21PM BLOOD PT-36.2* PTT-126.3* INR(PT)-3.9*
[**2114-2-21**] 04:21PM BLOOD Plt Ct-68*#
[**2114-2-21**] 08:43PM BLOOD PT-22.7* PTT-64.3* INR(PT)-2.2*
[**2114-2-22**] 01:58AM BLOOD PT-20.6* PTT-45.1* INR(PT)-1.9*
[**2114-2-22**] 06:00AM BLOOD PT-25.0* PTT-55.5* INR(PT)-2.4*
[**2114-2-21**] 07:20AM BLOOD UreaN-22* Creat-2.6*#
[**2114-2-21**] 12:59PM BLOOD Glucose-100 Na-147* K-2.6* Cl-116*
HCO3-12* AnGap-22*
[**2114-2-21**] 04:21PM BLOOD Glucose-165* UreaN-18 Creat-1.7* Na-148*
K-4.1 Cl-111* HCO3-15* AnGap-26*
[**2114-2-21**] 08:43PM BLOOD Glucose-211* UreaN-22* Creat-2.1* Na-144
K-3.0* Cl-104 HCO3-19* AnGap-24*
[**2114-2-22**] 01:58AM BLOOD Glucose-55* UreaN-22* Creat-2.3* Na-145
K-5.6* Cl-109* HCO3-12* AnGap-30*
[**2114-2-22**] 06:00AM BLOOD Glucose-20* UreaN-20 Creat-2.3* Na-146*
K-7.9* Cl-113* HCO3-9* AnGap-32*
[**2114-2-21**] 07:20AM BLOOD ALT-174* AST-254* LD(LDH)-870*
CK(CPK)-138 AlkPhos-131* Amylase-129* TotBili-0.4
[**2114-2-21**] 12:59PM BLOOD LD(LDH)-5880* CK(CPK)-2238*
[**2114-2-21**] 08:43PM BLOOD ALT-1222* AST-3314* LD(LDH)-4960*
AlkPhos-59 TotBili-1.1
[**2114-2-22**] 01:58AM BLOOD ALT-1175* AST-5049* LD(LDH)-5532*
AlkPhos-65 TotBili-1.7*
[**2114-2-22**] 06:00AM BLOOD ALT-[**2054**]* AST-6481* LD(LDH)-7700*
AlkPhos-73 TotBili-1.5
[**2114-2-21**] 07:20AM BLOOD Lipase-68*
[**2114-2-21**] 07:20AM BLOOD Albumin-3.8 Calcium-9.8 Phos-9.6*#
Mg-3.3*
[**2114-2-21**] 12:59PM BLOOD Calcium-7.2* Phos-4.8*# Mg-1.9
[**2114-2-21**] 04:21PM BLOOD Calcium-6.2* Phos-6.2* Mg-1.5*
[**2114-2-21**] 08:43PM BLOOD Calcium-7.9* Phos-3.3# Mg-1.4*
[**2114-2-22**] 01:58AM BLOOD Calcium-7.2* Phos-4.8* Mg-2.1
[**2114-2-22**] 06:00AM BLOOD Calcium-6.0* Phos-10.0*# Mg-2.0
[**2114-2-22**] 01:58AM BLOOD Vanco-16.3
[**2114-2-21**] 07:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2114-2-21**] 08:19AM BLOOD pO2-228* pCO2-20* pH-6.93* calTCO2-5*
Base XS--28 Comment-GREEN TOP
[**2114-2-21**] 10:57AM BLOOD Type-[**Last Name (un) **] pO2-202* pCO2-37 pH-7.13*
calTCO2-13* Base XS--16 Intubat-INTUBATED Comment-GREEN TOP
[**2114-2-21**] 12:58PM BLOOD Type-ART pO2-451* pCO2-34* pH-7.18*
calTCO2-13* Base XS--14
[**2114-2-21**] 03:41PM BLOOD Type-ART Temp-36.1 Rates-/24 pO2-20*
pCO2-75* pH-7.04* calTCO2-22 Base XS--14 -ASSIST/CON
Intubat-INTUBATED
[**2114-2-21**] 04:34PM BLOOD Type-CENTRAL VE pH-7.15* Comment-GREEN
TOP
[**2114-2-21**] 05:51PM BLOOD Type-ART Temp-36.7 Rates-24/ Tidal V-500
PEEP-5 FiO2-60 pO2-194* pCO2-30* pH-7.30* calTCO2-15* Base XS--9
-ASSIST/CON Intubat-INTUBATED
[**2114-2-21**] 07:08PM BLOOD Type-ART Temp-36.7 Rates-25/ Tidal V-500
PEEP-5 pO2-178* pCO2-31* pH-7.34* calTCO2-17* Base XS--7
-ASSIST/CON Intubat-INTUBATED
[**2114-2-21**] 08:58PM BLOOD Type-ART pO2-55* pCO2-30* pH-7.45
calTCO2-21 Base XS--1
[**2114-2-22**] 02:04AM BLOOD Type-ART pO2-165* pCO2-16* pH-7.56*
calTCO2-15* Base XS--4
[**2114-2-22**] 02:53AM BLOOD Type-ART pO2-102 pCO2-23* pH-7.40
calTCO2-15* Base XS--7
[**2114-2-22**] 05:57AM BLOOD Type-ART pO2-87 pCO2-25* pH-7.16*
calTCO2-9* Base XS--18 Intubat-INTUBATED
[**2114-2-21**] 07:31AM BLOOD Glucose-165* Na-146 K-3.1* Cl-104
calHCO3-8*
[**2114-2-21**] 08:19AM BLOOD Lactate-19.0*
[**2114-2-21**] 10:57AM BLOOD Glucose-258* Lactate-13.6* Na-140 K-2.9*
Cl-109
[**2114-2-21**] 03:41PM BLOOD K-3.5
[**2114-2-21**] 04:34PM BLOOD Lactate-11.6*
[**2114-2-21**] 05:51PM BLOOD Lactate-13.2* K-3.4*
[**2114-2-21**] 07:08PM BLOOD K-3.2*
[**2114-2-21**] 08:58PM BLOOD Lactate-10.8*
[**2114-2-22**] 02:04AM BLOOD Lactate-10.7*
[**2114-2-22**] 05:57AM BLOOD Lactate-11.3* K-7.6*
.
CT HEAD W/O CONTRAST [**2114-2-21**]:
The scan is limited by motion. There is no evidence of acute
hemorrhage, edema, mass, mass effect or major vascular territory
infarction. Nonspecific hypodensity in the periventricular and
subcortical white matter may be related to stated diagnosis of
demyelinating disorder or small vessel ischemic disease. There
is prominence of the ventricles and sulci indicating a mild
degree of diffuse parenchymal volume loss which is slightly
greater than expected for the patient's age. No soft tissue or
osseous abnormality is detected. The visualized paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION: The scan is limited by motion. No acute intracranial
abnormality.
.
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST; CT PELVIS W/O
CONTRAST [**2114-2-21**]:
CT CHEST WITHOUT IV CONTRAST: The heart is mildly enlarged. A
small amount
of calcification is noted in the aortic arch, but the great
vessels are
otherwise unremarkable. There are emphysematous changes of the
lungs,
predominantly in the bilateral apices. No pleural or pericardial
effusion is seen. There is no mediastinal, hilar, or axillary
lymphadenopathy.
CT ABDOMEN WITHOUT IV CONTRAST: There is a large amount of free
intraperitoneal air with foci of air in the hepatic hilum
adjacent to the
duodenum and concerning for duodenal perforation. The remaining
loops of
intra-abdominal bowel are unremarkable. Also noted is
perihepatic and
perisplenic free fluid which is simple in attenuation. The
liver, pancreas, kidneys, and adrenal glands are grossly normal.
The spleen demonstrates multiple tiny calcifications which may
be related to prior infection or granulomatous disease. A mild
amount of calcification is noted in the abdominal aorta. There
is no retroperitoneal or mesenteric lymphadenopathy.
CT PELVIS WITHOUT IV CONTRAST: The urinary bladder, uterus,
sigmoid colon and rectum appear normal. There is no pelvic free
fluid or lymphadenopathy.
BONE WINDOWS: No sclerotic or lytic osseous lesions are
identified.
CT RECONSTRUCTIONS: Multiplanar reformats were essential in
delineating the anatomy and pathology.
IMPRESSION: Limited non-contrast study with intra-abdominal free
fluid,
pneumoperitoneum, with several tiny foci adjacent to the
duodenum, concerning for duodenal perforation.
.
CT C-SPINE W/O CONTRAST: [**2114-2-21**]:
No cerical spine injuries. No fracture or malalignment
.
CXR AP [**2114-2-21**]:
1. Possible pneumoperitoneum which is better evaluated on
concurrent CT
torso.
2. Endotracheal tube 5.6 cm above the carina.
3. Cardiac enlargement.
.
CXR AP [**2114-2-21**]:
1. Distal tip of CVL projecting over SVC.
2. Interval advancement of endotracheal tube 2.5 cm above the
carina.
3. Interval placement of NG tube. Recommend advancing the tube
until the last port is in the stomach.
4. Interval placement of chest tube in the right lung. No
evidence of
pneumothorax.
5. Cardiac enlargement.
.
CXR AP [**2114-2-22**]:
Interval removal of mediastinal drain. Chest tube and right
central lines are unchanged in position. ET tube with tip
terminating 50 mm above the carina. Improvement of the right
lung base atelectasis. Unchanged appearance of the left
retrocardiac atelectasis. Unchanged mild cardiomegaly.
Brief Hospital Course:
.
60 year old lady with complicated demyelinating disorder was
found to have perforated duodenum and septic shock in Emergency
Department. Surgical consult was obtained in Emergency
Department. After carefully reviewing her case it was felt that
she is not a surgical candidate and she was thought to have very
poor prognosis. Patient had a right internal jugular central
line placed in Emergency Department. There was concern of
pneumothorax in Emergency Department during the line placement
due to desaturation and she had a chest tube placed in right
pleural space. Patient was also intubated in Emergency
Department for better airway support. Patient was admitted to
Medicine Intensive Care Unit for further management.
.
On arrival to the Medicine Intensive Care Unit, patient was in
severe septic shock and multiorgan failure including kidney and
liver failure. She was kept on broad spectrum antibiotics with
Vancomycin, Zosyn and Meropenem. Patient was on and off of
multiple pressors including Norepinephrine, Phenylephrine and
Vasopressin to keep her mean arterial pressure above 65.
Patient received IV fluid resuscitation with both normal sline
and bicarbonate given significant acidemia. She also went into
wide complex tachycardia shortly after arrival but converted on
her own to sinus rhthm with bundle branch block. She also
received potassium and calcium supplementation.
.
Patient started to have increased blood out put in her chest
tube, approximately 1.5 L and had bleeding around her chest tube
site. Thoracic surgery was consulted. Bleeding around the tube
improved with pressure. Given that the tube was draining and
her underlying condition (perforated bowel and septic shock)
worsened, no other intervention was recommended. Patient also
experienced hemolysis and went into dissiminated intravascular
coagulation. She received 10 units of packed redblood cells, 6
units of FFP and ddAVP.
.
Given her poor prognosis, code status was discussed with the
family. Her status was changed to CPR not indicated. Her
condition continue to worsen overnight despite optimal medical
managment. On [**2114-2-22**] AM patient became hypotensive and then
went into asystole. She was pronounced dead at 7:26 AM.
Family, including her husband, were present overnight. Her
family initially did not want an autopsy but changed their mind
the next day.
.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient passed away.
Discharge Condition:
Patient passed away.
Discharge Instructions:
Patient passed away.
Followup Instructions:
Patient passed away.
Completed by:[**2114-2-24**]
ICD9 Codes: 0389, 5849, 4271, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4315
} | Medical Text: Admission Date: [**2126-7-25**] Discharge Date: [**2126-8-6**]
Date of Birth: [**2056-9-2**] Sex: M
Service: MEDICINE
HISTORY OF THE PRESENT ILLNESS: The patient is a 69-year-old
male with a history of hepatic cirrhosis secondary to
ETOH/hepatitis C, with portal hypertension, gastric and
esophageal varices status post multiple sclerotherapy
treatments since [**Month (only) 547**], who was transferred from an outside
hospital to [**Hospital1 18**] for acute upper GI bleed secondary to
varices for a possible emergent [**Last Name (un) **]. The patient has had
multiple admissions to [**Hospital3 3583**] for GI bleeds and
encephalopathy, most recently on [**2126-7-21**] for worsening
encephalopathy but no GI bleed. The patient presented on the
date of admission to an outside hospital with nausea,
hematemesis (100 cc BRB) and melena. An EGD showed 4+
gastric varices, duodenal varices, duodenal AVM, no
esophageal varices. Duodenal AVM was injected with
hypertonic saline and epinephrine with bleeding control.
Hematocrit at 12:20 p.m. was 31.2, and then at 3:00 p.m. it
was 25.3.
The patient was intubated electively for a decline in mental
status and to protect his airway from aspiration and he was
Medflighted to [**Hospital1 18**]. He received 2 units of PRBCs (total 4
prior to transfer) without an appropriate bump in his
hematocrit. On [**Location (un) 7622**], the patient also required
Neo-Synephrine for hypotension. On arrival to [**Hospital1 18**], the
patient was off all pressors. A NG lavage of 250 cc of
saline returned approximately 300 cc of bright red blood and
clots. The blood pressure was 117/54, heart rate 82. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] tube was placed. A chest x-ray reported good
position and a gastric balloon was inflated with 300 cc of
air. A chest x-ray again confirmed good placement. The
patient was transfused 2 units overnight and was scheduled
for [**Last Name (un) **] the following morning.
PAST MEDICAL HISTORY:
1. Hepatic cirrhosis secondary to alcohol, hepatitis C.
2. Gastric varices.
3. Esophageal varices.
4. Encephalopathy with history of hyperammonemia.
5. Hypothyroidism.
6. IDDM.
7. BPH, status post TURP.
8. Hepatitis C.
9. GERD.
10. COPD.
11. Hypertension.
12. Status post cholecystectomy.
13. Status post right femoral/popliteal bypass.
14. PVD.
ALLERGIES: ASA, Tylenol.
MEDICATIONS ON TRANSFER:
1. Insulin sliding scale.
2. Propanolol 10 q. six hours.
3. Nadolol 40 p.o. q.d.
4. PPI 40 b.i.d. IV.
5. Donepezil 5 q.d.
6. Risperidone 25 p.r.n.
7. NPH 30 q.p.m., 36 a.m.
8. Synthroid 25 mcg.
9. Aldactone 100 q.a.m.
10. Lactulose 30 cc b.i.d.
11. Octreotide drip.
12. Ampicillin 2 grams.
13. Thiamine 100 mg.
14. Vitamin K 10 mg.
15. Pepcid.
FAMILY HISTORY: Mother died at 82 without medical problems.
The patient's father died at age 35. The patient has two
siblings with diabetes. He has six children and 19
grandchildren.
SOCIAL HISTORY: The patient has not drank alcohol for 24
years. He has a 70 pack year history of smoking but has not
smoked for 13 years. There is no history of IVDU. He lives
with his wife and daughter at home. His daughter helps to
care for him and his wife who has a memory disorder.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Afebrile,
BP 117/57, heart rate 82, pressure support ventilation.
General: The patient was lying in bed, intubated, blood
around the mouth, thin, pale. HEENT: The pupils were equal,
round, and reactive to light. Positive scleral icterus. No
lymphadenopathy. Neck: Supple. CV: Regular rate and
rhythm, S1, S2, no MRG. Lungs: Coarse rhonchi bilaterally
anteriorly. Abdomen: Soft, nontender, nondistended, positive
bowel sounds. No ascites. Extremities: No edema. DPs
positive.
LABORATORY/RADIOLOGIC DATA: White count 14.6, hematocrit
28.4, PTT 36.9, INR 1.7, fibrinogen 150, potassium 5.4. The
patient's LFTs were normal, total bilirubin was not checked.
An ammonia level was 47.
An EGD on the date of admission showed a normal esophagus,
cobblestoning, and large varices upon varices, point of
bleeding was identified and a large amount of residual
coffee-ground material without clots was found in the antrum
with cobblestoning. The duodenal bulb had a clot which was
lavaged to reveal an AVM. The AVM was injected with
hypertonic saline and epinephrine, gastric varices were
observed to stop bleeding.
HOSPITAL COURSE IN THE MICU: 1. GASTROINTESTINAL BLEED: On
the day of admission, [**2126-7-25**], a NG lavage showed
frank blood in the stomach. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube was placed the
same evening with good placement confirmed by chest x-ray.
The patient received 3 units of blood overnight on the night
of admission as well as 2 units of FFP and 1 bag of
platelets. The patient underwent a TIPS on [**2126-7-26**].
He required 6 units of blood. The TIPS was done and two
varices were coiled. A left IJ cordis was placed during the
procedure. The patient also had a femoral line placed on the
[**Location (un) 7622**] as well as two peripheral IVs.
An ultrasound on [**2126-7-28**] demonstrated TIPS was patent
and the [**Last Name (un) **] tube was removed. The patient, however,
still required blood. He received 2 units on [**2126-7-28**]
as well as FFP and platelets. On [**2126-7-31**], the
hematocrit still continued to drop and he again required 2
units and was slightly hypotensive. The patient was having
dark mahogany stools at this time.
On [**2126-8-1**], the hematocrit remained stable until
discharge from the MICU and he did not require further
transfusion.
2. CIRRHOSIS/ENCEPHALOPATHY: On [**2126-7-28**] following
the TIPS procedure, the patient's bilirubin rose to a level
of 20 and increased again on [**2126-7-29**] to 23. The
patient was quite jaundiced. He was intubated but was not
requiring any sedation for the intubation and was not
responsive. The patient increasingly became more awake on
[**2126-7-31**] and on [**2126-8-1**] was able to be
extubated. He was alert and oriented times three. He
continued to receive Lactulose during the entire admission;
when he could not receive it through his NG tube, he received
it rectally and he continued to have loose bowel movements.
His bilirubin level dropped over the course of the time in
the MICU and on discharge to the MICU was actually rising and
was 20 on discharge from the MICU. The patient was also
becoming increasingly jaundiced. He was slightly more
lethargic but still alert and oriented times three.
3. INFECTIOUS DISEASE: The patient initially on admission
was afebrile. He was receiving Levaquin for SBP prophylaxis.
On [**2126-7-29**], the patient spiked a fever to 103. He
was pan cultured and four out of four blood cultures from
[**2126-7-29**] grew gram-positive cocci in pairs and
clusters which turned out to be MRSA. Vancomycin was begun
on [**2126-7-29**]. A catheter tip from [**2126-7-29**] also
grew MRSA and also grew enterococcus which was also sensitive
to vancomycin. A sputum culture also grew MRSA. The
patient's fevers subsided within approximately 24 hours and
his white blood cell count which had elevated slightly also
dropped. He continued to have a lot of productive sputum.
The patient was also de-lined following spiking of the fever
and had his left IJ changed to a right subclavian. In
addition, he had his old femoral line removed. In addition,
he had his A line removed.
On discharge from the MICU, the patient was afebrile. He
still was having a lot of secretions which were requiring
suctioning and chest PT. His oxygen requirement was also
slightly increasing.
4. RESPIRATORY FAILURE: The patient was intubated for
airway protection on the date of admission, [**2126-7-25**],
and was kept on pressure support without sedation until
extubation on [**2126-8-1**]. He required 50% face mask
initially on extubation but because of increasing secretions,
the patient was increased to 70% face mask on discharge from
the MICU. He was on 50% face mask and saturating between 91
and 94%.
5. ENDOCRINE: The patient has insulin-dependent diabetes.
He was initially started on a sliding scale for his diabetes
but was switched to an insulin drip when his sugars required
increasing control. His insulin drip was changed on [**2126-8-2**]
to a sliding scale. The patient also was receiving Synthroid
for his chronic hypothyroidism.
The rest of this dictation will be completed by the medicine
intern following Mr. [**Known lastname 9464**] on the Medicine Floor.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 8141**]
MEDQUIST36
D: [**2126-8-6**] 05:00
T: [**2126-8-8**] 11:34
JOB#: [**Job Number 51916**]
ICD9 Codes: 2851, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4316
} | Medical Text: Admission Date: [**2154-9-1**] Discharge Date: [**2154-9-5**]
Date of Birth: Sex: F
Service: NSURG
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
woman found on the floor at homoe who was minimally
responsive and brought to an outside hospital where her head
CT showed diffuse subarachnoid hemorrhage with right inferior
temporal [**Doctor Last Name 534**] hemorrhage. There was no mas effect and no
shift. She was loaded with Dilantin and intubated and
transferred to [**Hospital 4415**] where a left
ventricular drain was placed. She was then transferred to
[**Hospital1 69**] for angiogram and
possible coiling.
Vital signs on admission was temperature 99.5, blood pressure
142/74, heart rate 78, Respiratory rate 21, sats 98 percent.
The patient was on Propofol and intubated with a vent
draining when she was examined on admission. She had
spontaneous movement of her bilateral upper extremities and
she withdrew her lower extremities briskly to stimulation.
Pupils were 2 down to 1.5 bilaterally. She did not follow
commands. She had positive corneals bilaterally. Her face
appeared symmetric. She had a past medical history of
hypertension.
LABORATORY DATA: White blood cell count was 27, hematocrit
46.8, platelets 301, sodium 142, K 3.2, chloride 107, CO2 23,
Bun 17, creatinine 0.9, glucose 149.
The patient was admitted to the ICU for close observation.
She was sent to angiogram on [**2154-9-1**] which showed a
ruptured right posterior communicating artery aneurysm which
she had coiling without complications. Post-op she was able
to follow commands and move all extremities to commands. The
patient was in the ICU post-op for close neurologic observation.
ON [**2154-9-2**], orthopedics were consulted due to a left ankle
fracture that was found at the outside hospital. The patient
was treated with minimal splinting and currently did not
require any surgical intervention for this fracture.
Neurological exam remained difficult to assess at times because
of agitation from the ET tube with resultant increased ICP and
decreased pCO2. Pupils were 3 down to 2.5 and the
patient was localizing to stimulation. On [**2154-9-4**], the
patient off sedation was very lethargic and slow to follow
commands requiring heavy stimulation such as sternal rub to
open eyes and squeeze with her right hand. No movement noted
with the left upper extremity and lower extremity moved with
stimulation only. Pupils, equal, regular, and react to light
and accommodation. ICP's remained a max of 14, ventricular
drain remained in place. The patient's spiking fevers up to
102.6. The patient had gram negative rods and 3 plus
monobacterial and Haemophilus influenzae in her sputum.
Urine was no growth to date and CSF was no growth. On
[**2154-9-4**], the patient became progressively more tachypneic
throughout the shift despite adjustments to the ventilator.
Head CT was done emergently which was negative for any change.
The patient's ICP was up howevere increased to 28.
The patient was thus taken emergently to the Operating Room and
underwent a right frontal craniectomy and duroplasty for
intractable edema. A head CT post- op demonstrated ischemic
watershed infarcts consistent with severe diffuse vasospasm.
Postoperatively, the patient's pupils were 2.5 down to 2
bilaterally. A angiogram was then performed to determine the
source of the infarcts and to rule out emboli from the coil
mass. The angiogram disclosed severe vasospasm with thread-
like vascular caliber. The patient had extensive posturing in
the left, minimal movement on the right. On [**2154-9-5**], a family
meeting was held and the patient was made CMO. The patient
expired on [**2154-9-5**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2155-1-2**] 11:42:55
T: [**2155-1-2**] 14:44:05
Job#: [**Job Number 57748**]
ICD9 Codes: 431, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4317
} | Medical Text: Admission Date: [**2114-4-16**] Discharge Date: [**2114-4-25**]
Date of Birth: [**2058-2-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2114-4-18**] Mitral Valve Replacement w/ 25/33 On-X valve, MAZE
procedure, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation
History of Present Illness:
56 y/o female with h/o DM, HTN and MVP who presented to OSH with
acute shortness of breath. She underwent an echo which revealed
a flail mitral valve secondary to torn chordae and an EF of 60%.
She was transferred to [**Hospital1 18**] for surgical management. Also
during this she developed new onset Atrial Fibrillation.
Past Medical History:
At Transfer: Mitral Regurgitation w/ Flail leaflet Atrial
Fibrillation, Congestive Heart Failure
PMH: Mitral Valve Prolapse, Diabetes Mellitus, Hypertension,
Depression
Social History:
Denies smoking. Mod. ETOH use.
Family History:
Non-contributory
Physical Exam:
VS: 90AF 141/89 18 96%RA
Gen: NAD
Neck: Supple, FROM, -JVD, -carotid bruits
CV: 90 Irreg with holosystolic murmur
Pulm: CTAB
ABD: Soft, NT/ND +BS
Ext: w/d -c/c/e, -varicosities, 2+ pulses throughout
Neuro: MAE, non-focal, A&O x 3
Pertinent Results:
[**4-17**] Cath: 1. Selective coronary angiography of this right
dominant system revealed no significant flow-limiting disease.
The LMCA, LAD, LCx, and RCA were all widely patent with only
mild luminal irregularities. 2. Resting hemodynamics revealed
mildly elevated right and left heart filling pressures with a
mean RA of 8mmHg and mean PCWP of 18mmHg. The PASP was 34mmHg.
The cardiac index was low-normal at 2.2l/min/m2. 3. Left
ventriculography revealed a calculated LVEF of 71% with no
regional mall motion abnormalities. There was severe (4+) mitral
regurgitation.
[**4-18**] Echo: PRE-BYPASS: Left ventricular systolic function is
hyperdynamic(EF>75%). Regional left ventricular wall motion is
normal. [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.]
Right ventricular chamber size and free wall motion are normal.
The anterior mitral valve leaflet has at least two flail
segments. Chordae can be seen in the left atrium intermittently.
There is at least moderate (2+) mitral regurgitation. There is
likely more mitral regurgitation present but the jet is
eccentric and posteriorly directed. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. A small secundum atrial septal
defect is present with a left-to-right shunt across the
interatrial septum is seen at rest. The left atrial appendage
emptying velocity is depressed (<0.2m/s). No spontaneous echo
contrast is seen in the left atrial appendage. No thrombus is
seen in the left atrial appendage. The descending thoracic aorta
is mildly dilated. There are simple atheroma in the descending
thoracic aorta. There is a trivial/physiologic pericardial
effusion. POST-BYPASS: Preserved [**Hospital1 **]-ventricular systolic
function. Left ventricular ejection fraction is about 55%-60%. A
[**Hospital1 **]-leaflet mechanical prosthetic valve is seated in the mitral
position. There is trace to mild mitral regurgitation which is
normal for this prosthesis. No perivalvular leak is seen but
image quality prevents complete exclusion. Mean gradient across
the mitral valve is 2.6 mm Hg. No evidence of aortic dissection
post de-canulation. The rest of the exam is unchanged from
pre-bypass.
[**4-24**] CXR: Since most recent radiograph, there appears to be
improved aeration to the lower lobes bilaterally with decreased
atelectasis within the retrocardiac region. A small layering
left-sided pleural effusion persists with no appreciable
right-sided effusion identified. A small branching linear
opacity projecting over the right mid hemithorax likely
represents a small area of subsegmental atelectasis and there is
otherwise unchanged appearance to cardiomegaly in this patient
noted to be status post median sternotomy and mitral valve
repair. There is no evidence of pneumothorax or pulmonary edema.
[**2114-4-16**] 05:46PM BLOOD WBC-6.2 RBC-5.37 Hgb-16.2 Hct-47.3 MCV-88
MCH-30.3 MCHC-34.3 RDW-13.8 Plt Ct-180
[**2114-4-24**] 07:00AM BLOOD WBC-8.2 RBC-3.21* Hgb-9.8* Hct-29.6*
MCV-92 MCH-30.6 MCHC-33.3 RDW-14.7 Plt Ct-386#
[**2114-4-16**] 05:46PM BLOOD PT-12.1 PTT-84.6* INR(PT)-1.0
[**2114-4-24**] 07:00AM BLOOD PT-20.6* PTT-116.3* INR(PT)-2.0*
[**2114-4-16**] 05:46PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-139
K-3.9 Cl-104 HCO3-24 AnGap-15
[**2114-4-24**] 07:00AM BLOOD Glucose-130* UreaN-10 Creat-0.9 Na-136
K-4.1 Cl-99 HCO3-27 AnGap-14
[**2114-4-24**] 07:00AM BLOOD Calcium-8.5 Phos-4.4# Mg-2.4
Brief Hospital Course:
Admitted [**4-16**] from OSH in CHF for cath which was done on [**4-17**].
This revealed 4+ MR, and normal coronaries, EF 70%. Underwent
MVR ( mechanical)/Maze/ligation of left atrial appendage on [**4-18**]
with Dr. [**Last Name (STitle) 1290**]. Transferred to the CSRU in stable condition
on propofol, insulin, and phenylephrine drips. Extubated that
evening and transferred to the floor on POD #1 to begin
increasing his activity level. Chest tubes and pacing wires were
also removed and coumadin started that evening. Heparin also
started until INR was therapeutic.[**Last Name (un) **] consult obtained for
management of diarrhea since starting metformin. INR 2.9 on POD
#7 and heparin DCed. Cleared for discharge to home with VNA
services on [**4-25**]. Pt. is to make all follow-up appts. as per
discharge instructions. Target INR is 3.0-3.5 for ONYX
mechanical valve. First blood draw [**4-27**] with results to Dr.
[**Last Name (STitle) 3321**] for coumadin dosing/management.
Medications on Admission:
MAT: Hep gtt, Lasix, Cozaar, Lopressor, Norvasc, Aspirin,
Colace, Prozac, RISS
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
6. Olmesartan 20 mg Tablet Sig: Two (2) Tablet PO daily ().
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO BID (2 times a day).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400mg twice a day until [**4-27**] then decrease
to 400mg once a day for 1 week then decrease to 200mg once a day
.
Disp:*120 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO Q12H (every 12 hours) for
10 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
13. Warfarin 6 mg Tablet Sig: goal INR 3-3.5 Tablets PO once a
day.
Disp:*60 Tablet(s)* Refills:*2*
14. Warfarin 1 mg Tablet Sig: goal INR 3-3.5 Tablets PO once a
day.
Disp:*60 Tablet(s)* Refills:*2*
15. Outpatient [**Name (NI) **] Work
PT/INR prn
goal 3.0-3.5 for Onyx Mitral Valve first draw [**4-27**] with results
to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Location (un) **] office # [**Telephone/Fax (1) 3183**] fax ([**Telephone/Fax (1) 72282**]
16. Coumadin
please take 6mg coumadin [**4-25**] and [**4-26**] - have [**Month/Year (2) **] checked [**4-27**]
and follow up with Dr [**Last Name (STitle) 3321**] for further dosing
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Replacement
Atrial Fibrillation s/p MAZE procedure
Congestive Heart Failure
PMH: Mitral Valve Prolapse, Diabetes Mellitus, Hypertension,
Depression
Discharge Condition:
good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, powders, or creams on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**] Follow-up
appointment should be in [**1-2**] weeks
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] [**Name (STitle) **] appointment should be in [**2-4**]
weeks
Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Wound check [**Hospital Ward Name **] 2 please schedule with RN
PT/INR goal 3.0-3.5 for Onyx Mitral Valve first draw [**4-27**] with
results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Location (un) **] office # [**Telephone/Fax (1) 3183**] fax ([**Telephone/Fax (1) 72283**]
Completed by:[**2114-5-3**]
ICD9 Codes: 4240, 4280, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4318
} | Medical Text: Admission Date: [**2146-10-4**] Discharge Date: [**2146-10-10**]
Date of Birth: [**2125-4-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
Placement of a hemodialysis tunneled catheter
History of Present Illness:
Ms. [**Known lastname 58968**] is a 21 y/o female with a h/o renal failure [**12-30**]
FSGS Dx [**12/2144**] (not on HD, being evaluated for transplant) who
presented to outpatient clinic for routine follow-up and was
noted to have an elevated creatinine to 16. Pt admitted to
feeling fatigued x 2-3 months, though this improved somewhat
with Procrit injections. She noted N/V and cold symptoms for the
prior 3 weeks. She described a non-productive cough, fatigue,
malaise, and N/V. She denied any hemetemesis or melena. She
denied any abdominal pain. Over the past few days prior to
presentation she also c/o fatigue and dizziness with exertion
(walking from one room to another), but denied
CP/SOB/palpitations. She denied confusion or difficulty with
speech. She noted 2 pillow orthopnea but denies PND. She
admitted to poor PO intake over past few weeks, but denied
diarrhea.
.
Pt presented to the ED with T 98.0, HR 80, BP 170/103, RR 18,
99%RA. Bedside TTE obtained showed moderate pericardial effusion
without RV collapse. A right femoral dialysis catheter was
placed by the renal service for urgent HD, and pt was
transferred to [**Hospital Unit Name 153**] for HD. She was without CP/SOB/N/V upon
arrival to the [**Hospital Unit Name 153**].
.
In the [**Hospital Unit Name 153**] the pt underwent HD and 0.5L of fluid was removed.
In the AM of [**2146-10-6**] in the CCU, she was slightly tachycardic
(HR 100's) but otherwise hemodynamically stable. Pulsus
paradoxus noted to be 10. Tunneled HD line (right IJ) was placed
by IR. Echo was repeated and showed a pericardial effusion with
worsening pericardial pressures, thought to be consistent with
early cardiac tamponade physiology. Patient was then transferred
to the CCU for closer monitoring given the acute change in the
echo.
.
She was monitored ON in the CCU and was then transferred to
medicine hemodynamically stable with no clinical evidence of
pericardial tamponade.
Past Medical History:
CRF - dx early [**2144**], biopsy proven FSGS, not on HD, being
evaluated for transplant. diagnosis made incidentally with
elevated SBP at routine sports physical.
HTN - [**12-30**] ARF.
Social History:
She denied tobbacco, alcohol, or IVDU. She admitted to
occasional marijuana use. Mother present in room at time of
interview.
Family History:
She has no family history of kidney disease or nephrolithiasis.
She also has no family history of diabetes or early coronary
disease. Her father died of [**Name (NI) 4278**] lymphoma and
neurofibrosarcoma.
Physical Exam:
VS: 99.5 178/108 73 18 100% RA; pulsus was <5
GEN: NAD
HEENT: PERRLA, sclera anicteric, OP clear, MMM, no LAD, no
carotid bruits. No JVD.
CV: regular, nl s1, s2, +S4. no murmurs, rubs.
PULM: CTA B, no r/r/w.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL
NEURO: alert & oriented x 3, no asterixis.
Pertinent Results:
[**2146-10-4**] WBC-9.2# RBC-2.66* Hgb-7.7* Hct-21.3*# Plt Ct-185
[**2146-10-5**] WBC-8.5 RBC-2.53* Hgb-7.2* Hct-20.2* Plt Ct-222
[**2146-10-5**] WBC-8.3 RBC-2.71* Hgb-7.6* Hct-22.0* Plt Ct-231
[**2146-10-6**] WBC-8.6 RBC-2.59* Hgb-7.5* Hct-21.7* Plt Ct-234
[**2146-10-7**] WBC-6.3 RBC-2.42* Hgb-7.1* Hct-20.5* Plt Ct-209
[**2146-10-8**] WBC-7.6 RBC-2.60* Hgb-7.6* Hct-22.1* Plt Ct-223
[**2146-10-10**] WBC-8.6 RBC-2.59* Hgb-7.6* Hct-22.6* Plt Ct-217
[**2146-10-4**] Neuts-76.7* Lymphs-17.8* Monos-2.9 Eos-2.3 Baso-0.2
.
[**2146-10-7**] Lupus-NEG
[**2146-10-7**] ACA IgG-6.2 ACA IgM-8.0
.
[**2146-10-4**] Glucose-100 UreaN-114* Creat-16.3*# Na-140 K-3.3 Cl-100
HCO3-22
[**2146-10-5**] Glucose-95 UreaN-72* Creat-11.8*# Na-142 K-3.1* Cl-104
HCO3-24
[**2146-10-5**] Glucose-83 UreaN-30* Creat-6.5*# Na-141 K-3.6 Cl-105
HCO3-25
[**2146-10-6**] Glucose-91 UreaN-35* Creat-8.2*# Na-141 K-4.0 Cl-104
HCO3-25
[**2146-10-7**] Glucose-89 UreaN-16 Creat-5.6*# Na-141 K-3.7 Cl-102
HCO3-30
[**2146-10-8**] Glucose-85 UreaN-14 Creat-4.9* Na-142 K-3.6 Cl-103
HCO3-31
[**2146-10-10**] Glucose-90 UreaN-38* Creat-7.6*# Na-138 K-3.7 Cl-96
HCO3-31
.
[**2146-10-5**] calTIBC-211* Ferritn-94 TRF-162*
[**2146-10-7**] Cryoglb-NO CRYOGLO
[**2146-10-5**] TSH-4.6*
[**2146-10-6**] TSH-3.9
[**2146-10-5**] PTH-176*
[**2146-10-6**] Free T4-1.3
[**2146-10-7**] HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE
[**2146-10-5**] ANCA-NEGATIVE B
[**2146-10-5**] C3-86* C4-26
[**2146-10-7**] HCV Ab-NEGATIVE
.
[**2146-10-4**] URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2146-10-4**] URINE Blood-SM Nitrite-NEG Protein-500 Glucose-TR
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2146-10-4**] URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-2
.
[**2146-10-4**] CXR PA/Lateral
Cardiac silhouette is moderately-to-severely enlarged, due to
cardiomegaly and/or pericardial effusion. There is no evidence
of elevated central venous or pulmonary arterial or left atrial
pressures. No pulmonary edema or pleural effusion is present.
Dr. [**Last Name (STitle) **] was paged to report these findings.
.
[**2146-10-5**]
Successful placement of a right IJ HD catheter.
.
[**2146-10-5**] Echo
Moderate circumferential pericardial effusion with
echocardiographic evidence for increased pericardial pressures
c/w early
tamponade physiology.
.
[**2146-10-10**] Echo
The left atrium is elongated. The right atrium is moderately
dilated. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic
regurgitation. The mitral valve appears structurally normal with
trivial
mitral regurgitation. There is borderline pulmonary artery
systolic
hypertension. There is a small pericardial effusion. There are
no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2146-10-5**],
the pericardial effusion appears smaller. There is no evidence
of tamponade.
Brief Hospital Course:
21 y/o female with h/o ESRD [**12-30**] to FSGS awaiting transplant who
presented with nausea and worsening fatigue and was found to
have ARF (cr 16) c/b a pericardial effusion. She was initially
admitted to the [**Hospital Unit Name 153**] for urgent HD. She was then transferred to
the CCU given her pericardial effusion that was found to have
early signs of tamponade. She was monitored overnight in the CCU
and was transferred to the medicine floor hemodynamically stable
with no clinical signs of tamponade and a normal pulsus. The
following issues were addressed during this hospitalization.
.
1. Pericardial Effusion
The [**Hospital **] hospital course was significant for a pericardial
effusion. The etiology was most likely [**12-30**] to ARF on CRI [**12-30**]
FSGS. The effusion most likely accumulated over the past few
months prior to admission. Her vitals remained stable throughout
admission. There was no evidence of tamponade physiology on
admission. She had a brief echo in the ED which r/o signs of
tamponade. A repeat echo on [**2146-10-5**] was concerning for early
tamponade physiology. She was transferred to the CCU and
monitored ON. She was hemodynamically stable with no clinical
signs/symptoms of tamponade. She was then trasferred to the
medicine floor. Her pulsus was monitored daily along with her BP
and HR. After session of HD, her clinical evidence of volume
overload improved which likely resolved her pericardial
effusion. A repeat echo on [**2146-10-10**] revealed a smaller
pericardial effusion with no signs of tamponade. She will most
likely need a repeat echo after discharge in [**11-29**] weeks.
.
2. ESRD [**12-30**] to FSGS on HD
She has a h/o FSGS proven on biopsy in 2/[**2144**]. She is currently
on the transplant list. Renal followed the pt during the entire
admission and the pt had HD sessions after placement of a right
IJ HD tunneled catheter on [**2146-10-5**]. Upon discharge, HD was
orchestrated with the help of social work in [**Hospital1 3597**] where pt goes
to college on a MWF schedule. Pt's admission symptoms improved
after HD sessions along with her clinical picture of volume
overload.
Medications on Admission:
Lasix 20 mg PO daily
Iron 65 mg PO BID
Lisinopril 40 mg PO daily
Cozaar 100 mg PO daily
Renagel 800 mg PO TID with meals
Procrit 5000 units MWF
Zemplar
Discharge Medications:
1. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ESRD
Pericardial effusion
Discharge Condition:
The patient was discharged hemodynamically stable afebrile with
appropriate follow up.
Discharge Instructions:
Please call your new PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or seek medical
attention in the emergency department if you experience any
chest pain, shortness of breath, fever, chills, nausea,
vomiting, diarrhea, abdominal pain, or any other concerning
symptom.
.
Please take all medications as prescribed.
.
Please keep all follow up appointments.
.
You will start dialysis at [**Hospital1 3597**] Dialysis on a Monday,
Wednesday, and Friday schedule. Your first session will be on
Wednesday, [**10-12**] at 3PM. Your new PCP will be Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
Followup Instructions:
Please follow up with your new PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**11-29**] weeks
by calling [**Telephone/Fax (1) 41132**] for an appointment.
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2147-1-3**] 9:10
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2146-10-10**] 10:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2146-10-12**]
ICD9 Codes: 5849, 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4319
} | Medical Text: Admission Date: [**2131-11-11**] Discharge Date: [**2131-11-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shaking.
Major Surgical or Invasive Procedure:
Central line placement
Intubation
Foley
History of Present Illness:
86 year old male with history of alcohol abuse, colon cancer
status post resection, and recent MI just discharged from
[**Hospital 1474**] Hospital on [**11-9**], who presented to [**Hospital 1474**] Hospital
early this morning with shaking and confusion. History is
mostly from the record as the patient is intubated and the wife
is a poor historian. Per the wife, she says he was doing well
just after discharge, and was walking around as much as he
could. She says he has not drank alcohol since he got home.
His only complaint has been profuse watery diarrhea, numerous
times a day, both in the hospital, and since discharge.
Otherwise he did not complain of chest pain, shortness of
breath, abdominal pain, fevers, or chills, prior to the day of
admission.
As mentioned above, he was recently admitted to [**Hospital 1474**]
Hospital from [**11-3**] to [**11-9**] after presenting with shaking. He
was found to have a cardiac enzymes leak, and underwent p-MIBI
on [**11-8**] that demonstrated transient ischemic dilatation of the
LV with a small to moderate sized region of ischemia involving
the lateral wall, as well as a small to moderate fixed inferior
defect with hypokinesis suggestive prior infarction. EF 50%.
No intervention was performed since he was in alcohol
withdrawal, and asymptomatic from a cardiac standpoint, however
plans were made for catheterization at [**Hospital1 18**] in the future. He
was discharged home on a prednisone taper for unclear reasons.
On arrival at [**Hospital 1474**] Hospital on the morning of admission,
vitals were T 104.3, HR 109, BP 116/59, 89% on 3L NC. His
hypoxia progressed and he was intubated. His blood pressure
declined to the 70s systolic and he was started on
norepinephrine via a left femoral line placed in their ED.
Given concern for meningitis an LP was performed, demonstrating
140 rbcs that cleared by tube 4, 2 WBC in tube 1, and 1 in tube
4, total protein of 80, glucose of 100 (interpreted as
negative). Gram stain was without bacteria or WBCs. Labs were
notable for a leukopenia of 2.5, with 12% bands. A UA had large
leukocyte esterase, positive nitrite, [**5-9**] WBC, and moderate
bacteria. He received a dose of ceftriaxone 2 grams (prior to
negative LP), vancomycin 1 gram, and flagyl 500 mg IV x 1 given
concern for clostridium difficile (bandemia). EKG demonstrated
ST depressions in V4-V6. BNP 53, troponin I < 0.1 and CK 35. He
was transferred to the [**Hospital1 18**] ER because of lack of beds in the
ICU at [**Hospital1 1474**].
Vitals in our ED were T 104.8, HR 101, BP 75/47, RR 32, 99% on
ventilator (AC 550 x 20, 60%, PEEP 5). He was continued on
norepinephrine, given 2.5 L IVF, and sent to the MICU.
Past Medical History:
1) CAD; ?MI, ?3VD: Patient presented to [**Hospital 1474**] Hospital in
early [**11-5**] with shaking and was noted to have a cardiac enzyme
leak. A p-MIBI revealed transient ischemic dilatation. He was
in alcohol withdrawal at the time, therefore he was started on
ASA, Plavix, Statin, and sent home with plans for
catheterization at [**Hospital1 18**] when able.
2) Type 2 diabetes
3) BPH
4) Alcohol abuse: Drinks [**1-1**] gallon of Whiskey a week, per
wife.
5) Colon cancer status post resection, details unclear.
Social History:
Quit smoking 10 years ago, smoked heavily previously - wife says
he does have 1 cigarette a week. Drinks [**1-1**] gallon of whiskey
per week. Lives with his wife of 59 years.
Family History:
Non-contributory
Physical Exam:
99.5, 108/76, 96, 20, 99% on AC 550 x 20, 60%, PEEP 5. Pip 19,
Pplat 15.
GENERAL: Elderly male, intubated, not sedated and writhing
around in bed. Withdraws to painful stimuli, purposeful
movements.
HEENT: Dry mucous membranes.
NECK: JVP 8-10 cm H20.
COR: RR, normal rate, no murmurs.
LUNGS: Difficult to auscultate over ventilator sounds.
ABDOMEN: Normoactive bowel sounds, soft, non-tender,
non-distended.
EXTR: Left groin with femoral line in place, adequate
hemostasis. Noon-edematous, warm.
Pertinent Results:
[**2131-11-11**] 09:34PM CK(CPK)-425*
[**2131-11-11**] 09:34PM CK-MB-4 cTropnT-0.18*
[**2131-11-11**] 03:49PM TYPE-ART PO2-160* PCO2-34* PH-7.34* TOTAL
CO2-19* BASE XS--6
[**2131-11-11**] 03:49PM GLUCOSE-178* LACTATE-1.6 K+-4.1
[**2131-11-11**] 03:49PM freeCa-1.12
[**2131-11-11**] 10:56AM TYPE-ART PO2-155* PCO2-35 PH-7.27* TOTAL
CO2-17* BASE XS--9
[**2131-11-11**] 10:56AM LACTATE-1.6
[**2131-11-11**] 08:54AM TYPE-ART PO2-267* PCO2-37 PH-7.27* TOTAL
CO2-18* BASE XS--8
[**2131-11-11**] 08:54AM LACTATE-1.5 K+-4.1
[**2131-11-11**] 08:54AM freeCa-1.09*
[**2131-11-11**] 08:47AM CK(CPK)-404*
[**2131-11-11**] 08:47AM CK-MB-3 cTropnT-0.40*
[**2131-11-11**] 08:47AM CORTISOL-9.9
[**2131-11-11**] 04:12AM LACTATE-2.6*
[**2131-11-11**] 04:05AM GLUCOSE-108* UREA N-49* CREAT-2.2* SODIUM-139
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-19* ANION GAP-15
[**2131-11-11**] 04:05AM CK(CPK)-398*
[**2131-11-11**] 04:05AM CK-MB-2 cTropnT-0.69*
[**2131-11-11**] 04:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2131-11-11**] 04:05AM URINE HOURS-RANDOM
[**2131-11-11**] 04:05AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2131-11-11**] 04:05AM WBC-12.4* RBC-3.70* HGB-11.3* HCT-32.0*
MCV-87 MCH-30.7 MCHC-35.5* RDW-13.5
[**2131-11-11**] 04:05AM NEUTS-80* BANDS-16* LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2131-11-11**] 04:05AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2131-11-11**] 04:05AM PLT COUNT-318
[**2131-11-11**] 04:05AM PT-13.9* PTT-32.0 INR(PT)-1.2*
[**2131-11-11**] 04:05AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2131-11-11**] 04:05AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2131-11-11**] 04:05AM URINE RBC-[**3-4**]* WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-0
Brief Hospital Course:
86 year old male with history of alcohol abuse, and recent MI
just discharged from [**Hospital 1474**] Hospital on Plavix on [**11-9**] with
steroid taper, who presented to [**Hospital 1474**] Hospital early this
morning with shaking, confusion, and profuse diarrhea, found to
have significant bandemia, sepsis requiring norepinephrine, as
well as perihilar infiltrates and hypoxic respiratory failure
requiring intubation.
1) Sepsis: Most likely sources were initially thought to be C.
Difficile and pneumonia, both nosocomially acquired. He was
treated initially with vancomycin and zosyn (to cover nosocomial
pneumonia), and flagyl empirically for C. Difficile.
Subsequently, however, a blood culture from [**Hospital 1474**] Hospital
returned with E. Coli, and his urine culture from [**Hospital1 18**] also
grew out E. Coli. He was therefore ultimately felt to have
urosepsis. Vancomycin and flagyl were discontinued, while zosyn
was continued. He was weaned off of norepinephrine within 24
hours. He had been started on stress dose steroids on admission
given that he had been on steroids for at least the last few
days prior to admission (prednisone 30), however these were
quickly tapered off.
2) Hypoxic respiratory failure: Most likely secondary to an
early acute lung injury, which is compatible with his bilateral
perihilar infiltrates. His ventilator settings were rapidly
weaned, and he was extubated 48 hours after arrival without
difficulty. Unfortunately the patient had to be reintubated due
to aggitation and was on the ventilation for 5 more days. He
was then weaned off the vent and extubated. At this point his
family made the patient DNR/DNI. The patient tolerated
face-mask oxygen delivery for 3 days and then again developed
respiratory distress and passed due to respiratory failure
3) Cardiac enzyme elevation, CAD: Cardiac enzymes were trended
and flat, and EKG was without changes concerning for an acute
process. He was continued on ASA, Plavix, and statin.
Cardiology followed the patient but he was not a candidate for
catheterization due to his poor prognosis otherwise.
4) Acute renal failure: Almost certainly pre-renal in the
setting of sepsis and hypotension, and improved with rehydration
to 1.4, which is likely his baseline.
5) Alcohol abuse: Per wife, he [**Name2 (NI) 9103**]'t drank in over a week
prior to admission. He did not exhibit any signs of withdrawal.
6) DM: He had finger sticks QID, with an insulin sliding scale.
Glyburide was held.
7) FEN: He had a diabetic, cardiac diet.
8) Prophylaxis: He was given SQ heparin, PPI.
9) Access: He arrived with a left femoral line that was removed
in exchange for an IJ central line. This, too, was removed once
he no longer had a pressor requirement.
10) Contact: Wife, [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 70640**].
Medications on Admission:
Gabapentin 600 mg TID
Glyburide 1.25 mg daily
Finasteride 5 mg daily
Omeprazole 20 mg daily
Allopurinol 100 mg daily
Vitamin B12 injections monthly
Prednisone taper 30 mg [**11-9**] through [**11-11**], 20 mg through [**11-14**],
10 mg through [**11-17**], then 5 mg daily "until f/u with
pulmonologist."
Imdur 10 mg daily
Metoprolol 75 mg [**Hospital1 **]
Plavix 75 mg daily
Albuterol MDI 1 puff Q 4- 6 hours prn
Atorvastatin 80 mg daily
Aspirin 325 mg daily
Multivitamin daily
Thiamine 100 mg daily
Folate 1 mg daily
Discharge Medications:
.
Discharge Disposition:
Expired
Discharge Diagnosis:
.
Discharge Condition:
.
Discharge Instructions:
.
Followup Instructions:
.
ICD9 Codes: 5849, 5990, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4320
} | Medical Text: Admission Date: [**2103-10-22**] Discharge Date: [**2103-11-3**]
Date of Birth: [**2055-6-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Transferred from OSH with hyperglycemia, AMS
Major Surgical or Invasive Procedure:
Intubation [**2103-10-22**]
Extubation and re-intubation [**2103-10-26**]
Extubation [**2103-10-30**]
CT head
TTE
History of Present Illness:
This is a 48yo generally healthy male who presented to an OSH
w/new onset MS changes x hours and new onset hyperglycemia. Per
pt's wife, he had been well when she left for work on the day of
presentation. When she returned home, he was slurring his
speech, having muscle weakness, and lost urinary continence. She
was concerned that he was having a stroke and called 911.
At the OSH, he had BG of 2300, CT head negative, CXR clear,
Insulin drip was started. He received 5.4 L IVF and 40mEq
potassium. There, he was hypertensive and tachycardic to the
130s. Cardiac enzymes were negative x 1. He was sating 100% on
NRB with ABG 7.17/50/244, AG of 46.
.
In the [**Hospital1 18**] ED, T 100.6 HR 127 BP 149/102 RR 25 O2sat was
initially 92%6LNC, then 25-30 98%NRB, MS improved. Pt received
300cc IVF, 20mEq potassium repletion for K 2.8. A second set of
cardiac enzymes were negative.
.
On ROS, the patient's wife endorses pt had cough x 2 weeks,
nonproductive. She otherwise denies pt having had any fevers,
chills, weight change, nausea, vomiting, abdominal pain,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity edema,
urinary frequency, urgency, dysuria, lightheadedness, vision
changes, headache, rash or skin changes.
Past Medical History:
[**Name (NI) **] pt hasn't seen a doctor in years and is "healthy".
Social History:
Lives with wife, currently unemployed. ~ 5 beers/week. [**3-17**]
cigarettes daily. Occassional marijuana. Drinks 5-6 mountain dew
daily and does not generally drink fluids without sugar in them.
Family History:
Mother died of complications of scleroderma. Otherwise, negative
for DM, cardiac disease, and cancers.
Physical Exam:
Vitals: T: 102.5 BP: 106/61 HR: 136 RR: 36 O2Sat:97% on 100%NRB
GEN: tachypneic, lethargic, initially aware he is hospitalized
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dryMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2
PULM: tachypneic, decreased BS at bases BL, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords, diminished DP/PT pulses
NEURO: oriented to "hospital" only. CN II ?????? XII grossly intact.
Moves all 4 extremities. Unable to complete neuro exam due to
noncompliance.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission Labs:
[**2103-10-22**] 10:15PM BLOOD WBC-19.6* RBC-4.88 Hgb-15.1 Hct-47.6
MCV-98 MCH-30.9 MCHC-31.7 RDW-13.7 Plt Ct-251
[**2103-10-22**] 10:15PM BLOOD Neuts-88* Bands-1 Lymphs-6* Monos-3 Eos-0
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2103-10-22**] 10:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2103-10-22**] 10:15PM BLOOD PT-13.5* PTT-23.9 INR(PT)-1.2*
[**2103-10-22**] 10:15PM BLOOD Glucose-1317* UreaN-50* Creat-2.3*
Na-153* K-2.8* Cl-116* HCO3-22 AnGap-18
[**2103-10-22**] 10:15PM BLOOD CK(CPK)-898*
[**2103-10-23**] 02:07AM BLOOD ALT-55* AST-36 AlkPhos-221* TotBili-0.2
[**2103-10-23**] 05:36AM BLOOD Lipase-641*
[**2103-10-22**] 10:15PM BLOOD CK-MB-5
[**2103-10-22**] 10:15PM BLOOD cTropnT-<0.01
[**2103-10-22**] 10:15PM BLOOD Calcium-8.6 Phos-2.8 Mg-2.8*
[**2103-10-28**] 12:00AM BLOOD calTIBC-191* Ferritn-719* TRF-147*
[**2103-10-23**] 02:07AM BLOOD %HbA1c-13.4*
[**2103-10-30**] 01:05AM BLOOD Triglyc-457*
[**2103-10-23**] 02:07AM BLOOD Acetone-NEGATIVE Osmolal-414*
[**2103-10-23**] 07:26PM BLOOD TSH-0.36
[**2103-10-23**] 02:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2103-10-22**] 10:21PM BLOOD Type-[**Last Name (un) **] FiO2-100 pO2-52* pCO2-53*
pH-7.24* calTCO2-24 Base XS--5 AADO2-608 REQ O2-99 Intubat-NOT
INTUBA
[**2103-10-22**] 10:21PM BLOOD Glucose-GREATER TH Lactate-2.2* Na-159*
K-2.9* Cl-114*
Other labs:
[**2103-10-31**] 05:18AM BLOOD WBC-23.6*# RBC-3.56* Hgb-11.2* Hct-32.5*
MCV-91 MCH-31.4 MCHC-34.4 RDW-13.0 Plt Ct-434#
[**2103-10-31**] 03:30PM BLOOD Hct-31.3*
[**2103-11-1**] 07:40AM BLOOD WBC-21.0* RBC-3.41* Hgb-10.7* Hct-30.7*
MCV-90 MCH-31.3 MCHC-34.8 RDW-13.7 Plt Ct-457*
[**2103-11-2**] 07:30AM BLOOD WBC-17.8* RBC-3.43* Hgb-10.6* Hct-31.2*
MCV-91 MCH-30.8 MCHC-33.8 RDW-12.8 Plt Ct-454*
[**2103-10-30**] 01:05AM BLOOD Glucose-254* UreaN-52* Creat-2.9* Na-141
K-3.8 Cl-106 HCO3-24 AnGap-15
[**2103-10-30**] 08:02PM BLOOD Glucose-65* UreaN-44* Creat-2.3* Na-146*
K-3.1* Cl-110* HCO3-26 AnGap-13
[**2103-10-31**] 03:30PM BLOOD Glucose-226* UreaN-37* Creat-1.9* Na-141
K-3.6 Cl-107 HCO3-24 AnGap-14
[**2103-11-1**] 07:40AM BLOOD Glucose-89 UreaN-30* Creat-1.7* Na-140
K-3.7 Cl-105 HCO3-24 AnGap-15
[**2103-11-1**] 07:40PM BLOOD Glucose-216* UreaN-25* Creat-1.6* Na-133
K-3.8 Cl-101 HCO3-21* AnGap-15
[**2103-11-2**] 07:30AM BLOOD Glucose-108* UreaN-21* Creat-1.4* Na-138
K-4.2 Cl-106 HCO3-23 AnGap-13
[**2103-10-29**] 04:23AM BLOOD ALT-67* AST-62* LD(LDH)-300*
CK(CPK)-2860* AlkPhos-81 TotBili-0.3
[**2103-11-1**] 07:40AM BLOOD ALT-103* AST-99* LD(LDH)-440* AlkPhos-82
TotBili-0.4
[**2103-11-2**] 07:30AM BLOOD ALT-99* AST-85* AlkPhos-71 TotBili-0.4
[**2103-10-30**] 01:05AM BLOOD Lipase-154*
[**2103-11-1**] 07:40AM BLOOD Lipase-174*
[**2103-11-2**] 07:30AM BLOOD Lipase-162*
[**2103-10-23**] 07:26PM BLOOD CK-MB-9 cTropnT-0.03*
[**2103-10-24**] 09:07AM BLOOD CK-MB-7 cTropnT-0.03*
[**2103-10-28**] 11:40AM BLOOD CK-MB-2 cTropnT-<0.01
[**2103-10-28**] 12:00AM BLOOD calTIBC-191* Ferritn-719* TRF-147*
[**2103-10-23**] 02:07AM BLOOD %HbA1c-13.4*
[**2103-11-2**] 07:30AM BLOOD Triglyc-268* HDL-26 CHOL/HD-7.9
LDLcalc-125 LDLmeas-120
[**2103-10-23**] 07:26PM BLOOD TSH-0.36
Significant Radiology:
[**2103-10-24**] Abd U/S:
IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease, including more significant hepatic
fibrosis or cirrhosis, cannot be excluded on the basis of this
examination.
2. Limited visualization of the pancreas.
3. Dilated fluid-filled bowel.
4. Spleen not examined.
[**2103-10-27**] CT Head without contrast:
HEAD CT WITHOUT IV CONTRAST: There is no hemorrhage, edema, mass
effect, or shift of normally midline structures. There is no
evidence of major vascular territorial infarction. The
ventricles and sulci are normal in size and configuration for
the patient's age. The left maxillary sinus demonstrates
aerosolized mucosal secretions, which may be related to
intubation.
IMPRESSION: No hemorrhage, edema, or mass effect.
[**2103-10-29**] TTE:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Diastolic function could not be
assessed. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
is no aortic valve stenosis. 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.
Brief Hospital Course:
48 yo [**Male First Name (un) 4746**] who has not been to a physician in many years and no
known medical diagnosis presented on [**10-22**] w confusion,
weakness, slurred speech and was found to have blood sugar in
[**2094**] range and corrected sodium of 175 at local ED, was
transferred to [**Hospital1 **], was intubated for airway protection and
treated with iv fluids and insulin. Briefly needed to be on
pressors [**1-13**] low bp likely from significant dehydration and
hypovolemia. He also had leukocytosis w bandermia on admission,
so there was also concern for sepsis, so pt was started on
Vanc/Zosyn/levo. U/A and CXR were negative and with the
exception of a contaminated blood culture on [**10-23**], cultures
remained negative until [**10-31**]. On [**10-31**] types of
stenotrophomonas and a pan-sensitive klebsiella were grown from
[**10-25**] sputum cultures and pt was started on bactrim for tx of
possible pna with stenotrophomonas & pan-[**Last Name (un) 36**] klebsiella
He was also in ARF and had transaminitis and elevated lipase
presumed [**1-13**] hypovolemic shock. Abd US showed echogenic liver
consistent with fatty infiltration.
Friday [**10-26**] he was thought to have a fixed and dilated R
pupil and underwent a stat head CT which was unremarkable.
Neurosurgery was also consulted and noted anisocoria with the L
pupil being larger than the right but both reactive to light. He
was briefly extubated that day but had to be reintubated for inc
resp distress attributed to laryngeal edema as his total fluid
balance was +15 L. He was given racemic Epi, decadron, heliox
and lasix but continued to be tachypnic and with BPs in the
215/120 range. He was then emergently re-intubated. He was
successfully weaned and extubated on [**10-30**] without event.
Steroids were stopped [**10-31**]. He was transferred to floor on
[**11-1**].
This morning, pt is sitting in chair comfortably. He spoke
with nutritionist on thursday and learned more about diabetes.
He has also been learning how to inject insulin from nurses. He
has no complaints to report today
AP: 48 M w new onset diabetes presents with hyperglycemic
hyperosmolar nonketoacidosis
.
# Hyperosmolar Nonketosis (HONK): now essentially resolved.
Still has mildly elevated Osmolality of 324
.
# Diabetes Mellitus:
- Appreciate [**Last Name (un) **] input
- Pt given lantus and humalog sliding scale instructions at ds
as per Dr.[**Name (NI) 80202**] recommendation from [**Last Name (un) **]
- Scripts for glargine/humalog pen given to wife, prescription
already filled and pt was using insulin pen before dc
-Pt was also started on Metformin as Cr decreased down to 1.4.
[**Last Name (un) 3390**] should recheck BMP at visit and if >1.5 discontinue the
metformin
- Apprecitae Nutrition and RN going over diabetes education and
insulin use. Pt has been taught insulin administration, checking
finger sticks and following sliding scale
- Aspirin 81mg qD
.
# Leukocytosis: on presentation to ICU, had bandemia, fever,
therefore treated as sepsis w/ Vanc, zosyn, levo which were
eventually d/c'ed and now on Bactrim for sputum cx growing 2
types of stenotrophomonas & pan-sensitive klebsiella. His
elevation in White count likey from steroids as was downtrending
at discharge. Pt remained afebrile on floor with stable vitals
and decision was made to treat possible pna with 7 day course of
bactrim (4 more days p dc)
- f/u cultures remained neg at discharge.
-Pt has new [**Last Name (un) **] appt on [**11-9**] and it is recommended that [**Month (only) 3390**]
check CBC, bMP and LFTS to ensure that these are resolving. DC
summary faxed to [**Month (only) 3390**]'s office
.
# Acute renal failure: Presented with Creatinint of 7 but did
not need dialysis. At discharge cr was steadily decreasing and
was down to 1.4. Nephrology was initially following but signed
off. Recommend that [**Month (only) **] recheck BMP at visit
# Hypertension: bp normal, initially hypotensive [**1-13**] volume
depletion and ?sepsis, tx w fluids and pressors in ICU but then
became hypertensive was temporarily placed on hydralazine but
has not needed it on the floor. Pt discharged on no bp meds as
on floor SBP ranged in 100-120 range without medications
# Transaminitis: elevation first seen on [**10-23**], thought [**1-13**]
shock liver/pancreas although HONK can elevate pancreatic
enzymes. Abd US on [**10-24**] showed echogenic liver consistent with
fatty infiltration but other forms of liver disease cannot be
ruled out
- LFTs/lipase continue to trend down. Recheck w [**Month/Year (2) **]. [**Name10 (NameIs) **] not
normalized, consider further workup such as hep panel etc
# Sacral wound - pt had an unstagable wound at gluteal fold
which required dressing change daily. Pt was set up with home
VNA for wound care and for diabetes monitoring.
.
# Access: CVL removed [**10-31**], PIVs in place
.
# FEN: diabetic diet
.
# Code: Full
# Dispo: [**First Name8 (NamePattern2) **] [**Last Name (un) **], can dc today and have fu [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] clinic.
Pt educated on symptoms of hypoglycemia and told to check blood
sugar right away for symptoms or take [**Location (un) 2452**] juice, regular
soda or hard candy. Pt told to call [**Last Name (un) **] for low blood surgars
or sugars >300 at [**Telephone/Fax (1) 2378**] and ask to speak with the doctor
on call.
Pt also is establishing new [**Telephone/Fax (1) **]. [**Name Initial (NameIs) **]'s office called, they will
follow VNA orders. DC summary faxed to their office on day of
discharge.
Medications on Admission:
None
Discharge Medications:
1. Lantus Solostar 300 unit/3 mL Insulin Pen Sig: One (1)
injection Subcutaneous at lunch: Please give yourself 30 units
at lunch .
Disp:*6 pens* Refills:*2*
2. Humalog KwikPen 100 unit/mL Insulin Pen Sig: as directed
injection Subcutaneous four times a day: as directed. Please use
separate sliding scale printed for you at discharge.
Disp:*10 pens* Refills:*2*
3. BD Insulin Pen Needle UF Orig 29 x [**12-13**] Needle Sig: One (1)
needles Miscellaneous five times a dy.
Disp:*qs needles* Refills:*2*
4. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] four
times a day.
Disp:*120 strips* Refills:*2*
5. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous four times a day.
Disp:*120 lancets* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
9. Aquacel Hydrofiber Dressing 4 X 4 Bandage Sig: One (1)
bandage Topical once a day: as per wound care directions.
Disp:*30 bandage* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
home health and hospice of [**Location (un) **]
Discharge Diagnosis:
New diagnosis of diabetes
HONK
ARF - resolving
Transaminitis - resolving
Pneumonia
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital with blood sugars of [**2094**]. You
have diagnosis. You initially needed to be on breathing machine
but you recovered well. You will need to check your blood sugars
atleast four times daily. Please follow instructions carefully.
We have set you up with a primary care doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]
appointment. Please keep them. Please contact your [**Name2 (NI) 387**]
doctors with [**Name5 (PTitle) 691**] questions regarding your blood sugars.
If you notice symptoms of low blood sugar such as shaking,
sweating, confusion, decreased alertness, check your blood sugar
right away or give your self [**Location (un) 2452**] or apple juice, regular soda
or hard candy
If your blood sugars are greater than 300-400 or less than 70,
please call [**Last Name (un) **] at [**Telephone/Fax (1) 2378**] and ask to talk to the doctor
on call
On Monday, please call Eni at [**Last Name (un) **] at [**0-0-**] and ask
that you be set up with Diabetes education within the week as
per DR. [**Last Name (STitle) 9978**]
Followup Instructions:
1. [**Last Name (un) **]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**], NP at [**Last Name (un) **] on [**11-13**], at 4PM. Call
[**Telephone/Fax (1) 4847**] if you need to change this appointment
2. Dr. [**Last Name (STitle) **], ph: [**Telephone/Fax (1) 80203**]. [**Last Name (NamePattern1) 80204**],
[**University/College **]-Hitchcock [**Location (un) 8117**], [**Numeric Identifier 30090**]. Fax [**Telephone/Fax (1) 80205**]. Appt is
Friday, [**2106-11-8**]:00AM
ICD9 Codes: 5845, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4321
} | Medical Text: Service: Date: [**2117-6-3**]
Surgeon: [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
DATE OF ADMISSION: [**2117-6-3**].
DATE OF DISCHARGE: [**2117-7-5**].
HISTORY OF THE PRESENT ILLNESS: The patient is an
84-year-old male with known aortic stenosis, who came in with
acute exacerbation of his symptoms requiring admission. He
underwent an echocardiogram and he is scheduled for an AVR.
PAST MEDICAL HISTORY: History is significant for mitral
valve prolapse, aortic stenosis, hypertension, status post
cholecystectomy and appendectomy, status post tonsillectomy,
adenoidectomy, macular degeneration, and recent onset chronic
atrial fibrillation and congestive heart failure.
MEDICATIONS AT HOME:
1. Dyazide once a day.
2. Quinine p.r.n. for cramps.
3. Lopressor 12.5 mg b.i.d.
4. Protonix 40 mg once a day.
5. Coumadin 2.5 mg every day.
The patient's echocardiogram in [**2117-4-5**], had an ejection
fraction of 45% to 55%.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is a former smoker with 20 pack-
per-year-history.
PHYSICAL EXAMINATION: On initial examination, he was a
pleasant elderly male. Chest was clear, irregular heart rate
with bilateral 1+ to 2+ pitting edema and no JVD. The
patient was admitted to the Cardiothoracic Surgery Service,
Dr. [**Last Name (Prefixes) 40779**] for AVR. The patient underwent AVR on
[**2117-6-4**]. He underwent an AVR with #23 CE pericardial valve
and a TV repair using a #32 CE ring. Bypass time: 112
minutes. Cross-clamp time: 63 minutes. The patient was
postoperatively transferred to the Cardiothoracic Intensive
Care Unit, A-paced with a rate of 82 beats per minute
requiring Neo-Synephrine for pressor support. The patient
was transfused several units of blood cells and FFP on the
day of operation. TEE immediately within the perioperative
area showed normal systolic function and a dilated RV. The
patient was still intubated on postoperative day #1 and on
pressor support.
On postoperative day #2, he was weaned off pressors and thus
sedated. Chest tubes were discontinued. He was weaned and
on [**6-6**], [**2117**], postoperative day #2, he was extubated.
Cardiovascularly, he remained in atrial fibrillation, which
he was in preoperatively for which he was receiving
Amiodarone.
On postoperative day #3, [**2117-6-7**], the patient still required
some .................... for pressor support. Renal
function and pulmonary function were within normal limits at
this time.
On postoperative day #4, [**2117-6-8**], the patient had Amiodarone
restarted, p.o. basis as well as a drip. By postoperative
day #5, we had noticed a bump in the creatinine to 1.2. We
will continue aggressive diuresis using Lasix. The patient
was having fluid overload. EP was consulted regarding for
TE, which showed no evidence of a thrombus. We obtained
consent for cardioversion.
The Pulmonary Department was consulted on [**2117-6-9**] for
pulmonary status. This showed interstitial space disease.
At that time, the Pulmonary Service [**2117-6-9**] thought that
this was due to a fluid overload on top of his disease. They
continued aggressive diuresis of the patient.
On [**2117-6-10**], the patient was, despite cardioversion, back in
atrial fibrillation. The patient was, at this point,
intubated due to reversing respiratory status and sedated.
He was, at this point, on a procainamide drip to attempt
control of the atrial fibrillation. Lasix drip was continued
in attempt to aggressively diurese him. We were attempting
to wean him off pressor support. The Electrophysiology
Service agreed with our procainamide.
We continued to have difficulty ventilating him. The
Pulmonary Department was following and agreed with our
management.
On postoperative day #7, [**6-11**], [**2117**], the patient was
stable. Plan remained the same. The Department of Nutrition
was involved and tube feeds were started at 30 cc an hour
previously. We were attempting goal rate of
....................calories using tube feeds.
The Pulmonary Department continued to follow,
Electrophysiology Service as well.
On postoperative day, [**2117-6-12**], the patient remained in
atrial fibrillation and sedated. The patient was, at this
point, on heparin drip secondary to atrial fibrillation.
Pulmonary consultation was called. They continued to follow.
We were attempting to extubate the patient and weaning his
respiratory support.
On postoperative day #9, [**2117-6-13**], we stopped the Lasix and
started Bumex, which increased his urine output. He still
required pressor support. Tube feeds were taken to goal.
With aggressive diuresis, we noticed that the creatinine had
jumped as high as 1.6 during this postoperative period.
On postoperative day #10, the patient was doing better on
[**6-14**]. He still required Nitroglycerin support. We
continued diuresing with Lasix. At this point, the
creatinine was done to 1.1. The atrial fibrillation
continued and we were continuing to anticoagulate the
gentleman.
The Department of Nutrition continued to follow the patient
and advised.
On postoperative day #11, [**2117-6-15**], the patient's mental
status was improving. EF was better with invasive
monitoring. We were able to reduce his pressor support down
to 5. He had a lowered requirement from 0.8 to 0.4.
On postoperative day #12, the patient continued on heparin
drip and on tube feeds and Ceftazidime and Lovenox for prior
diagnosed sputum infection. The patient remained intubated.
Mental status was improving. Chest x-ray showed feeding tube
remaining in the stomach. He had interstitial lung disease
with worsening. Of note, the creatinine was stable at 1.1.
The vasopressor support was continuing.
On postoperative day #13, [**2117-6-17**], the patient remained in
atrial fibrillation. The patient remained intubated and
pressor support was done, reconsidered extubation. He was
still on heparin drip tube feeds. Neo was weaned off slowly.
On postoperative day #14, [**2117-6-18**], the patient was in
atrial fibrillation again. The patient still had copious
secretions. Pressor-support ventilation, we were unable to
extubate. The patient was anticoagulated well. The patient
is now receiving free water. Creatinine was stable at 0.9.
On postoperative day #16, [**2117-6-20**], the patient continued
with Ceftazidime and heparin drip, nourishes. The patient
was extubated. Wires were discontinued. heparin was
continued. The patient was doing well. Ceftazidime and
Levofloxacin were continued.
The Speech Department was consulted on the 17th. They
cautioned us regarding allowing him p.o. intake. Of note,
during the rest of the hospital stay, the patient was
evaluated and it was thought he would not be able to
tolerated p.o.
On postoperative day #18th, the respiratory status was
tenuous. The patient was continued on the Ceftazidime. We
continued the Ceftazidime and Levofloxacin. Pulmonary
consultation was called for question of chest CT, repeat
sputum cultures, chest PT. PT was involved in his care at
this point.
On [**6-17**], [**2117**], at this point, he had failed a swallow
evaluation and he was being diuresed. Respiratory status
remained tenuous. Kidney function was okay. We continued
him Amiodarone and heparin. We discontinued the Levofloxacin
and Ceftazidime.
On postoperative day #20, [**2117-6-24**], the patient was stable
with aggressive pulmonary toilet. The heparin drip was
continued.
On the 20th, we attempted a percutaneous endoscopic
gastrectomy, which was unsuccessful.
On postoperative day #21, we continued aggressive respiratory
status. The Department of Neurology was consulted on
[**2117-6-25**] for confusion. They felt that the patient had mild
encephalopathy possibly due to an increasing sodium, which at
this point, had reached 150, and asked us to consider doing
MRI to rule out any further pathology.
On postoperative day #22, [**2117-6-26**], the patient was
continued on heparin and SSRI. We continued diuresing with
Bumex. We started the patient on Diflucan for yeast in the
sputum.
On [**2117-6-28**], the patient was stable. No changes were made.
.................... was asked to see him again seen and it
was decided that the patient would not be able to take
p.o.'s for some time. In accordance with that an open
gastrostomy and open tracheostomy was scheduled. Open
tracheostomy indication was pulmonary care and PEG was
because we failed to do the percutaneous wound safely. The
patient was taken to the operating room on [**6-29**] and had
that done successfully without complications. We had shut
off the heparin before the operation. Postoperatively, the
patient had some SIMV pressor support, which we were then
able to wean down to CPAP. On [**2117-7-1**] no major events
happened. The patient was continued on Fluconazole and
heparin drip.
On [**2117-7-1**], the patient was agitated and given some
sedation. On [**2117-7-2**], postoperative #28, the patient was
given Lopressor. Chest PT was continued. Tube feeds were
continued. We continued Fluconazole. The respiratory status
remained concerning and we continued to diurese. The
Department of Psychiatry was involved. Regarding to
recommendations, we discontinued all the benzodiazepines,
opiates, and anticholinergics and started him on Haldol.
On [**2117-7-3**], the patient was having hypercapnia. He was put
back on the CPAP pressor support, which was then later weaned
off. He continued Fluconazole. The heparin drip was
continued, anticoagulation for chronic atrial fibrillation.
On [**7-4**], [**2117**] the patient was therapeutic on Coumadin,
which has been started and heparin drip was discontinued.
The patient was doing well.
In accordance with the family's wishes, the patient was
arranged for hospice. The patient, at this point, was DNR.
The issues upon discharge are as follows:
The patient is some delirious. The patient should await all
anticholinergics, no opioids, benzodiazepines. He is being
sent home on Haldol per the Department of Psychiatry/patient.
CARDIOVASCULAR: The patient is on Lopressor 12.5 mg p.o.
b.i.d.
GASTROINTESTINAL: The patient is getting tube feeds of
Promote with fiber at 75 cc an hour. He will get Prevacid at
30 mg q.d for G-tube, Fluconazole 20 mg until the 5th of this
month, Albuterol nebulizers for the respiratory status.
FLUIDS, ELECTROLYTES, AND NUTRITION: For diuresis, he will
receive Lasix 20 mg q.d. along with potassium
supplementation. For anticoagulation, he will receive
Coumadin 1 mg today and tomorrow. INR is therapeutic at 2.7
and it is to be checked tomorrow. Dr. [**Last Name (STitle) **] of the
Department of Cardiology will follow the INR dosing for a
goal target of 2 to 2.5. He is aware of this, and he will do
so. The patient is to have nothing orally. We are to
maintain his comfort and optimal level of function with
hospice at home.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 28973**]
D: [**2117-7-5**] 10:22
T: [**2117-7-5**] 10:31
JOB#: [**Job Number 40780**]
ICD9 Codes: 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4322
} | Medical Text: Admission Date: [**2104-8-17**] Discharge Date: [**2104-8-20**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
change in behavior and left sided neglect
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83y/o female p/w above symptoms to [**Hospital 8**] [**Hospital 1263**] Hospital.
She is a resident of Nursing home ([**First Name5 (NamePattern1) 18404**] [**Last Name (NamePattern1) 69170**] Nrs Home,
[**Telephone/Fax (1) 69171**]) with baseline function of verbal with good sense
of humor, wheel chair but can eat by herself. Caregiver noticed
that she has been odd in the way of response in
conversation over the 3days. Today, they noticed that patient
did not pay attendtion to the person who stood left side of her,
and also she did not responded when she was touched her left
side of the body. She was brought into [**Hospital 1263**] Hospital, where
she was found to have Rt thalamic hemorrhage (3.2 x 2.6cm) and a
focus of hyperdensity at left frontal lobe. The lateral
ventricles were prominent, possible hydrocephalus. She was
transferred to [**Hospital1 18**] for further management.
ROS: No fever, vomiting, diarrhea, pain, headache.
Past Medical History:
HTN
hyperlipidemia
Pacemaker
schizophrenia
dementia
hypothyroidism
Social History:
From [**Hospital3 **]. HCP is sister who lives in the area.
Family History:
NC
Physical Exam:
Admission exam:
T-97.0 BP-141/52 HR-58, reg RR- 23 SaO2 97%, r/a
Gen: Awake, no distress
HEENT: clear ears, conjunctivas, oral membrane, no neck bruit,
no goiter
Neck: no rigidity
Chest: vesicular sound, symmetrical, symmetrical chest
Heart: S1, S2 nl, no murmur
Abd: soft but slightly distended w/o tenderness, no mass, had
sagittal scar (umbilicus removed) with one puncture scarring
(most likely drainage wound). Hepatosplenomegaly not appreciated
but difficult to exam due to sl distention.
Skin: no lesions, skin stigmata, moist, turgor nl
Exts: cotracture at bilateral knee.
NEURO
MS Awake w/o any stimuli, did not respond to the question (name,
place, how are you feeling), did not follow any simple command
(lift your leg, squeeze your hand). Respond to the voice said
muffling sound and one word able to pick was "help".
CN: Fundus normal disc margin. Eyes deviated to the right, no
nystagmus, oculocephalic reflex could not break deviation.
Symmetrical NLF, mouth angle, normal gag reflexes, uvula at
midline. Smacking movement at mouth. SCM seemed to be normal
bulk, strength
Motor: Spontaneous anti gravity movement at rt arm, grasped
examiner's fingers (unrelated to the command). Rt toe wiggling
(unrelated to the command), left arm, leg showed no spontaneous
movement). Cog-wheel like rigidity at LUE and LLE (knees had
contracture)
Reflex:
[**Hospital1 **] Tri BR Pat [**Doctor First Name **]
Rt 2 2 2 2 2
Lt 3 3 3 3 3 no foot clonus. Bil planters going down.
Sensory: No withdrawal to all extremities. Grimace on facial
anoxic stimuli.
Pertinent Results:
CBC: 8.4 >11.0/31.6< 146
Diff N:76 Band:6 L:10 M:5 E:2 Bas:0 Metas: 1
140 105 22 215 AGap=18
------------------
4.0 21 1.1
CK: 28 MB: 2 Trop-*T*: <0.01
PT: 13.4 PTT: 29.1 INR: 1.2
NCHCT: FINDINGS: There is a large 4cm hemorrhagic focus lying
within the right thalamus tracking into the ventricles with
moderate amount of blood layering within the occipital horns
(right greater than left). There is brain atrophy as indicated
by enlarged sulci and cisterns, but the marked enlargement of
the ventricles and appearance of the third ventricle indicates
superimposed hydrocephalus. Fourth ventricle is within normal
limits. Small amount of adjacent subarachnoid hemorrhage is
present within the right parietal lobe. More chronic changes are
also present including periventricular white matter
hypodensities representing the sequela of chronic small vessel
infarction, a previous left frontal infarct, and prior lacunar
infarcts bilaterally in the basal ganglia.
A second tiny 5 mm high density, likely hemorrhagic focus is
also identified within the convexity of the left frontoparietal
cortex. Underlying neoplasm and ischemia cannot be excluded for
the above findings.
IMPRESSION:
1. Large 4 cm hemorrhage centered in the right thalamus tracking
into the occipital horns bilaterally with hydrocephalus.
2. 5-mm left frontoparietal convexity high density, (likely
hemorrhagic)
Underlying neoplasm and ischemia cannot be excluded. When
patient's condition stabilizes, evaulation with MR would provide
further clarification.
Brief Hospital Course:
83y/o woman with dementia who presented with right thalamic
hemorrhage and left frontoparietal convexity focus (unclear if
neoplasm, ischemia, or bleed). Considering her etiology, and
current and BP at OSH (SBP 140's) differential diagnosis
included hypertensive versus amyloid bleed. MRI/MRA was the
preferrable evaluation but could not be done due to hx of Pacer.
PMH of HTN, hyperlipidemia suggested possibility of ischemia at
left frontal lobe, but considering large bleeding, aspirin was
held. Patient was admitted to the ICU for blood pressure
management. She was treated for a urinary tract infection with
Ciprofloxacin. Cardiac enzymes were negative x3. Patient was
doing when when on morning of [**8-19**] patient had increased
difficulty breathing. Concern was for aortic dissection given
unusual pattern of calcification of the aortic arch on CXR.
Also, resolving LLL infiltrate suggested possible pneumonia.
Patient's next of [**Doctor First Name **] was contact[**Name (NI) **] regarding code status and
stated that patient would not have wanted extraordinary measures
including intubation or resuscitation. Furthermore, patient's
sister expressed that the patient would have wanted to be made
comfortable in this situation. Patient was subsequently made CMO
code status and transferred to the floor. She expired from
respiratory failure on [**2104-8-20**].
Medications on Admission:
Atenolol 25mg po daily
Lipitor 41mg po daily
Levothyroxine 100mcg po daily
Omeprazol 20mg po daily
Enulose syrup 30ml [**Hospital1 **]
Ferrous sulfate 325mg po bid
Remeron 15mg po QHS
Ativan 0.5mg QHS
Hydrocodone/APAP 5/500mg 1 Tab po q8h prn pain
Senna, Bisacodyl, Docusate, Milk of magnesia 30ml po daily prn
Actonel 35mg po weekly on empty stomach
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary cause of death: Respiratory failure
Secondary cause of death: Right thalamic hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2104-9-7**]
ICD9 Codes: 431, 5990, 2720, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4323
} | Medical Text: Admission Date: [**2119-5-17**] Discharge Date: [**2119-6-1**]
Date of Birth: [**2067-9-29**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 21114**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Central venous line placement, PICC placement, Intubation, NG
tube, Lumbar puncture
History of Present Illness:
(History per patient's domestic partner and HCP): 51 y.o. male
with HIV (CD4 of 559 and VL undetectable in [**Month (only) 547**]), ESRD [**1-7**] IgA
nephropathy s/p DDRT in '[**14**], DM, CAD who initially presented to
an OSH with a chief complaint of SOB. Patient was recently
discharged from [**Hospital1 18**] with presumed CAP after extensive work-up
was otherwise negative for TB (by AFB and Quanteferon Gold) and
PCP. [**Name10 (NameIs) **] was initially treated with Levofloxacin, followed by
Ceftriaxone and Azithromycin, then finally Cefpodoxime for 7
days on discharge to complete a total of 2 weeks of antibiotics.
He returned home and was in his normal state of health until
approximately 3 days ago when he began experiencing shortness of
breath and a cough, intermittently productive of clear sputum.
Reportedly, he had no F/C, N/V during this time. He has chronic
diarrhea in the setting of HAART. On the day of admission,
patient woke up feeling profoundly short of breath and also
complaining of neck pain and stiffness without headache. His
partner then notes that he vomited a very large amount of brown
emesis with no blood. Approximately 2 hours later, the patient
was lightheaded and unsteady on his feet and his partner, a
dialysis tech, took his blood pressure and recorded an SBP of
70. Temperature was also noted to be elevated to 102. EMS was
then notified and patient was taken to [**Hospital6 5016**].
.
At [**Hospital3 **], patient continued to be hypotensive in the 70s
and hypoxic to 86% on RA. He was given 3 L NS and a CXR was
ordered, which showed a RLL infiltrate. He was then given
Levofloxacin and transferred to [**Hospital1 **] for further management.
.
In the [**Hospital1 18**] ED, patient was noted to be hypotensive to SBP 72
and relatively hypoxic with O2 sat of 93% on 4L NC. A repeat CXR
showed a right lung infiltrate and a probable effusion on the
left. Given continued O2 requirement and hypotension, patient
was intubated and started on Levophed then subsequently admitted
to the MICU for further management.
Past Medical History:
DM I
Diabetic retinopathy
Nephropathy, s/p CRT [**2114**], on HIV-transplant protocol
Hyperlipidemia
Neuropathy, c/b ulcers
Charcot foot with R calcaneal injury and collapse/fracture
Necrobiosis lipoidica diabeticorum
Osteoporosis
Depression
Hypertension
Anemia
Syphilis in [**2094**], treated with penicillin
Toxoplasmosis seropositivity
h/o perianal condyloma
h/o c. diff colitis s/p hospitalization in [**2109**]
Social History:
Mr. [**Known lastname **] was born in [**State 350**]. He works for the IRS in
[**Location (un) 2268**]. Lives with long-time partner in monogamous
relationship. No h/o asbestos. Remote h/o tobacco 15yrs x [**12-7**]
ppd. Denies current alcohol use, but has a history of abuse.
Family History:
His mother is deceased, she had breast cancer and CAD. His
father died of a perforated gastric ulcer with peritonitis. He
has one older brother with hepatitis, and a younger brother with
cerebral palsy. No other disorders that he is aware of run in
his family.
Physical Exam:
VS: T - 98.4, BP - 118/54 (.03 Levophed), HR - 78, RR - 16, O2 -
99% AC 500/14/5/100%
GEN: Sedated, intubated, appears comfortable
HEENT: NC/AT, PERRLA, EOMI, no conjuctival injection, anicteric,
OP clear, MMM, Neck supple, no LAD, no carotid bruits
CV: Heart sounds difficult to appreciate given loud, coarse BS
PULM: Diffusely roncherous. No appreciable wheezes
ABD: Markedly distended, tympanic to percussion, no wincing on
palpation, decreased BS
EXT: warm, dry, no c/c; 2+ pitting edema b/l in [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: Multiple areas of chronic skin breakdown with necrotic
centers that do not appear super-infected
Pertinent Results:
[**2119-5-29**] CXR Portable: Mild pulmonary edema has resolved. There
is linear atelectasis in the right mid and lower lung zones.
There are no pleural effusions. Appropriate position of
right-sided PICC line with tip in the mid SVC.
.
[**2119-5-25**] CXR Portable: Increasing mild pulmonary edema. Improving
left basilar atelectasis.
.
[**2119-5-24**] Echo: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. The right atrial
pressure is indeterminate. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%) There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
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. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
.
[**2119-5-24**] CXR Portable: The right middle lobe consolidation,
stable since the [**2119-5-23**] examination, has clearly improved
since the [**2119-5-18**] examination. The left lower lobe opacity
has worsened. The small left pleural effusion is stable. There
is no right pleural effusion. The endotracheal tube is 2 cm from
the carina. The right internal jugular line tip is at the
caval/brachiocephalic junction.
.
[**2119-5-23**] CXR Portable: Mild pulmonary edema is noted demonstrated
by increased prominence of peripheral septal lines. Component of
right middle lobe opacity has improved with minimal improvement
of left lower lobe opacity. Moderate left pleural effusion and
associated atelectasis remain. The upper lungs remain clear. No
appreciable right pleural effusion is noted.
.
[**2119-5-21**] CXR Portable: Comparison is made with prior chest x-ray
of [**5-20**]. A perihilar edema persists, left hemidiaphragm
remains obscured indicating collapse consolidation in the left
lower lobe and the right heart border is also obscured
indicating a right lower lobe infiltrate.
.
[**2119-5-20**] Abdomen Portable:
.
[**2119-5-17**] CT head w/o contrast: There is no hemorrhage, edema,
mass, mass effect, or evidence of acute vascular territorial
infarction. Ventricles and sulci are unchanged in size and
configuration. Dense atherosclerotic calcifications are noted on
the carotid siphons and vertebral arteries. Left phthisis bulbi
is unchanged.
IMPRESSION: No acute intracranial process. No change from
[**2119-4-19**].
[**2119-5-17**] CXR Portable: 1. Right IJ catheter terminating in the
contralateral brachiocephalic vein and directed laterally. 2.
Interstitial edema with more focal right middle lobe opacity may
reflect either "atypical" edema or pneumonia.
[**2119-6-1**] 05:56AM BLOOD WBC-5.6 RBC-2.62* Hgb-9.4* Hct-27.7*
MCV-106* MCH-35.9* MCHC-34.1 RDW-18.0* Plt Ct-742*
[**2119-5-29**] 05:15AM BLOOD Neuts-56.3 Lymphs-31.0 Monos-6.2 Eos-5.6*
Baso-1.0
[**2119-5-24**] 05:44AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-1+
[**2119-5-29**] 05:15AM BLOOD PT-13.5* PTT-29.4 INR(PT)-1.2*
[**2119-6-1**] 05:56AM BLOOD Glucose-193* UreaN-13 Creat-0.8 Na-141
K-3.7 Cl-108 HCO3-21* AnGap-16
[**2119-5-31**] 05:01AM BLOOD ALT-62* AST-38 LD(LDH)-320* AlkPhos-134*
TotBili-0.3
[**2119-5-30**] 06:13AM BLOOD CK-MB-6 cTropnT-0.06*
[**2119-5-30**] 01:49AM BLOOD CK-MB-7 cTropnT-0.08*
[**2119-5-27**] 07:28PM BLOOD CK-MB-15* MB Indx-0.9 cTropnT-<0.01
[**2119-5-27**] 03:04AM BLOOD CK-MB-18* MB Indx-0.7
[**2119-6-1**] 05:56AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.9
[**2119-6-1**] 05:56AM BLOOD VitB12-1070* Folate-16.4
[**2119-5-18**] 07:43AM BLOOD Cortsol-18.5
[**2119-5-18**] 07:42AM BLOOD Cortsol-15.9
[**2119-5-18**] 07:42AM BLOOD Cortsol-9.9
[**2119-5-18**] 05:08AM BLOOD IgG-897 IgA-189 IgM-66
[**2119-5-26**] 06:07PM BLOOD B-GLUCAN-Test
[**2119-5-23**] 12:52PM BLOOD MISCELLANEOUS TESTING-Test Name
[**2119-5-23**] 12:52PM BLOOD MISCELLANEOUS TESTING-Test Name
[**2119-5-18**] 04:33PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-
TEST
[**2119-5-18**] 04:33PM BLOOD B-GLUCAN-Test
[**2119-5-17**] 10:23PM BLOOD COCCIDIOIDES ANTIBODY,
IMMUNODIFFUSION-Test
[**2119-5-17**] 10:23PM BLOOD STRONGYLOIDES ANTIBODY,IGG-Test Name
[**2119-5-17**] 10:23PM BLOOD BLASTOMYCOSIS ANTIBODY (BY CF AND
ID)-Test Name
Brief Hospital Course:
[**Hospital **] hospital course was as follows, by problem:
.
# Hospital aquired pneumonia s/p hypoxic respiratory failure: At
admissions, considerations included HAP given recent
hospitalization and "failed" course of abx for CAP (although
initially improved clinically) and aspiration given lack of gag
and BAL showing OP flora and prominent infiltrate RML. Patient
had been recently treated for pneumonia, which was felt to be
CAP given negative Quanteferon Gold, PCP and Legionella [**Name9 (PRE) 8019**]
and current work-up had been unrevealing for possible organisms.
Patient's immunocomprised status was certainly of concern,
though negative workup as above made the more atypical
considerations less likely. Patient was intubated (note
difficult intubation) and treated with a 14 day course of zosyn
and vancomycin and 5 day course of azithromycin. Patient was
successfully extubated, transitioned to the floor on 2L to
complete the antibiotic course, and at discharge was satting
>96% on room air. Cultures never produced a clear pathogen. A
sputum sample on [**5-19**] did show sparse growth of [**Female First Name (un) 564**]
glabrata, for which he was temporarily treated with fluconazole.
Patient improved considerably outside of the ICU. Patient was
unable to provide a repeat sputum sample, and given his clinical
improvement and the lack of efficacy of fluconazole for [**Female First Name (un) 564**]
glabrata, the medication was stopped at discharge.
.
# Hypertension: The patient's initial hypotension was attributed
to hypovolemia given response to fluids. Sepsis was considered
initially, but no source was identified. Following transfer from
the MICU, the patient was found to be hypertensive for much of
the remainder of his hospital course. His beta-blocker and [**Last Name (un) **]
were increased and a calcium-channel blocker added; at discharge
his BP was better controlled.
.
# NSTEMI: The patient had an NSTEMI while in the ICU, and a
second episode of elevated troponins (without EKG changes) after
transfer to the floor. In the first episode, the patient was
briefly put on heparin gtt. Cards consulted and felt most likely
demand in setting of respiratory distress and thus no
intervention was planned. The second episode was associated with
chest pain thought to be more MSK in nature and related to his
frequent coughing. He was maintained on his beta-blocker and his
aspirin was increased to 325mg daily. At discharge, he was free
of chest pain, SOB, and palpitations. Outpatient follow-up for
further evaluation and stress test was arranged with his
cardiologist.
.
# C. difficile: Positive stool study this admission. Started on
metronidazole on [**5-23**] with some slowing of his diarrhea. Loose
stools improved during course of stay outside of MICU. On
discharge (ie last day of antibiotics), patient was sent out
with additional 14 day course of metronidazole. As patient has
history of chronic diarrhea, his home regimen of tincture of
opium was also started.
.
# Positive coccidoides: Serum test positive, although patient
was also on Bactrim for PCP [**Name Initial (PRE) 1102**] (risk of
false-positive). Given history of HIV and on immunosuppression
for renal transplant, patient was initially treated on
fluconazole as above. On day of discharge, fluconazole
discontinued.
.
# ARF/ESRD s/p transplant: Patient had elevated creatinine at
presentation - likely secondary to hypovolemia/underperfusion
which hypotensive - which resolved through the hospital stay.
Calcitriol and nephrocaps were continued at home dose.
Tacrolimus dosing was temporarily cut in half secondary to
interaction with fluconazole, and increased to home dose once
fluconazole was discontinued. Tacrolimus trough was checked
daily. Prednisone was continued at home dose, and Bactrim SS for
PCP [**Name Initial (PRE) 1102**]. At discharge, creatinine was well in normal
range.
.
# HIV: No active issues; on HAART. Continued medications for
neuropathy, and treated for chronic diarrhea as above.
.
# DM: Developed AG met acidosis with positive ketones in MICU;
was placed back on insulin gtt. Gap closed and placed back on
home dose of Lantus and insulin SS. Patient was then changed
from Lantus to NPH for easy of titration. Patient's blood
glucose remained elevated for much of hospital course, with
daily adjustments of NPH. On discharge, patient was restarted on
his home regimen of Lantus and sliding scale insulin.
.
# Anemia: At admission, hematocrit was >37. For remainder of
hospital course, hct remained in upper 20s. Given elevated MCV,
patient appeared to have a macrocytic anemia. Vitamin B12 was
found to be elevated, and folate was within normal range.
.
# Depression: Continued Effexor
.
# Hyperlipidemia: Pravastatin held given mild transaminitis, up
from baseline, and elevated CK not attributable to cardiac
source.
.
#COMMUNICATION: Patient's domestic Partner, [**Name (NI) **]: [**Telephone/Fax (1) 21115**]
(cell), [**Telephone/Fax (1) 21116**] (home)
Medications on Admission:
Ambien 10 mg PO QD
Amitriptyline 10 mg PO QHS
Androgel 1%
Aspirin 81 mg PO QD
Bactrim SS 1 tab QMWF(?)
Calcitriol .25 mcg QTues/Sat
Combivir 1 tab [**Hospital1 **]
Creon 20 sa [**Male First Name (un) **] 3 tablets w/ meals 1 w/ snacks
Diovan 160mg QAM/80 mg QPM
Effexor XR 150 mg PO QD
Flomax 0.4 mg PO QHS
Fosamax 70 mg Q Sunday
Furosemide 80 mg [**Hospital1 **]
Lantus 33 U QHS w/ Humalog according to carb counting
Lomotil PRN
Lorazepam 1 mg PO QHS
Metoprolol 150 mg PO BID
Nephrocaps 1 cap PO QD
Neurontin 300 mg QID (1 tablet at 8AM, 2PM, 5PM, 2 tablets QHS)
Pravastatin 10 mg PO QD
Pred Forte 1% gtt
Prednisone 5 mg PO QD
Prilosec 40 mg PO QD
Prograf 1 mg PO BID
Viramune 1 tab PO BID
Dilaudid PRN for pain
Opium Tincture PRN for diarrhea
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
3. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Prednisolone Acetate 1 % Drops, Suspension Sig: Two (2) Drop
Ophthalmic DAILY (Daily).
5. Tacrolimus 0.5 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Effexor XR 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 2X/WEEK
(TU,SA).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QMWF.
11. Valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
14. Opium Tincture 10 mg/mL Tincture Sig: Fifteen (15) Drop PO
BID (2 times a day).
15. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
17. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
18. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO at
bedtime.
19. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
20. Humalog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous four times a day.
21. Lantus 100 unit/mL Solution Sig: 33 units Subcutaneous at
bedtime.
22. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: for a
total of 300 mg daily.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
23. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: for a
total of 300 mg daily.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary:
1. Hospital acquired pneumonia
2. Hypoxic respiratory failure, now resolved
3. Colitis secondary to clostridium dificle
4. Elevated troponins, now resolved
5. Acute renal failure/End-stage renal disease s/p transplant
([**2115**])
Secondary:
1. HIV, on HAART
2. Diabetes mellitus
3. Hyperlipidemia
4. Hypertension
Discharge Condition:
Hemodynamically stable. Ambulatory. Patient to work with
physical therapy at home.
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**5-17**] for treatment of a severe
pneumonia. At admission, you were intubated and taken to the
intensive care unit. The pneumonia was treated with a 14 day
course of antibiotics. While in the hospital were also found to
have an infection of your colon; you will continue treatment for
this at home for an additional 14 days. In the hospital, you had
2 episodes of increased work of your heart. As an outpatient,
you should followup with your cardiologist to undergo a stress
test.
Physical therapy will work with you at home to help you regain
your strength.
The following changes have been made to your home medication
regimen. You will now take Diovan 160mg twice daily, and
metoprolol extended release once daily. You should stop taking
Pravastatin. We have also added one additional medication:
Flagyl 500mg PO three times daily for 14 days.
Contact your medical provider for any fever, shortness of
breath, worsening of productive cough, or for any other
concerns.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2119-6-6**] 10:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2119-6-7**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2119-6-13**] 11:00
[**Hospital **] [**Hospital 982**] Clinic, [**2119-8-1**] 2:30. You will be contact[**Name (NI) **] if
an earlier appointment becomes available.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21117**] MD, [**MD Number(3) 21118**]
Completed by:[**2119-6-3**]
ICD9 Codes: 0389, 5070, 5849, 3572, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4324
} | Medical Text: Admission Date: [**2197-2-5**] Discharge Date: [**2197-2-8**]
Date of Birth: [**2124-4-2**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stent placement to right
coronary artery
History of Present Illness:
72 M h/o HTN, DM2, hyperlipidemia, who awoke from sleep at 3AM
"feeling lousy", subsequently had 1 loose bowel movement, then
developed substernal chest pressure [**6-3**], non-radiating, no SOB,
+diaphoresis. He took one full aspirin. He was taken to OSH by
his wife, where he was noted to have inferior sinus brady (50s),
with STE II, III, avF, STD in V1, V2, 1mm avR, aVL. K=3.0, tropI
< 0.04, CK 83, cre 1.2.
.
At OSH ([**Location (un) **]), given asa, plavix 300, aggrastat, heparin gtt,
and was transferred to [**Hospital1 18**] for cath. In cath lab, pt received
atropine [**2-25**] mild hypotension with bradycardia (SBP 100s),
afterwhich HR=122, still sinus, pt noted to have total occlusion
of distal RCA, which were stented with BMS x 2. chest pain
resolved after cath completely, STE segments improved on tele
per report, however persist on post-cath EKG.
.
ROS: +"diarrhea" - 2 loose BMs/day. no blood.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope. Pt climbs
flight of stairs without difficulty, no trouble walking [**1-25**] city
blocks.
Past Medical History:
- HTN <1y
- DM 11y, followed by endocrinologist, never on insulin.
- hyperlipidemia
- lyme disease - 4y ago, primarily manifests as arm/leg aches
- h/o "acute granular nephritis" in teens, no residual CKD.
- left inguinal hernia repair, 10y ago.
- denies CVA, CAD, PE/DVT, cancer.
Social History:
Social history is significant for the absence of current/ever
tobacco use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. brother MI [**57**], paternal grandfather MI late
60s. pt is a jehovah's witness, declines all blood products.
also worked as produce manager, retired 2 weeks ago.
Physical Exam:
VS: 97.4 107 128/71 15 100%2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 10 cm lying flat. prominent heart
sounds R>L carotid, no frank murmur.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. R groin femoral/arterial
sheath in place.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2197-2-5**] 07:58AM PT-15.0* PTT-141.4* INR(PT)-1.3*
[**2197-2-5**] 07:58AM PLT COUNT-198
[**2197-2-5**] 07:58AM WBC-9.9 RBC-4.11* HGB-13.5* HCT-35.6* MCV-87
MCH-32.8* MCHC-37.9* RDW-12.5
[**2197-2-5**] 07:58AM TRIGLYCER-30 HDL CHOL-41 CHOL/HDL-2.8
LDL(CALC)-69
[**2197-2-5**] 07:58AM %HbA1c-7.5*
[**2197-2-5**] 07:58AM CALCIUM-8.4 PHOSPHATE-4.1 MAGNESIUM-1.8
CHOLEST-116
[**2197-2-5**] 07:58AM CK-MB-104* MB INDX-9.1* cTropnT-2.45*
[**2197-2-5**] 07:58AM ALT(SGPT)-24 AST(SGOT)-88* CK(CPK)-1142* ALK
PHOS-55 TOT BILI-0.3
[**2197-2-5**] 07:58AM estGFR-Using this
[**2197-2-5**] 07:58AM GLUCOSE-287* UREA N-19 CREAT-1.0 SODIUM-139
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18
[**2197-2-5**] 02:12PM MAGNESIUM-2.1
[**2197-2-5**] 02:12PM CK-MB-230* MB INDX-9.0* cTropnT-11.57*
[**2197-2-5**] 02:12PM CK(CPK)-2545*
[**2197-2-5**] 02:12PM POTASSIUM-5.3*
[**2197-2-5**] 10:03PM PLT COUNT-210
[**2197-2-5**] 10:03PM CK-MB-106* MB INDX-6.3* cTropnT-7.93*
[**2197-2-5**] 10:03PM CK(CPK)-1695*
[**2197-2-5**] 10:03PM POTASSIUM-4.1
Brief Hospital Course:
ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS:
.
72M PMH s/f HTN, DM, hyperlipidemia, who presented with chest
pain on [**2-5**], and was found to have total occulsion of the RCA
s/p bare metal stent placement.
.
# CAD/Ischemia: Found to have total occlusion of RCA on cardiac
catheterization with bare metal stent placement. Started on
aspirin, plavix, high dose statin. Lisinopril and metoprolol
titrated as blood pressure tolerated.
.
# Pump: EF of 55%. No evidence of heart failure, acute or
chronic. Mild left ventricular systolic dysfunction by ECHO.
.
# Valves: Normal valvular function by ECHO.
.
# HTN: Titrated ACE-I and bblocker as blood pressure tolerated.
.
# hyperlipidemia - Started on high dose statin.
.
# DM: Sugars were labile while in house. Initially low then
elevated to the 400s on half dose of home regimen. Restarted on
home regimen of insulin with improvement in finger sticks.
.
# lyme disease - 4y ago, primarily manifests as arm/leg aches.
no h/o myocarditis per pt.
.
# CKD - h/o "acute granular nephritis" in teens, no residual CKD
per pt, baseline creatinine unknown, currently 1.2. Remained
stable while in house.
.
# jehovah's witness - pt declines all blood products.
.
# Code: FULL CODE.
.
# Communication:
- wife ([**Doctor First Name **]) [**Telephone/Fax (1) 30846**].
Medications on Admission:
glyburide 5mg po bid
metformin 1000mg po bid
lisinopril 10mg po qdaily
lovastatin 20mg po qdaily
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. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
5. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
6. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Inferior myocardial infarction
Secondary: Diabetes Mellitus, Hyperlipidemia
Discharge Condition:
Good, chest pain free; vital signs stable.
Discharge Instructions:
You were admitted to the hospital because you had a heart
attack. This was due to a blockage in your coronary artery. You
had a stent placed to open up the blockage.
.
You were started on new medications. These include:
Aspirin
Plavix
You should continue to take these medications unless otherwise
directed by your cardiologist.
.
You were noted to have minor blockages in other arteries of
your heart. Therefore, you will need a follow up stress test in
[**4-30**] weeks.
.
Please contact your doctor or return to the emergency room if
you develop chest pain, shortness of breath, lightheadedness,
palpitation, etc.
Followup Instructions:
Outpatient stress 6-8 weeks
Follow up with Dr. [**Last Name (STitle) **] on [**2197-2-23**] at 10:15am.
([**Telephone/Fax (1) 30847**].
Please contact Dr [**Last Name (STitle) 7526**] in Cardiology at ([**Telephone/Fax (1) 30848**]
affiliated with [**Hospital3 3765**]. Please schedule an appointment
to see Dr. [**Last Name (STitle) 7526**] within one month. If you have difficulty
scheduling an appointment, please contact Dr. [**Last Name (STitle) **] to obtain
an alternate referral.
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4325
} | Medical Text: Admission Date: [**2114-6-24**] Discharge Date: [**2114-7-3**]
Date of Birth: [**2055-9-30**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
liver failure secondary to hepatitis B cirrhosis
Major Surgical or Invasive Procedure:
paracentesis
Brief Hospital Course:
58yo male recently diagnosed with advanced hepatitis B cirrhosis
and transferred to [**Hospital1 18**] on [**2114-6-24**], for liver failure and
transplant evaluation. He initially presented to [**Hospital3 60734**] with painless jaundice in late [**Month (only) 116**] and returned to
[**Hospital1 18**] with worsening jaundice, ascites, abdominal pain/
distension secondary to ascites. He was admitted to the medicine
service and began a liver transplant workup. He was started on
cipro and flagyl for biopsy findings concerning for cholangitis.
Ursodiol and rifaximin were started. CXR demonstrated pneumonia.
Cipro was switched to Levaquin. Chest CT demonstrated
multifocal opacities with tree in [**Male First Name (un) 239**] distribution. A pulmonary
pre-op eval was obtained. PFTs were ordered. ARF resolved with
IV hydration.
He was coagulopathic with guaiac positive stool. An
EGD/colonoscopy was done on [**6-29**] noting 1 cords of grade I
varices were seen in the gastroesophageal junction. The varices
were not bleeding. Diverticulosis of the sigmoid colon and
descending colon were noted with grade 2 internal hemorrhoids
and rectal varices seen in his rectum.
Otherwise normal colonoscopy to cecum.
ABD CT noted a cirrhotic liver with evidence of portal
hypertension including recanalized umbilical vein and
splenomegaly, no suspicious focal liver lesions, conventional
hepatic arterial and venous anatomy, patent portal vein, small
amount of ascites, diverticulosis and a non-obstructing right
renal stone.
Cardiac cath was done on [**6-27**] revealing mild to moderate
pulmonary hypertension, preserved cardiac output and elevated
biventricular filling pressures.
He developed hepatorenal syndrome (creat 6.0, inr 7.0 and t.bili
52)and contrast nephropathy. Octreotide, midodrine and albumin
were started. Meld increased to 50. [**6-30**], paracentesis was done
for 2.5 liters.
He was transferred to the MICU for worsening respiratory
status,mental status changes, worsening hyperbilirubinemia and
renal failure. CVVHD was started, broad spectrum antibiotics
were continued and FFP was given to correct INR. He became
hypovolemic and hypoglycemic. Pressor support was required Foley
was placed with 360cc output. Albumin was given and Levophed was
added for pressor support. A liver/abd ultrasound was done
detecting portal vein thrombus.
Care was transferred to the Transplant Surgery service on [**8-1**]
and he was moved to the SICU for management. On [**7-3**], he decided
that he wanted to stop treatment. He wished for CMO status.
After a family meeting with staff, CMO status was established.
He was discharged to home with Hospice services arranged.
Discharge Medications:
1. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
2. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO
q2-4h as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
hepatitis b infection
end stage liver disease
anemia
cholangitis
hepatorenal syndrome
portal vein thrombus
Discharge Condition:
comfort measures only/hospice
Discharge Instructions:
Mr. [**Known lastname 85385**] was transferred from [**Hospital6 2561**] for
management of fulminant liver failure secondary to hepatitis B
infection. He now wishes to be made comfort measures only and be
discharged on home hospice.
Followup Instructions:
Followup with home hospice, contact Dr. [**Last Name (STitle) 497**] or [**Doctor Last Name **] as
needed.
Completed by:[**2114-8-21**]
ICD9 Codes: 5849, 486, 5715, 4168, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4326
} | Medical Text: Admission Date: [**2135-5-16**] Discharge Date: [**2135-5-19**]
Date of Birth: [**2066-6-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Nausea/Vomiting --> Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 m with type 1 DM, congenital solitary kidney, CRI, HTN,
gastritis, presents with nausea/vomiting and DKA.
Reports 2-3 days of "stomach upset", with nausea and occasional
non-bloody, non-bilious vomiting. Began to have anorexia so
decreased insulin doses. He took 12 units the night PTA, and
then none the morning he presented because he felt too unwell
with subjective fevers and sweats. Denies cough, SOB, chest
pain, myalgias, dysuria but has had a few loose stools after
taking ExLax for constipation. No sick contacts, unusual food,
travel. Of note patient was admitted [**2135-3-23**] for DKA with
identical symptoms, cause was unknown but thought to have some
element of medication non-compliance. Per prior notes, he has
also had intermittent nausea and vomiting for several months.
On arrival to ED, afebrile but tachycardic with SBP 100s,
comfortable
occ vomiting guaiac positive brown stool given normal saline
and 10 units regular insulin IV labs notable for anion gap 31,
normal WBC count.
Past Medical History:
1.Type I DM - dx [**2106**], HbA1c on [**3-24**] was 8.9
2. Hyperlipidemia
3. One kidney, congenital
4. Legally blind in L eye [**3-5**] MVA
5. CRI - baseline 1.3-1.4
6. Hypertension
7. Lumbar radiculopathy (L5?)
8. H. Pylori gastritis ([**3-11**]) s/p triple therapy treatment
9. Gastritis, duodenal ulcer ([**3-11**])
Social History:
Patient lives in [**Location (un) 4398**] w/ partner [**Name (NI) **]. Recently retired
school administrator, retired now as a consultant. Prior 15-pk
year history, quit 30+ years ago. [**2-2**] EtOH drinks/day, no
illicits.
Family History:
Mother 77 d colon CA, father 86 d CAD s/p MI; 9 siblings: 1 d
lung CA, 1 d colon CA (none under 50). Diabetes runs in the
family.
Physical Exam:
VS: Temp: 98.2 HR: 117 BP: 119/62 RR: 26 O2sat: 100% on RA
GEN: pleasant and talkative, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, dry mucous membranes
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: tachycardic, S1 and S2 wnl, no m/r/g
ABD: nd, scant b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, 2+ DP/PT pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. No focal deficits
Pertinent Results:
[**2135-5-16**] 06:37PM GLUCOSE-GREATER TH K+-5.1
[**2135-5-16**] 06:20PM GLUCOSE-576* UREA N-24* CREAT-1.7* SODIUM-140
POTASSIUM-5.2* CHLORIDE-91* TOTAL CO2-18* ANION GAP-36*
[**2135-5-16**] 06:20PM ALT(SGPT)-24 AST(SGOT)-21 LD(LDH)-193 ALK
PHOS-110 AMYLASE-52 TOT BILI-1.5
[**2135-5-16**] 06:20PM LIPASE-19
[**2135-5-16**] 06:20PM ALBUMIN-4.9* CALCIUM-11.3* PHOSPHATE-2.8
MAGNESIUM-2.2
[**2135-5-16**] 06:20PM WBC-10.6# RBC-4.41* HGB-13.8* HCT-40.3 MCV-91
MCH-31.3 MCHC-34.3 RDW-12.5
[**2135-5-16**] 06:20PM NEUTS-82* BANDS-0 LYMPHS-11* MONOS-3 EOS-0
BASOS-1 ATYPS-3* METAS-0 MYELOS-0
[**2135-5-16**] 06:20PM PT-12.8 PTT-24.5 INR(PT)-1.1
[**2135-5-17**] 12:15 pm URINE Site: NOT SPECIFIED
**FINAL REPORT [**2135-5-19**]**
URINE CULTURE (Final [**2135-5-19**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Labs on Discharge:
[**2135-5-19**] 05:50AM BLOOD Glucose-111* UreaN-10 Creat-1.1 Na-140
K-4.1 Cl-100 HCO3-29 AnGap-15
Brief Hospital Course:
68 m with type 1 DM, congenital solitary kidney, CRI, HTN,
gastritis, presents with nausea/vomiting and DKA.
# Diabetic Ketoacidosis: The patient presented with
nausea/vomiting and was found to have a glucose 500s with an
anion gap of 31. Unclear precipitant - gastroenteritis,
gastroparesis, other infection though infectious workup has been
negative. The patient was started on an insulin gtt, and as the
AG closed, he was switched to SSI and NPH [**Hospital1 **] , FSBS was
subsequently well controlled. [**Last Name (un) **] was consulted and felt the
patient should change from his prior 75/30 regimen to the above
in an effort to increase his compliance around variable po
intake. He will see the NP at [**Last Name (un) **] Center the day following
discharge and a follow up appointment has been scheduled with a
[**Last Name (un) **] Fellow in the near future. By the time of discharge the
patient was tolerating a regular diet with BG in the low 100s.
# Acute Kidney Injury on CKD: Baseline chronic kidney disease
with a creatinine of 1.2 - 1.3. Admission Cre 1.7, likely
prerenal due to volume depletion from poor PO intake and
vomiting. Cr below baseline at 1.1 after hydration. Taking POs
without difficulty.
# Nausea/Vomiting: History of persistent nausea and vomiting
despite normal gastric emptying study ([**3-11**]). Recently treated
for H. Pylori. Likely secondary to gastritis, pt completed h.
pylori tx but did not continue PPI after, also possible viral
gastroenteritis vs gastroparesis (despite negative gastric
emptying study). Continued PPI and metoclopramide for nausea
vomiting and gastritis and discharged on omeprazole.
# Hypertension: Will restart home dose [**Last Name (un) **] now that renal
failure resolved.
# Hyperlipidemia: [**Last Name (un) 7396**] and ASA.
# Radiculopathy: Renally-dosed Neurontin.
Medications on Admission:
1. Valsartan 160 mg daily
2. Rosuvastatin 80 mg daily
3. Aspirin 81 mg daily
4. Gabapentin 600 mg tid
7. Reglan 10mg tid with meals
8. Humalog Mix 75-25 17 u AM, 17 u PM
9. Humalog 100 sliding scale per carb counts
Discharge Medications:
1. Neurontin 600 mg Tablet Sig: Two (2) Tablet PO three times a
day.
2. Rosuvastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day.
3. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous twice a day.
Disp:*5 vials* Refills:*6*
4. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous four times a day: Per sliding scale.
Disp:*3 vials* Refills:*5*
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day.
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Humalog sliding scale
Please use attached sliding scale, checking your FS four times
daily
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
DM Type I
gastritis
Discharge Condition:
stable
Discharge Instructions:
You were admitted with DKA that responded to IV fluids and
insulin. You must be diligent about checking your blood glucose
regularly. We have also changed your insulin regimen. Please
call your PCP or return to the ER if you develop any further
nausea, vomiting, fevers or new symptoms.
Followup Instructions:
[**Last Name (un) **] Nurse educator, [**Last Name (un) **] Center [**5-20**] 10:00AM
[**Last Name (un) **] fellow [**5-30**] at 3:00 PM
Provider: [**Name10 (NameIs) 1089**] [**Name11 (NameIs) 1090**], MD Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2135-6-2**]
3:10
Please call Dr.[**Name (NI) 20819**] office at [**Telephone/Fax (1) 2393**] for a follow
up appointment in [**3-7**] weeks. At that time you can discuss
restarting your ASA.
ICD9 Codes: 5849, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4327
} | Medical Text: Admission Date: [**2112-10-6**] Discharge Date: [**2112-10-14**]
Date of Birth: [**2055-4-7**] Sex: F
Service: SURGERY
Allergies:
Ativan
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
[**2112-10-10**] Thoracic Endovascular Aortic Aneurysm Repair
History of Present Illness:
HPI: 57F heavy smoker with recent admission [**2112-10-1**] - [**2112-10-3**]
with
chest and abdominal pain and odynophagia who was found to have
circumferential mural thrombus in the supra-renal aorta on cross
sectional imaging. At that time the aortic pathology was though
to be chronic. Ultimately, her pain resolved with the initiation
of a PPI and GI cocktail, and was discharged home after a 3 day
hospital stay. On [**10-6**] she again presented to an OSH with
abdominal pain where a CT abdomen was done which showed an
aortic
dissection. She was emergently transferred to [**Hospital1 18**] where a CTA
of the torso confirmed an aortic dissection of the descending
thoracic aorta (at the level of the left pulmonary vein) to just
below the takeoff of the celiac. At the time of presentation to
[**Hospital1 18**] she was not complaining of any abdominal pain and her
vascular exam was unchanged (palpable bilateral upper and lower
extremity pulses).
.
Past Medical History:
Sinusitis
Past Surgical History:
Lap CCY, Tubal Ligation
Social History:
Married to retired police officer, 5 children. Current [**1-25**] PPD
smoker with > 30 yr smoking history. No alcohol or IVDA.
Family History:
89yo father with CHF
Physical Exam:
Physical Exam:
Alert and oriented x 3
VS:BP 110' 70's HR 70-80's RR stable / AF
Carotids: 2+, no bruits or JVD
COR; S1 S2
Resp: Lungs clear
Abd: Soft, non tender / obese / (+ BM)
Ext: Pulses: palpable DP /PT bilaterally /Feet warm, well
perfused. No open areas
Incisions: CDI
Wounds: Left Right groin puncture site: Dressing clean dry and
intact. Soft, no hematoma or ecchymosis
Lumbar drian site intact / no drainage / no fluctuance
Pertinent Results:
[**2112-10-6**] PORTABLE CHEST
FINDINGS: The heart size is within normal limits. The
mediastinal contours are prominent. The lungs are clear of
consolidation, although there is minimal bibasilar atelectasis.
There is prominence of the central pulmonary vasculature as
well. There is no large pleural effusion or pneumothorax.
IMPRESSION: Mediastinal prominence may represent an unfolded
aorta, although correlation with subsequent torso CTA performed
on the same date is recommended; minimal pulmonary vascular
congestion and bibasilar atelectasis.
[**2112-10-6**] ct chest
CT OF THE CHEST WITH CONTRAST: The thyroid gland is normal and
symmetric in appearance. The trachea and central airways are
patent to the segmental level.
Extensive emphysema is seen throughout the upper lungs.
Bibasilar atelectasis is noted.
The esophagus is normal. There is no axillary, mediastinal, or
hilar
lymphadenopathy.
A small amount of pericardial fluid in the superior recess is of
relative low attenuation but slightly above that of simple fluid
(20-25 [**Doctor Last Name **]). Coronary calcification is noted.
CT OF THE ABDOMEN WITH CONTRAST: The liver is normal in
attenuation without focal lesion or intra- or extra-hepatic
biliary ductal dilatation. The gallbladder is surgically
absent. The CBD is mildly prominent, compatible with
post-cholecystectomy state, measuring 11 mm, probably due to
prior cholecystectomy. The pancreas, spleen, and right adrenal
gland are normal.
A 9 mm hypodensity in the left adrenal gland (2:99) is
indeterminate on this study but unchanged. A 6 mm hypodense
focus in the interpolar region of the right kidney is too small
to characterize. There is no hydronephrosis.
The stomach, small and large bowel appear unremarkable with the
exception of sigmoid diverticula without active inflammatory
changes. A fat-containing ventral hernia is noted. There is no
mesenteric or retroperitoneal adenopathy. There is no free air
or free fluid in the abdomen.
CT OF THE PELVIS WITH CONTRAST: The bladder is densely filled
with contrast. From the prior study, the uterus and ovaries are
unremarkable. The rectum is normal. There is no pelvic or
inguinal adenopathy. There is no free pelvic fluid.
OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion
concerning for osseous malignancy. Minimal multilevel
degenerative changes are seen in the spine.
CTA: Extensive high density thickening of the aortic wall
involving the
descending aorta, beginning at the level of the left subclavian
artery and
extending to the level just below the renal arteries is similar
or slightly progressed from the previous examination of [**9-30**] and
compatible with intramural hematoma. A new frank type B
dissection flap across the lumen begins at the level of the left
pulmonary vein (2:47) and extends just to the level just beyond
the celiac artery. The celiac artery appears to fill off the
false lumen, with the remainder of the intra-abdominal arteries
filling off the true lumen. Minimal intramural hematoma
involves the proximal superior mesenteric artery. Multiple
areas of intramural contrast extravasation and/or ulceration are
new along the upper descending aorta within the intramural
hematoma, but above formation of the flap (2:25, 2:39, 2:38 and
2:101). There are ulcerating Atherosclerotic plaques and patchy
calcification along the lower
descending thoracic aorta.
Just beyond the origin of the left common carotid and left
subclavian there is focal irregularity (2:6 and 2:5), which are
likely related to plaque at a site of vessel tortuosity.
Axial measurements of the aortic lumen measure up to 35 x 31 mm
in axial
dimensions along the proximal descending aorta. Along the upper
ascending
aorta measurements up to 37 x 34 mm correspond to slight
ectasia.
An aortic aneurysm is seen (2:139) at the level of the inferior
mesenteric
artery takeoff, measuring 2.7 cm, distinct from the dissection
and consistent with an incidental finding.
BONES: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. Type B aortic dissection extending from the level of the
left pulmonary vein to just beyond the celiac artery with the
celiac artery filling off the false lumen. Minimal fluid in the
superior pericardial recess is mildly hyperdense, so a
hemorrhagic component is possible although apparent measured
increase in attenuation may be technical in etiology.
2. Distal infrarenal aortic aneurysm just above the [**Female First Name (un) 899**] takeoff
measuring 2.7 cm; attention in follow-up imaging is recommended
for surveillance.
3. Indeterminate 9 mm hypodense left adrenal lesion, but most
likely benign, although not fully characterized. Attention in
follow-up imaging surveillance is recommended; alternatively if
further characterization is desired at this time or before
follow-up imaging of the dissection, dedicated CT or MR protocol
could be considered.
4. Diverticulosis without evidence of active inflammation.
5. Coronary artery calcifications.
Preliminary findings were discussed with Dr. [**Last Name (STitle) **] by Dr.
[**First Name (STitle) **] in person at 2231 at the time of discovery on [**2112-10-6**].
[**2112-10-7**] CT HEAD
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or infarction. The ventricles and sulci are normal in
size and configuration. The basal cisterns appear patent and
there is preservation of [**Doctor Last Name 352**]-white matter differentiation.
No fracture is identified. The visualized paranasal sinuses,
mastoid air
cells and middle ear cavities are clear. The globes are
unremarkable.
CONCLUSION: No evidence of hemorrhage, mass, mass effect, or
acute
infarction.
[**2112-10-10**]: CT CHEST/ ABD/ PELVIS :
FINDINGS:
CT CHEST: The visualized portion of the thyroid is unremarkable
in
appearance. There are multiple subcentimeter nodules in
bilateral breasts. The trachea is midline. The airways are
patent to the subsegmental level.
There is severe centrilobular emphysema throughout the lungs
with apical
predilection. There is bibasilar atelectasis. There are no
effusions,
nodules or pneumothorax.
There is no supraclavicular, axillary, mediastinal or hilar
lymphadenopathy.
Pericardial fluid is again noted, but is slightly decreased in
amount from previous examination. Coronary artery calcification
is noted. The heart and great vessels are otherwise
unremarkable in appearance.
CT ABDOMEN: The liver is homogeneous in appearance with no
focal lesions
without intrahepatic biliary duct dilatation. The gallbladder
is surgically absent and the CBD is prominent measuring 1.2 cm
in diameter compatible with post-cholecystectomy. The pancreas
and spleen are unremarkable in appearance. The right adrenal
gland is unremarkable in appearance. There is a stable 9-mm
hypodensity in the left adrenal gland, likely representing
adenoma. There is a stable 6-mm hypodensity in the interpolar
region of the right kidney that is too small to fully
characterize by CT examination, but likely representing a simple
cyst. Otherwise, bilateral kidneys present symmetric uptake and
excretion of contrast without hydronephrosis, stones, worrisome
lesions or perinephric abnormalities.
The stomach, duodenum and small bowel are unremarkable in
appearance with no focal wall thickening or obstruction noted.
There are scattered diverticula throughout the large intestine,
predominantly located in the sigmoid colon. There is no
mesenteric or retroperitoneal lymphadenopathy. There is no free
air or ascites within the abdomen. There is a fat-containing
ventral hernia as well as a small umbilical hernia.
CT PELVIS: The uterus and bilateral ovaries are unremarkable in
appearance. There is a small amount of air within the bladder,
compatible with recent instrumentation. There is no pelvic or
inguinal lymphadenopathy. There is no free pelvic fluid.
OSSEOUS STRUCTURES: Degenerative changes are noted throughout
the spine. There are no focal lesions in the visualized osseous
structures concerning for malignancy.
CTA: Again noted is extensive high-density thickening of the
aortic wall
beginning proximally at the level of the left subclavian artery
and extending to just inferior of the renal arteries as well as
dissection flap, beginning at the level of the left pulmonary
vein and extending just beyond the celiac artery. The extent of
dissection is stable; however, there is increased amount of
hematoma within the false lumen at the level of the celiac
artery which is narrowing the false lumen and presenting mass
effect on the true lumen. Despite the increased mass effect,
the celiac artery has preserved flow and is filling off of the
false lumen. The SMA and [**Female First Name (un) 899**] are patent, receiving flow from
the true lumen. There are multiple areas of descending aorta
ulceration as well as atherosclerotic plaques, which are stable
from previous examination. Maximum dimensions of the aortic
lumen within the ascending aorta measures 4.0 x 3.7 cm and in
the descending aorta 3.5 x 3.5 cm, representing slight ectasia.
Again noted is a focal aortic aneurysm at
the level of the [**Female First Name (un) 899**] measuring 2.7 cm.
IMPRESSION:
1. Type B aortic dissection extending from the level of the
left pulmonary vein to just beyond the celiac artery with the
celiac artery filling from the false lumen. Extent of
dissection is unchanged; however, there is increased amount of
clot in the false lumen, narrowing the false lumen, presenting
greater mass effect on the true lumen. However, flow is
preserved.
2. Distal infrarenal aortic aneurysm at the level of the [**Female First Name (un) 899**].
3. 9 mm hypodense lesion in the left adrenal gland, most likely
representing an adenoma. Attention on followup imaging is
recommended.
4. Diverticulosis.
5. Coronary artery calcifications as well as multiple
ulcerative
atherosclerotic plaques within the aorta.
6. Fat-containing umbilical as well as ventral hernia.
7. Small right interpolar renal hypodensity too small to fully
characterize by CT, but likely representing a simple cyst.
8. Extensive emphysema.
9. Small focus of air within the bladder that could represent
recent
instrumentation or infection. Clinical correlation is
recommended.
[**2112-10-11**] CT Chest abd pelvis
Final Report INDICATION: 57-year-old woman with known type B
dissection status post repair presents with epigastric pain,
evaluate for flow within the SMA and celiac.
COMPARISON: CTA torso [**2112-10-10**].
TECHNIQUE: Helical axial MDCT images were obtained from the
chest, abdomen and pelvis after the administration of IV
contrast in the arterial phase. Multiplanar reformatted images
were obtained in the sagittal and coronal planes.
DOSE REPORT: Total DLP [**2074**].98 mGy-cm.
FINDINGS:
CT OF THE CHEST: The visualized portion of the thyroid is
unremarkable. The trachea is midline. The airways are patent to
the subsegmental levels. Severe emphysematic changes are noted
in bilateral lungs. Bilateral pleural effusions are new since
most recent prior examination. There is adjacent opacification
which most likely represents compressive atelectasis; however,
infectious process cannot be completely excluded.
There is atherosclerotic calcification involving the coronary
vessels. There is no evidence of pericardial effusion.
Mediastinal, axillary and hilar lymph nodes do not meet CT size
criteria for pathology.
The heart and great vessels are otherwise unremarkable in
appearance.
CT OF THE ABDOMEN: The liver is homogenous in appearance
without evidence of focal liver lesions. There is no evidence
of intrahepatic biliary dilation. The patient is status post
cholecystectomy. The spleen, pancreas and right adrenal gland
are unremarkable. 9 mm left adrenal nodule is unchanged from the
prior examination. Bilateral kidneys show no evidence of
hydronephrosis.
Retroperitoneal and mesenteric lymph nodes do not meet CT size
criteria for pathology. There is no free air or free fluid
within the abdomen.
CT OF THE PELVIS: The bladder contains a Foley. Air within the
bladder
likely represents instrumentation. The uterus appears
unremarkable. There is evidence of sigmoid and descending colon
diverticulosis without evidence of diverticulitis.
Bilateral pelvic side wall lymph nodes do not meet CT size
criteria for
pathology. Small fat-containing ventral hernia is noted.
CTA: Patient is status post repair of type B dissection with
EVAR stent graft extending from the level of the left subclavian
artery and to just inferior to the origin of the renal arteries.
The dissection appears to extend into the celiac
trunk(301:104); it is difficult to say if this was present on
the prior study. Both sides of the dissection flap, however
appear perfused homogenously with patent celiac trunk. The SMA
and [**Female First Name (un) 899**] are patent. Again noted are areas of aortic ulcerations
as well as atherosclerotic plaques stable from the prior
examination. Maximum dimension of the aortic lumen within the
ascending aorta measures 2.8 x 3.6 cm and the 3.1 x 3.1 cm
within the descending aorta. Again
noted is a focal aortic aneurysmal morphology at the level of
the [**Female First Name (un) 899**]
measuring 2.7 cm (3:140 and 602b:47).
3D reformations generated in the imaging lab of the aorta and
endovascular stent include 3D MIP and VR rotations, curved
reformatted images, and 3D measurements (below). These were
reviewed in the interpretation of this examination.
Measurements:
Aortic valve: 3.8 cm
Aortic cusps: 4.4 cm
Ascending aorta/[**MD Number(3) 26547**]: 4.0 cm
Ascending aorta/Proximal arch: 3.6 cm
Proximal descending thoracic aorta/Distal arch (stent lumen +
aorta wall): 2.8 cm Maximum, descending thoracic aorta (stent
lumen + aorta wall): 5.0 cm Abdominal aorta, celiac trunk (stent
lumen + aorta wall): 2.8 cm Abdominal aorta, SMA (stent lumen +
aorta wall): 2.8 cm
IMPRESSION:
1. Status post repair of type B aortic dissection with EVAR
stent graft
extending from the level of the left subclavian artery to just
below the
origin of the renal arteries.
2. Distal infrarenal aortic aneurysm at the level of the [**Female First Name (un) 899**],
unchanged.
3. Dissection appears to extend into the celiac trunk. Both
sides of the
dissection flap demonstrate homogenous perfusion with patency of
celiac trunk SMA and [**Female First Name (un) 899**].
4. Unchanged 9 mm right adrenal nodule.
5. Bilateral pleural effusions with adjacent compressive
atelectasis new from the prior exam.
6. Ventral fat containing hernia.
[**2112-10-13**] CXR
Final Report
CHEST RADIOGRAPH
INDICATION: Fever, evaluation for pneumothorax and line
position.
FINDINGS: As compared to the previous radiograph from [**10-12**], [**2112**], the venous introduction sheath on the right has been
changed to a right internal jugular vein catheter. The signs
indicative of bilateral parenchymal opacities at the lung bases,
most likely fluid overload, have decreased in severity. The
size of the cardiac silhouette, including the aortic stent
graft, is unchanged.
Brief Hospital Course:
On [**10-6**] the pt presented to an OSH with abdominal pain where a
CT abdomen was done which showed an aortic dissection. She was
transferred to [**Hospital1 18**] and had a confirmatory CTA. She was
admitted to the ICU for blood pressure control and serial
abdominal exams.
At the time of presentation to [**Hospital1 18**] she was not complaining of
any abdominal pain and her vascular exam was unchanged (palpable
bilateral upper and lower extremity pulses). She was agitated
while in the ICU and received Ativan to which she became
delerious. She was seen by psychiatry for acute delerium and
they asked to hold ativan and to use Hadol for any agitation.
She remained stable and the plan was to manage her medially.
She was transferred to the VICU. On the morning of [**2112-10-10**] she
was complaining of upper abdominal pain and retro sternal pain.
Her VS were stable at that pt as was her EKG. On exam she
looked slightly pale without diaphoresis. Her distal pulses
were all palpable at that time. She was sent for stat CTA and
then sent to prep and hold where she was consented for TEVAR.
It was noted on the CT that she had extension of her dissection
with possible compressive thrombus.
She underwent the procedure without complication. She was
recovered in the VICU and did well. Her diet and activity were
advanced. She was voiding freely and tolerating an oral diet.
She ambulated without assistance. Her follow up appts were
scheduled. She was councelled to follow up with her PCP within
two weeks.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from last discharge.
1. Omeprazole 40 mg PO DAILY
2. Donnatol 10 mL PO BID:PRN abdominal pain
3. Atorvastatin 20 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. DiCYCLOmine 10 mg PO QID
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. DiCYCLOmine 10 mg PO QID
4. Omeprazole 40 mg PO DAILY
5. Acetaminophen-Caff-Butalbital [**1-25**] TAB PO Q6H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg [**1-25**]
tablet(s) by mouth q 4 hours Disp #*30 Tablet Refills:*0
6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*14 Tablet Refills:*0
7. Metoprolol Tartrate 12.5 mg PO BID
hold for SBP < 100, HR < 60
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*0
8. Donnatol 10 mL PO BID:PRN abdominal pain
Discharge Disposition:
Home
Discharge Diagnosis:
Aortic Dissection / Type B
Intramural Aortic Thrombus
complicated urinary tract infection
delerium / acute / medication reaction
headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a Type B Aortic
Dissection
You underwent a Envovascular repair of this aneurysm without
complication. You were found to have a urinary tract infection
and were started on antibiotics for this. You also had a
reaction to ATIVAN that caused you to be very confused - This is
now listed in our system as an allergy to avoid this reaction
again.
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
MEDICATIONS:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT AT HOME:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-26**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: [**Telephone/Fax (1) 90383**]
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Dr. [**Last Name (STitle) **] would like to see you in the office in one
months time - an appointment has been made for you - if you need
to change the date/time, please call the office at [**Telephone/Fax (1) **]
thank you
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 590**] Date/Time:[**2112-11-14**] 1:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2112-11-14**] 2:45
As always, please call your primary care physician for an
appointment to be seen in the next two weeks to inform and
update them of your care. I attempted to make an appointment for
you but the office was closed. This is very improtant that you
follow up.
Name: ATTAR,[**Female First Name (un) **]
Address: [**Last Name (un) 28705**], [**Location (un) 28706**],[**Numeric Identifier 28707**]
Phone: [**Telephone/Fax (1) 24306**]
Fax: [**Telephone/Fax (1) 75010**]
Completed by:[**2112-10-14**]
ICD9 Codes: 5990, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4328
} | Medical Text: Admission Date: [**2169-4-6**] Discharge Date: [**2169-4-11**]
Date of Birth: [**2107-12-13**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Demerol / Donnatal / Pollen Extracts / Latex
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Back pain, L>R leg pain
Major Surgical or Invasive Procedure:
POSTERIOR LUMBAR LAMINECTOMY AND FUSION T12-S1
History of Present Illness:
Ms. [**Known lastname **] is a 61-year-old female with degenerative lumbar
scoliosis
and spinal stenosis associated with the syndrome of neurogenic
claudication.
She continues to have difficulty with walking. She is not able
to walk more than half a block before she is forced to stop and
rest. This has interfered
significantly with her activities of daily living. She is
unable
to perform one of her favored avocations, which is hiking in the
[**Doctor Last Name 6641**] for this reason. She has had multimodal and prolonged
course of conservative care consisting of physical therapy,
medications, epidural steroid injections, activity
modifications,
and chiropractic care. Her syndrome has been refractory to
these
interventions.
Past Medical History:
Past medical history is significant for mild hypertension,
history of seasonal allergies, non-insulin-dependent diabetes
mellitus, her last hemoglobin A1c was 6.0, and a history of
depression and a mild bipolar disorder.
Social History:
Social History: The patient is not currently working, was
previously occupied as a registered nurse. She does not smoke
cigarettes, but did smoke formally for 30 years two packs per
day. She does not consume alcohol.
Family History:
Non-contributory
Physical Exam:
AVSS
Well appearing, NAD, comfortable
BUE: SILT C5-T1 dermatomal distributions
BUE: [**3-21**] [**Doctor First Name **]/Tri/Bic/WE/WF/FF/IO
BUE: tone normal, negative [**Doctor Last Name 937**], 2+ symmetric DTR
bic/bra/tri
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: [**3-21**] IP/Qu/HS/TA/GS/[**Last Name (un) 938**]/FHL/Per
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
Pertinent Results:
[**2169-4-8**] 03:37AM BLOOD WBC-10.5 RBC-3.60* Hgb-10.6* Hct-30.4*
MCV-85 MCH-29.4 MCHC-34.7 RDW-14.0 Plt Ct-242
[**2169-4-9**] 06:05AM BLOOD Hct-27.9*
[**2169-4-8**] 03:37AM BLOOD Glucose-157* UreaN-7 Creat-0.5 Na-137
K-3.5 Cl-103 HCO3-26 AnGap-12
[**2169-4-8**] 03:37AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.1
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service
on [**2169-4-6**] and taken to the Operating Room for the above
procedures performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#3. Physical therapy
was consulted for mobilization OOB to ambulate. Hospital course
was otherwise unremarkable. On the day of discharge the patient
was afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet.
Medications on Admission:
AMITRIPTYLINE - (Prescribed by Other Provider) - Dosage
uncertain
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
CELECOXIB [CELEBREX] - (Prescribed by Other Provider) - 200 mg
Capsule - 1 (One) Capsule(s) by mouth twice a day
ESTRADIOL [VIVELLE] - (Prescribed by Other Provider) - 0.05
mg/24 hour Patch Semiweekly -
EXENATIDE [BYETTA] - (Prescribed by Other Provider) - 10
mcg/0.04 mL per dose Pen Injector - twice a day
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
LAMOTRIGINE [LAMICTAL] - (Prescribed by Other Provider) - 100
mg
Tablet - 0.5 (One half) Tablet(s) by mouth once a day
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 1
(One) Tablet(s) by mouth twice a day
OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg
Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth
once
a day
PAROXETINE HCL [PAXIL] - (Prescribed by Other Provider) - 40 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
POTASSIUM CHLORIDE [KLOR-CON M20] - (Prescribed by Other
Provider) - 20 mEq Tab Sust.Rel. Particle/Crystal - 1 (One)
Tab(s) by mouth twice a day
PROPOXYPHENE N-ACETAMINOPHEN [DARVOCET-N 100] - (Prescribed by
Other Provider) - 100 mg-650 mg Tablet - 1 (One) Tablet(s) by
mouth at bedtime
TRAMADOL [ULTRAM] - (Prescribed by Other Provider) - 50 mg
Tablet - 1 (One) Tablet(s) by mouth three times a day as needed
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - Dosage uncertain
GUAIFENESIN - (Prescribed by Other Provider) - Dosage uncertain
MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth
once a day
Discharge Medications:
1. Amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal EVERY OTHER DAY (Every Other Day).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
4. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QSUTUTHSA ().
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
8. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Glimepiride 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Estradiol 0.05 mg/24 hr Patch Semiweekly Sig: One (1) Patch
Semiweekly Transdermal 2x/week ().
12. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*40 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Degenerative Scoliosis
Discharge Condition:
Stable
Discharge Instructions:
Discharge InstructionsYou have undergone the following
operation: Lumbar Laminectomy and Fusiion
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking
around.- Rehabilitation/ Physical Therapy: o 2-3 times a day you
should go for a walk for 15-30 minutes as part of your recovery.
You can walk as much as you can tolerate. o Limit any kind of
lifting.- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.- Brace: You may have been given a brace.
This brace is to be worn when you are walking. You may take it
off when sitting in a chair or while lying in bed.- Wound Care:
Remove the dressing in 2 days. If the incision is draining
cover it with a new sterile dressing. If it is dry then you can
leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call
the office. - You should resume taking your normal home
medications.- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.-
Followup Instructions:
Follow up:
oPlease Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.oAt the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.oWe will then see you at 6 weeks from the
day of the operation and at that time release you to full
activity.Please call the office if you have a fever>101.5
degrees Fahrenheit and/or drainage from your wound.
You have a prescheduled follow-up appointment with ORTHO
XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] on Date/Time:[**2169-4-24**] at2:10
you have a prescheduled follow-up appointment with Dr. [**Name8 (MD) 32783**],
MD Phone:[**Telephone/Fax (1) 3736**] on Date/Time:[**2169-4-24**] at 2:30
Completed by:[**2169-4-11**]
ICD9 Codes: 4019, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4329
} | Medical Text: Admission Date: [**2170-8-16**] Discharge Date: [**2170-8-22**]
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 1642**]
Chief Complaint:
Vomiting & Dark Diarrhea
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
This is a 84 year old male with a history of CAD (s/p cypher to
RCA in [**2166**]), recent AAA repair in [**6-14**], HTN, hyperlipidemia,
COPD, PUD who presents from his NH on [**8-16**] with vomitting,
abdominal pain and dark stools. He notes that several days ago,
he began to have nausea, vomitting, loose stools and abdominal
pain. Due to these symptoms he has had limited PO intake. He was
brought to the ED due to persistent loose stools and abdominal
pain.
.
In the ED: VS 97.2 102 101/66 20 100% RA. He had a CTA that
showed a duodenitis and absence of dissection. He was given
Cipro 400mg IV x1, Flagyl 500mg IV x1 given for duodenitis. He
was initially admitted with a hct to 30, and then the following
AM noted to have hct to 22. He was given 1 unit pRBC for this
and transfered to the MICU, though he was hemodynamically stable
throughout. Plan was for patient to undergo an EGD, but this
procedure was held due to a coagulopathy with an INR to 2.3. He
was given 5mg PO vitamin K and 2 units of FFP (INR down to 1.6).
During his blood product transfusion, he developed chest pain
that was left sided, and associated with mild SOB. His ECG
revealed inferolateral ST depressions. His chest pain
self-resolved. Troponins trended from 0.04 to peak of 0.11, most
recently down to 0.1 so no longer being followed. CKs and CK-MB
have been flat throughout. Thought to be consistent with demand
ischemia. Cardiology was consulted and recommended conservative
management with holding ASA and continuing BB.
.
In the MICU, patient received a total of 6 units prbcs, and
eventually hematocrit began to stabilize and increase over the
last 24 hours. Additionally became hypertensive, currently on
BB, started on hydralazine for easy on/off if he develops
hemodynamically significant re-bleed. At this time, patient is
transfered to the medicine floor with plan for EGD in the
morning pending stable INR (1.4 yesterday).
.
At this time, patient is feeling well. No BM for several days,
feels he has more energy. No nausea or vomiting. His only
complaint is his chronic arthritis for which he requests
tylenol. No fevers, chills, abdominal pain, chest pain,
shortness of breath.
Past Medical History:
Past Medical History:
1. Coronary artery disease, status post MI in [**2166**]. 2 vessel
disease s/p successful PCI to mid-RCA, EHCO: EF 45% with no
significant valvular disease ([**2169**])
2. Hypertension.
3. Hyperlipidemia.
4. Paroxysmal atrial fibrillation.
5. History of abdominal aortic aneurysm.
6. History of deep venous thrombosis.
7. Chronic obstructive pulmonary disease: FEV1 70%, FEV/FVC 79%
[**2166**]
8. Peptic ulcer disease.
9. History of esophagitis.
10. History of gastrointestinal bleeding.
11. Diverticulosis.
12. Renal insufficiency.
13. Lumbosacral radiculopathy.
14. Depression.
15. History of hip fracture.
.
PAST SURGICAL HISTORY:
1. Status post stent graft surgery for abdominal aortic
aneurysm.
2. Status post [**Location (un) 260**] filter placement for history of DVT.
3. Status post hip replacement.
4. Status post AAA repair.
Social History:
Lived with wife of 60 years at home, but currently at rehab.
Supportive family with 1 daughter, 2 granddaughter and
great-granddaughters. Retired [**Name2 (NI) **] professor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 532**]. Denies
tobacco, etoh, drugs. At home, he uses a walker for ambulation.
Family History:
noncontributory
Physical Exam:
VS 98.1 134/82 72 18 100%@RA
Gen: Awake, reluctantly converstant, admits being confused
HEENT: Dry oropharynx, CNII-XII otherwise intact
Pulm: B CTA
CV: S1& S2 appreciated without murmur
Abd: Non tender to palpation, non distended, BS present. Old
bruising on left abdomen. Several surgical scars.
Ext: No edema, 2+ distal pulses
Pertinent Results:
[**2170-8-16**] 10:15AM PT-20.5* PTT-30.3 INR(PT)-1.9*
[**2170-8-16**] 10:15AM PLT COUNT-521*
[**2170-8-16**] 10:15AM NEUTS-63.4 LYMPHS-30.4 MONOS-4.1 EOS-0.8
BASOS-1.3
[**2170-8-16**] 10:15AM WBC-10.7 RBC-3.40* HGB-10.1* HCT-30.6* MCV-90
MCH-29.7 MCHC-33.0 RDW-16.6*
[**2170-8-16**] 10:15AM ALBUMIN-3.1* CALCIUM-8.9 PHOSPHATE-2.8
MAGNESIUM-2.2
[**2170-8-16**] 10:15AM CK-MB-NotDone
[**2170-8-16**] 10:15AM cTropnT-0.04*
[**2170-8-16**] 10:15AM LIPASE-16
[**2170-8-16**] 10:15AM ALT(SGPT)-11 AST(SGOT)-24 CK(CPK)-90 ALK
PHOS-51 TOT BILI-0.3
[**2170-8-16**] 10:15AM estGFR-Using this
[**2170-8-16**] 10:15AM GLUCOSE-93 UREA N-53* CREAT-1.7* SODIUM-143
POTASSIUM-5.5* CHLORIDE-112* TOTAL CO2-22 ANION GAP-15
[**2170-8-16**] 10:22AM HGB-10.5* calcHCT-32
[**2170-8-16**] 10:22AM LACTATE-2.1* K+-5.2
[**2170-8-16**] 02:48PM LACTATE-1.3
ECHO:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is infero-lateral hypokinesis. The remaining LV
segments appear hyperdynamic and therefore the overall left
ventricular systolic function is preserved (LVEF = 55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2169-10-18**],
the LVEF has improved.
CTA CAP:
IMPRESSION:
1. No evidence of aortic dissection or endograft leak s/p aortic
aneurysm
endograft repair.
2. Focal thickening in the duodenum with some adjacent fat
stranding,
suggestive of duodenitis.
3. Interval improvement in the left lower lobe consolidation.
4. Air in the bladder. Correlate for recent catheterization.
Otherwise, may represent infection. Correlate with urinalysis.
EGD findings:
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Diffuse continuous moderate inflammation of the mucosa
with no bleeding was noted in the antrum.
Duodenum:
Mucosa: Diffuse continuous marked inflammation of the mucosa
with no bleeding was noted throughout the duodenum.
Excavated Lesions A single cratered non-bleeding 20mm ulcer was
found in the proximal bulb. A small visible vessel was present
in the center of the ulcer. Clipping was attempted, but three
endoquick clips were non-adherent. Some oozing was noted after
the clipping attempt, 4cc of epinephire were injected at the
ulcer border at three separate sites.
Impression: Moderate inflammation in the antrum
Marked inflammation in the duodenum
Ulcer in the proximal bulb
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
# GI Bleed: Patient presented with 4 day history of vomiting
and melena without any PO intake and abdominal pain. On his
first night he displayed no symptoms. The following morning,
pt's INR was found to be 2.3. Hematocrit dropped to 22 from 30.2
EGD Cancelled. 2 U FFP transfused followed by 2 units PRBCs in
preparation for EGD. During administration of 1st unit of blood,
called to bedside for a trigger: Patient had chest pain with ST
Depression in I, II, aVF, V3-6. Resolved with SL Nitroglycerin.
Lipitor 80mg, Lopressor 25mg PO TID restarted. After discussion
with Cardiology & Geriatrics (Primary) 325mg ASA started.
Intermediate Hct drawn after 1.5 Units PRBC administered showing
21.2. At this point the unit was consulted. No blood per rectum,
no hemtatemesis. Patient has no new complaints at this time.
During his ICU admission, the patient received 5 units pRBCs.
Initially, he did not have an appropriate HCT bump, but then he
began to bump appropriately and was hemodynamically stable for
transfer to the floor. He had no further episodes of melena or
chest pain. His cardiac enzymes began to trend downwards. His
HCT goal was greater than 30 given dynamic ECG changes and
likely ischemia. He was then transferred back to the floor
since he remained hemodynamically stable and bumping
appropriately to pRBCs with no further transfusions. EGD done
which showed non-bleeding ulcer in duodenal bulb with visible
vessel that was not able to be clipped. It was injected with
epinephrine. No further bleeding while admitted. H. pylori IgG
was checked and was found to be positive prior to discharge.
Patient was discharged on 2 week course of triple therapy for H.
pylori.
# Pneumonia: Patient admitted with PICC line in place from MSSA
Pneumonia. Nafcillin course completed on [**8-16**], no signs or
symptoms of pneumonia on this admission. PICC line was
discontinued prior to discharge.
# Hypertension: The patient was initially maintained on home
regimen of Amlodipine, Hydralazine and Lopressor until transfer
to the MICU. His lopressor was decreased to 12.5 mg TID given
HR in the 50s on telemetry. His hydralazine was ultimately
decreased to 50mg TID. He was started on Lisinopril for BP
control in the setting of recent MI. BP well-controlled at the
time of discharge.
# Anxiety: The patient was initially maintained on home regimen
of Effexor & Xanax.
# AAA Repair: Assessed and cleared by [**Month/Year (2) **] surgery that
examined the CT and felt there were no issues with the graft.
# Chronic Back pain: The patient continued home Oxycodone 5mg
PO Q4hrs PRN pain and Neurontin 100mg PO BID.
# Stage [**Month/Year (2) 1105**] CKD: The patient's Cr was below baseline of 1.7-2
during admission after fluid administration and low PO intake
over the last few weeks. His baseline Cr 1.7-2, secondary to
hypertension.
# CAD: Patient maintained on home beta blocker and
anti-hypertensives. Home Aspirin was held during the acute
bleed. Otherwise as above. It was also held at the time of
discharge per primary attending until seen by GI given how large
the patient's bleed had been. Restarting this medication should
be discussed with the patiet's primary care physician as an
outpatient.
# Coagulopathy: INR was 2.3 at the time of admission. Improved
with vitamin K, FFP and increased nutrition. Was likely due to
malnutrition and was stable and improved prior to discharge.
# Code Status: Patient request DNR/DNI status with Dr. [**Last Name (STitle) **].
Ordered entered and confirmed [**2170-8-17**].
Medications on Admission:
Simvastatin 20 mg PO Qday
Aspirin 325 mg PO Qday
Pantoprazole 40 mg PO BID
Albuterol 90 mcg/Actuation Aerosol 2 Puff IH Q6H PRN Dyspnea
Alprazolam 1 mg PO QHS
Venlafaxine 225 mg PO Qday
Ferrous Sulfate 325 mg PO Qday
Gabapentin 100 mg PO TID
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO BID
Bisacodyl 10 mg PR QHS:PRN Constipation
Hydralazine 50 mg PO Q6H
Metoprolol Tartrate 25 mg PO TID
Amlodipine 10mg PO Qday
Furosemide 20 mg PO Qday
Oxycodone 5 mg PO Q4h PRN Pain
Nafcillin 2g IV Q6h, completed [**8-16**]
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. 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*
4. Outpatient Lab Work
Please draw CBC and Chemistry panel including Na, K, HCO3, Cl,
BUN, Cr and call into Dr. [**Last Name (STitle) 65810**] at [**Telephone/Fax (1) 719**].
5. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO QPM (once a day (in the
evening)).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO QAM (once a day (in the
morning)).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): please take this while you are taking
oxycodone.
Disp:*60 Capsule(s)* Refills:*2*
11. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
12. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
13. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
15. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
16. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Upper GI bleed
Duodenal ulcer
H. Pylori positive
NSTEMI
Coronary artery disease
Hypertension
Chronic kidney disease
Discharge Condition:
Hemodynamically stable with stable hematocrit
Discharge Instructions:
You were admitted with a GI bleed. You were given blood and had
an upper endoscopy that showed ulcers in your stomach. You were
also found to be H. pylori positive as below. You should take
protonix twice a day to help heal your ulcer and to prevent
additional ulcers from forming. You are also being prescribed
two weeks of two antibiotics to erradicate the H. Pylori. Please
take these as directed.
It is very important that you follow up with the
Gastroenterologist for further evaluation and management.
If you notice an increase in the number of dark stools you are
having, if you notice blood in your stools, or if you develop
chest pain, shortness of breath, abdominal pain, change in your
urinary habits, or any other symptom that is concerning to you,
please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room
immediately.
Several of your medications have been changed:
1. Simvastain: Please take 80mg daily
2. Hydralazine: Please take this three times daily
3. Please do not take aspirin, ibuprofen or other non-steroidal
anti-inflammatory medications until you discuss this with your
gastroenterologist given that these medicines can predispose you
to GI bleeding.
4. You have been started on a medication called Lisinopril for
your hypertension. Please take this as directed.
5. Your Metoprolol dose has changed from 25 mg three times daily
to 12.5 mg three times daily.
6. You are also positive for H. Pylori which is likely causing
your ulcers. You will be treated with two weeks of antibiotics
(amoxicillin and clarithromycin). Please take these as directed.
7. We are holding your Lasix for now. Please discuss restarting
this with your primary care physician.
You should have lab work done this upcoming [**Last Name (Titles) 2974**] which should
be called into your primary care doctor's office.
Followup Instructions:
Please keep the following appointments:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2170-8-30**] 11:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2170-8-30**] 12:15
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2170-10-22**]
3:20
Gastroenterology:
Provider: [**Name10 (NameIs) 16385**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2170-9-12**] 2:00
Primary care:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2170-8-24**] 10:30
ICD9 Codes: 5859, 2724, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4330
} | Medical Text: Admission Date: [**2173-5-11**] Discharge Date: [**2173-5-15**]
Date of Birth: [**2126-9-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Amoxicillin / Erythromycin Base / Ultram / Sulfa
(Sulfonamides)
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
MVR
History of Present Illness:
46 yo male with known MVR, with worsening of DOE and
palpitations. ECHO - severe MR
Past Medical History:
PMHx: MVP, hyperlipidemia, HTN, BPH, GERD, neuropathic pain, R
knee surgery, sinus surgery x2, Lap chole, discectomy L5/S1
Social History:
Active drinker
smoking 30 yr pack history
Family History:
Family with cad less then 55 y.o
Physical Exam:
a/o
nad
grossly intact
supple
neg bruits
cta
rrr
pos bs
palp distal pulses
Pertinent Results:
[**2173-5-14**] 05:45AM BLOOD
WBC-8.0 RBC-3.27* Hgb-9.6* Hct-26.7* MCV-82 MCH-29.3 MCHC-35.9*
RDW-13.6 Plt Ct-161
[**2173-5-14**] 05:45AM
BLOOD Plt Ct-161
[**2173-5-14**] 05:45AM BLOOD
Glucose-120* UreaN-20 Creat-1.3* Na-133 K-3.9 Cl-98 HCO3-28
AnGap-11
[**2173-5-12**] 02:32AM
BLOOD Calcium-8.0* Phos-3.1 Mg-1.9
[**2173-5-13**] 09:40PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2173-5-13**] 11:20 AM
CHEST (PORTABLE AP)
Reason: ? ptx s/p CT removal please do at 1130am
FINDINGS: A right-sided chest tube has been removed without
pneumothorax identified. NG tube and endotracheal tube have been
removed. As a result, there is discoid atelectasis at the left
lung base with low lung volumes. Median sternotomy wires and
mitral valve prosthesis remain stable. No effusion or
pneumothorax.
IMPRESSION: Left lower lobe discoid atelectasis without
pneumothorax.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 15815**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 15816**] (Complete)
Done
[**2173-5-11**] at 10:22:40 AM
Test Information
Date/Time: [**2173-5-11**] at 10:22 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: aw1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.5 cm
Left Ventricle - Fractional Shortening: *0.22 >= 0.29
Left Ventricle - Ejection Fraction: 50% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Low normal LVEF. [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Normal descending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Myxomatous mitral valve leaflets. Moderate/severe
MVP. Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2.Overall left ventricular systolic function is low normal (LVEF
50-55%). [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.]
3. Right ventricular chamber size and free wall motion are
normal.
4.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
5.The mitral valve leaflets are myxomatous. Severe (4+) mitral
regurgitation is seen. There is severe prolapse of P2.
6.Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2173-5-11**]
at 745 am.
Post Bypass
1. Patient is being A paced.
2. Biventricular systolic function is unchanged.
3. Annuloplasty ring seen in the mitral position. Trace mitral
regurgitation present. Mean gradient across the mitral valve is
5 mm Hg.
4. Aorta intact post decannulation.
Brief Hospital Course:
pt admitted
pre-op'd for valve repair
underwent surgery without complications
transfered to the CVICU in stable condition
extubated POD # 1
Ct removed POD # 2 / Foley removed POD # 2 - urinating with out
difficulty
Diet advanced
PW removed POD # 3
PT consult
stable for Dc
Diuresed throught the the hospital course
Medications on Admission:
[**Last Name (un) 1724**] Lisinopril 40 qd, Minipress 1 [**Hospital1 **], Genfibrozil 600 [**Hospital1 **],
Omeprazole 20 daily, Buspar 15 [**Hospital1 **], Amitriptyline 10 qam,
Neurontin 600 [**Hospital1 **]
Discharge Medications:
1. Prazosin 1 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
Disp:*60 Capsule(s)* Refills:*2*
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed: prn.
Disp:*50 Tablet(s)* Refills:*0*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Buspirone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. 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*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
.partners [**Name (NI) **]
Discharge Diagnosis:
MVP
hyperlipidemia
HTN
BPH
GERD
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:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 15817**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 15818**] Follow-up appointment
should be in 2 weeks
Completed by:[**2173-5-15**]
ICD9 Codes: 4240, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4331
} | Medical Text: Admission Date: [**2128-12-22**] Discharge Date: [**2128-12-28**]
Date of Birth: [**2128-12-22**] Sex: F
Service: Neonatology
Dictating for: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D.
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 30106**] [**Name2 (NI) **] is a
1715-gram baby girl [**Name2 (NI) **] at 31 and 6/7 weeks gestational age
to a 36-year-old gravida 1, para 0 (to 1), mother with
prenatal screens of maternal blood type B positive, antibody
negative, group B strep status positive, hepatitis B surface
antigen negative, and rapid plasma reagin was nonreactive.
Past medical history of mother was remarkable for myomectomy
for fibroids. There was a normal amniocentesis for both
twins. This twin had a prenatal ultrasound suggestive of
clubbed foot which was not confirmed postpartum.
The prenatal course was remarkable for spontaneous
dichorionic-diamniotic twin with concordant growth and
diet-controlled gestational diabetes. There was prior
preterm labor treated with magnesium sulfate and bed rest,
and the mother was betamethasone complete on [**2128-11-23**].
There was premature rupture of membranes at nine hours prior
to delivery. The mother received two doses of terbutaline
and was started on intrapartum penicillin. A cesarean
section was performed for mild presentation and changing
cervix. This twin emerged with a vigorous cry and had Apgar
scores were 7 at one minute of age and 8 at five minutes of
age.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
was notable for a birth weight of 1715 grams (50th
percentile), head circumference of 29.5 cm (50th percentile),
and a length of 40.5 cm (25th percentile). Physical
examination was notable for a preterm infant in
mild-to-moderate respiratory distress with vital signs as
noted, pink color, soft anterior fontanel, normal faces,
intact palate, mild retractions, coarse breath sounds with
fair entry. No murmurs. Femoral pulses were present. The
abdomen was flat, soft, and nontender without
hepatosplenomegaly. Normal external genitalia. Both feet
easily corrected to a neutral position. Normal perfusion.
Normal tone and activity.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: The infant was initially in mild
respiratory distress and was started on continuous positive
airway pressure of 6 cm of water but with increasing
fractional inspired oxygen concentration from 28% up to 40%
with increased work of breathing and tachypnea up to now
100s, she was intubated and given surfactant at approximately
five hours of age. After the dose of surfactant, her
ventilator settings were weaned rapidly, and she was
extubated back to continuous positive airway pressure by the
second of life. She remained on continuous positive airway
pressure until day of life five when she was weaned to nasal
cannula with minimal flow (from 13 cc to 25 cc of 100%
fractional inspired oxygen concentration. She continued to
do well on nasal cannula with minimal increase work of
breathing. She has not had significant apnea of prematurity
and has not been started on caffeine.
2. CARDIOVASCULAR ISSUES: The infant has not had any active
cardiovascular issues and has maintained blood pressures in
the normal range throughout her admission.
On approximately day of life five, a soft benign-sounding
heart murmur was noticed which is not as apparent at the time
of discharge. No active cardiovascular issues.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The infant was
initially kept nothing by mouth and started on D-10-W at 80
cc/kg per day which was transitioned to peripheral parenteral
nutrition. She was kept nothing by mouth until 12 hours
after extubation, at which time she was started on Premature
Enfamil. She has been advancing easily on breast milk 22,
full enteral feeds of 140 cc/kg per day, and is now advancing
on calories. The infant's current feeds consist of maternal
milk at 22 calories per ounce at 140 cc/kg per day; all PG.
She has not had problems with hypoglycemia.
4. GASTROINTESTINAL ISSUES: The infant's maximum bilirubin
was 10.1 on [**12-25**]; at which time she was started on
single phototherapy. Her most recent bilirubin on the day of
discharge (on [**12-28**]) was 6.1/0.2; and phototherapy was
discontinued.
4. HEMATOLOGIC ISSUES: Maternal blood type was B positive
and antibody negative. The infant's blood type is not known
at this time. The infant's hematocrit on admission was 49%.
5. INFECTIOUS DISEASE ISSUES: Initial complete blood count
on admission showed a white blood cell count of 11,300 (with
13% polys, 81% lymphocytes, and 3% monocytes). Her
hematocrit was 49%. Her platelets were 402,000. Given
maternal group B strep status positive status and premature
birth, the infant was started on ampicillin and gentleman
which was discontinued at 48 hours after no growth in the
blood cultures. Blood cultures remained negative. No active
Infectious Disease issues.
6. NEUROLOGIC ISSUES: HUS should be performed in the next
week.
7. SENSORY ISSUES: Hearing screening has not yet been
performed. Ophthalmology screening has also not yet been
performed given the gestational age at 31 and 6/7 weeks
gestational age this may be considered at a later date.
CONDITION AT TRANSFER: Stable.
DISCHARGE DISPOSITION: Level II nursery at [**Hospital **] Hospital.
PRIMARY PEDIATRICIAN: The primary pediatrician is Dr. [**First Name8 (NamePattern2) 2411**]
[**Last Name (NamePattern1) 40271**].
CARE/RECOMMENDATIONS:
1. Current feeds are breast milk 22 calories per ounce at
140 cc/kg per day PG.
2. Medication: No medications at this time.
3. Car seat testing has not been performed.
4. State newborn screen was sent on [**12-25**] with the
results pending.
5. No immunizations have been given.
IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) [**Month (only) **] at less than 32 weeks gestation.
(2) [**Month (only) **] between 32 and 35 weeks gestation with 2/3 of the
following: Plans for day care during respiratory syncytial
virus season, with a smoker in the household, neuromuscular
disease, airway abnormalities, or with school-aged siblings;
or (3) With chronic lung disease.
Influenza immunization should be considered annually in the
Fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSES:
1. Prematurity at 31 and 6/7 weeks gestational age.
2. Status post respiratory distress syndrome.
3. Hyperbilirubinemia (on phototherapy)..
DR.[**First Name (STitle) 1877**],[**First Name3 (LF) **]
Dictated By:[**Name8 (MD) 50790**]
MEDQUIST36
D: [**2128-12-28**] 08:31
T: [**2128-12-28**] 09:01
JOB#: [**Job Number 52639**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4332
} | Medical Text: Admission Date: [**2130-2-27**] Discharge Date: [**2130-3-6**]
Date of Birth: [**2088-2-10**] Sex: M
Service: [**Location (un) **]
CHIEF COMPLAINT: Aspiration status post electroconvulsive
shock therapy.
HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old
male who underwent ECT shock therapy for depression for the
first time on [**2-28**]. Following ECT, the patient had an
episode of vomiting a small amount of bilious material. His
oxygen saturation decreased to the 80s. He woke up
diaphoretic, complaining of shortness of breath and chest
pain. EKG disclosed sinus tachycardia. His blood pressure
was stable. He was administered Lopressor and heart rate
decreased to the 100-110 range. He was sent to the Emergency
Department where he was found to have an oxygen saturation of
66% with an arterial blood gas that was 7.33/45/26. The
patient was intubated for hypoxic respiratory failure. He
subsequently developed tachycardia to the 170s and his
systolic blood pressure declined to 85/40. The patient's
blood pressure improved with decreasing his sedation
(propofol) but he had a persistent narrow complex
tachycardia. Rate did not decrease with administration of
adenosine. The patient was shocked with 100 joules x 2 yet
heart rate remained in the 130s. In the Emergency Department
the patient was given doses of Levophed and Flagyl. He was
sent to the medical intensive care unit for further
treatment.
PAST MEDICAL HISTORY: 1. Depression since [**2113**]. 2. History
of pneumothorax.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: 1. Wellbutrin 150 b.i.d. 2. Klonopin 1 b.i.d.
3. Remeron 15 h.s.
SOCIAL HISTORY: Tobacco one pack per day, occasional
marijuana use. The patient is married and has two daughters
ages 8 and 11.
FAMILY HISTORY: Depression and bipolar disease.
PHYSICAL EXAMINATION: In general he was a young male lying
in bed in no apparent distress. Vital signs in the Emergency
Department were temperature 97.2, heart rate 130, blood
pressure 133/79, respiratory rate 30, oxygen saturation
89-92% on 15 liters of oxygen by face mask. On the floor his
temperature was 100.2, heart rate 115, blood pressure 101/55,
respiratory rate 31, oxygen saturation 100% on
assist-controlled ventilation 750 x 18, FIO2 50%, PEEP 5.
HEENT: Normocephalic, atraumatic, pinpoint symmetric pupils,
endotracheal tube in place. Neck: No cervical
lymphadenopathy, no thyromegaly. Chest: Coarse breath
sounds throughout. Heart: Tachycardic, no murmurs, gallops,
or rubs. Abdomen: Midline scar, diminished bowel sounds,
nondistended. Extremities: No cyanosis, clubbing or edema.
LABORATORY DATA: White count 7.5, hematocrit 30.5, platelet
count 187. There were 64% neutrophils, 20% bands, 15%
lymphocytes. Chemistries: Sodium 150, potassium 2.5,
chloride 122, bicarbonate 19, BUN 15, creatinine 0.6, glucose
75, calcium 4.9, magnesium 1.1, phosphorous 2.8. Urinalysis
was yellow, notable for [**3-15**] red blood cells, 0-2 white blood
cells, few bacteria, no yeast.
Chest x-ray: 1. Collapse of left lower lobe. 2. Minimal
patchy right basilar opacity possibly due to aspiration. 3.
Emphysema.
EKG: Atrial tachycardia versus atrial fibrillation/flutter
versus AVNRT 116-170s, no ST segment changes.
IMPRESSION: This was a 42-year-old male with depression
status post ECT complicated by vomiting, aspiration and
hypoxia requiring intubation. Narrow complex tachycardia
likely secondary to catecholemine surge following this
episode. Arrhythmia likely exacerbated by electrolytes
abnormalities.
HOSPITAL COURSE: 1. Pulmonary: The patient required
intubation due to hypoxic respiratory failure presumed
secondary to aspiration and obstruction of airways. Review
of chest x-ray disclosed bibasilar infiltrates and left lower
lobe collapse. Left lower lobe collapse further investigated
by chest CT likely represents bullous disease. There was no
evidence of pulmonary embolus. The patient was maintained on
the ventilator. He was administered clindamycin to cover for
aspiration pneumonia. He underwent chest physical therapy.
He was successfully extubated on [**3-2**]. On transfer to
the floor he continued to undergo chest physical therapy and
suctioning.
2. Infectious disease: As noted above the patient was
started on a course of clindamycin for aspiration pneumonia.
On [**3-4**] his antibiotics were changed to levofloxacin
and Flagyl. The patient was to complete a 14-day course of
antibiotics.
3. Cardiology: A. Rhythm: As noted above on admission the
patient had a supraventricular tachycardia thought to be due
to catecholemine surge/hypoxia. Cardiology consultation was
obtained. Electrolytes were repleted. TSH was found to be
within normal limits. The patient's heart rate improved
during his hospital stay. The patient has been started on
diltiazem.
B. Ischemia: The patient's cardiac enzymes were cycled. He
ruled out for myocardial infarction. He is to be started on
aspirin.
4. Psychiatry: Consult service followed the patient during
his hospital stay. His outpatient psychiatrist is Dr.
[**Last Name (STitle) 46087**]. Following extubation the patient was accompanied by
a sitter at all times since he expressed suicidal ideation.
He was maintained on Klonopin. His other antidepressants
were withheld. He was administered Seroquel p.r.n. anxiety.
Further management of the patient's depression will occur in
the inpatient setting.
5. GI: The patient was maintained on Pepcid during his
hospital stay.
6. Prophylaxis: The patient was maintained on subcutaneous
heparin during his hospital stay.
7. Nutrition: The patient was administered a regular diet.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: The patient is to be discharged for
inpatient psychiatric hospitalization for management of his
depression.
DISCHARGE DIAGNOSES:
1. Depression.
2. Aspiration.
3. Hypotension.
4. Respiratory failure.
5. Supraventricular tachycardia.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Diltiazem 120 mg p.o. q.d.
3. Clonazepam 1 mg p.o. b.i.d.
4. Albuterol inhaler p.r.n.
5. Levofloxacin 500 mg p.o. q.d. for seven more days to
complete a 14-day course.
6. Flagyl 500 mg p.o. t.i.d. for seven days to complete a
14-day course.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-ADP
Dictated By:[**Name6 (MD) 36873**]
MEDQUIST36
D: [**2130-3-6**] 13:29
T: [**2130-3-6**] 13:49
JOB#: [**Job Number 7862**]
ICD9 Codes: 5070, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4333
} | Medical Text: Admission Date: [**2122-10-21**] Discharge Date: [**2122-10-22**]
Date of Birth: [**2092-9-22**] Sex: F
Service: MED
Allergies:
Aspirin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of Breath
Asthma Attack
Major Surgical or Invasive Procedure:
none
History of Present Illness:
30 yo woman with severe asthma since childhood required multiple
intubations (>10x, with last one in [**7-28**]) was admitted due to
another episode of asthma attack. Pt reported that she has been
maintained on prednisone 20mg po qod since [**7-29**], she is
followed by Dr. [**Last Name (STitle) 50575**] of pulmonary and her most recent PFT
([**2122-10-4**]) showed worsening dz (FEV1/FVC=45(56% pred). Pt
reported that around 11pm last night she had an asthma attack(
she has on avg 3 attacks per wk). She feels this was
precipitated by here walking between the heat of her home and
the cold outside mult times. She took nebs and went to bed at
1am and woke up at 6am wheezing, nebs didn't help, called EMS.
She them collapsed and doesnot remember anything until she woke
up in the ED.
By report of the family and ambulance, the pt given CPR by
brother when she stopped breathing. The EMS gave her O2, nebs
a, and .3 sc epi which brought her sats to 95%. In the ED
(arrived ~7am) she was given solumedrol 125mg x 1, heliox mask
vent at 10L, and cont nebs to maintain sats. Her symptoms
slowly improved as the morning progressed. By the time she
arrived at the ICU (12pm) she no longer required nebs to
maintain sats or avoid SOB.
In the past, pt had been on high dose steroid for [**1-27**] yrs (~80
mg prednisone daily then decadron 4mg daily) which ended [**2-26**]
due to pt developed cushingnoid syndrome. After her last
hospitalization [**7-29**], her outpt pulmonogist started her on
prednisone 20 mg qod.
Past Medical History:
Asthma
eczema
Fe Def Anemia
Nasal Polyps
Social History:
No ETOH, No Tob, No drugs.
Married, lives with huband and brother
[**Name (NI) **] Health student at BU
Family History:
Distant relatives have DM, asthma
Physical Exam:
Admission exam:
T 98.8 P 99 RR 11 BP 129/86 O2 91 on 10L heliox
Gen - A+Ox3, [**Last Name (un) 1425**] young woman, spleaking in full sentances,
no accessory muscles when breathing,
HEENT: EOMI, PERRL, OP clear, no icterus, moon face
Neck: supple, posterior hump, acanthosis nigricans, no LAD
Cor: RRR no m/r/g
Chest: diffuse expiratory wheezes, no rales, no ronchi
Abd: obese with striae, NT/ND, +BS, no HSM
Ext: nl bulk and tone, +2 DP bilat, thickened toenails b/l, no
c/c/e
Pertinent Results:
[**2122-10-21**] 07:10AM GLUCOSE-192* UREA N-11 CREAT-1.0 SODIUM-140
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-28 ANION GAP-17
[**2122-10-21**] 07:10AM ALT(SGPT)-16 AST(SGOT)-15 CK(CPK)-103 ALK
PHOS-136* AMYLASE-107* TOT BILI-0.3
[**2122-10-21**] 07:10AM cTropnT-<0.01
[**2122-10-21**] 07:10AM CK-MB-3
[**2122-10-21**] 07:10AM ALBUMIN-3.7 CALCIUM-8.8 PHOSPHATE-6.8*#
MAGNESIUM-2.2
[**2122-10-21**] 07:10AM WBC-20.1* RBC-4.85 HGB-14.1 HCT-43.0 MCV-89
MCH-29.0 MCHC-32.7 RDW-14.9
[**2122-10-21**] 07:10AM NEUTS-52.7 LYMPHS-32.8 MONOS-2.9 EOS-10.6*
BASOS-1.0
[**2122-10-21**] 07:10AM PLT COUNT-372
[**2122-10-21**] 07:10AM PT-13.8* PTT-26.9 INR(PT)-1.2
CXR - no CHF< or focal consolidation
PFT [**2122-10-4**] (after albuterol)
FVC 2.10 / 71% pred
FEV1 0.94 / 40% pred
Fev1/FVC 45 / 56% pred
imp: marked obstructive vent def
since [**7-29**] FVC decreased 17%, FEV1 decreased 27%)
Brief Hospital Course:
30 yo F with a hx of severe asthma who presents with an attack.
1) Asthma - The patient is now recovering from her asthma
attack. She is no longer requiring freq nebs and was able to
avoid intubation.
Home asthma meds including theophylline, montelukast,
fluticasone, salumedrol, and were continued. Also the patient
was given 125 methylprednisolone q8h. She remained stable
overnight without any SOB. Pt placed on insulin SS w/ steroids.
In the morning of the day after abmission the pt was felt
stable to go home with pulm follow-up. She was switched to a
prednisone taper starting at 60mg qday and going to 30mg qday.
Also she will be started on protonix to avoid GERD which may
exacerbate her asthma. As an outpt she should be worked up for
OSA
2) FEN - house diet
3) Access - PIV
4) Comm - with pt
Full Code
Medications on Admission:
Theophylline 300mg SR [**Hospital1 **]
Montelukast 10mg qday
Albuterol 1-2 puffs q4h
Fluticasone 2 puffs [**Hospital1 **]
salmeterol 1 puff qday
albuterol nebs [**Hospital1 **]
prednisone 20mg qod
Discharge Medications:
1. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Theophylline 300 mg Capsule, Sust. Release 12HR Sig: One (1)
Capsule, Sust. Release 12HR PO BID (2 times a day). Capsule,
Sust. Release 12HR(s)
3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
4. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
5. Ipratropium Bromide 0.02 % Solution Sig: Five Hundred (500)
mcg Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
Disp:*60 vials* Refills:*6*
6. Prednisone 20 mg Tablet Sig: see comments Tablet PO once a
day: Take 3 tabs a day for 2 days. Then take 2 tabs a day for 2
days. Then take 1 and a half tablets a day until your
appointment with Dr. [**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma Exacerbation
Discharge Condition:
stable
Discharge Instructions:
PLease [**Name8 (MD) 138**] MD or return to hospital if you have another attack
that is not responsive to your nebulizers.
Followup Instructions:
Primary Care: Please follow up with your PCP or NP as soon as
you are discharged. At the time please mention your prolonged
steroid use and possible questions regarding diabetes care.
Pulmonary: Please f/u with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 5091**]
Thursday [**2122-10-29**] 2:30pm
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4334
} | Medical Text: Admission Date: [**2180-4-27**] Discharge Date: [**2180-5-26**]
Date of Birth: [**2136-2-6**] Sex: M
Service: SURGERY
Allergies:
Imipenem/Cilastatin Sodium / Meropenem
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Liver failure, s/p OLT x2
Respiratory failure
L hemothorax, fibrothorax, trapped lung
GI bleed
Major Surgical or Invasive Procedure:
[**2180-5-1**] Flexible bronchoscopy, left thoracoscopy with removal of
pleural fibrin and blood, left limited thoracotomy with partial
decortication of the left lung.
[**2180-5-18**] Intra-abdominal bleeding from the hepatic artery, s/p
coil embolization of the hepatic artery.
History of Present Illness:
Mr. [**Known lastname 6359**] is a 44 year old gentleman who has had two
orthotopic liver transplantations. He had a difficult
postoperative course, ultimately was in
rehabilitation center where he developed shortness of breath and
a feeling of being unwell. He presented on [**2180-4-27**] and was found
to have a left pleural effusion. A small chest tube was placed
and 200cc bloody serosanguineous fluid was aspirated. Subsequent
CT scan demonstrated that the fluid collection was loculated.
The patient had been intubated due to his respiratory distress.
There were no signs of sepsis. He was taken to the OR on [**2180-5-1**]
for a thoracoscopy to evacuate the pleural fibrin and blood.
During the procedure, it was discaocerd that he had trapped lung
and, therefore, a limited thoracotomy with partial decortication
was performed.
Past Medical History:
ESLD secondary to Hepatitis C cirrhosis
h/o acute/chronic rejection
sp Orthotopic liver transplant # 1 on [**2178-12-2**] c/b recurrent
hepatitis C
sp Ex lap and repair of IVC bleed [**2178-12-5**]
sp Ex lap and evacuation of intra abdominal hematoma [**2178-12-8**]
sp Orthotopic liver transplant # 2 on [**2179-10-23**] secondary to
recurrent Hepatits C c/b distal CBD necrosis
s/p hepaticojejunostomy secondary to distal bile duct necrosis
on [**2179-11-10**]
s/p Ex-lap, abdominal washout, abdominal closure [**2179-11-14**]
s/p Ex lap & repair of recipient bile duct leak/closure of bile
duct stump [**11-18**] c/b hepatic artery bleed s/p stent [**12-28**]
Abdominal wound dehiscence
Entero-cutaneous fistula
history of VRE bacteremia [**4-29**]
history of thrombocytopenia
history of polysubstance abuse
Social History:
+h/o etoh, iv drugs and tobacco
Physical Exam:
[**Medical Record Number 26101**] 115/60 100% RA
A&O, juandiced. mildly dyspneic. NAD
Anasocoria, pupils reactive. eomi. icteric sclerae
S1S2nl. no MRG
Coarse LLL, Fine rales RLL, mild dyspnea
+BS, ND, No rebound, No guarding. Lg wound pouch to gravity
drag. green bilious sucus drg. Wound base granulating; stoma at
6 o'clock. Capped PTC epigastric area. R mid abd capped T.tube.
No CCE
Skin: resolving erythematous generalized rash with peeling of
hands/feet.
Brief Hospital Course:
After his left thoracotomy for left trapped lung, Mr. [**Known lastname 6359**]
was transferred back to the ICU. His nutritional status was
supported by TPN. He remained on the ventilator for a few days
but could be extubated. However, he decompensated shortly
thereafter and had to be reintubated. On [**5-18**], he developped a
massive GI bleed and he was transported emergently to the cath
lab. A fistula was discovered between the previously stented
hepatic artery/GDA into his GI tract. The hepatic as well as the
gastroduodenal arteries were coiled. Postoperatively, the
bleeding subsided. Mr. [**Known lastname 6359**] received multiple blood products
to maintain his HCT. He remained on the ventilator for
repiratory failure and could not be weaned off. Multiple
discussions were held with the family, who decided to make him
DNR/DNI. After he made no progression over the next days, the
family decided to make him CMO. At this time he was a
non-operative candidate with a large enterocutaneous fistula in
his R abdomen, respiratory failure, intermittent fulminant
GI-bleed and s/p liver transplant.
He expired peacefully with his mother and his aunt at his
bedside on [**2180-5-26**].
Medications on Admission:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Hydromorphone HCl 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed.
6. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection every six (6) hours: follow sliding scale insulin
orders.
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
11. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
12. Dolasetron Mesylate 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
13. Promethazine HCl 25 mg/mL Solution Sig: One (1) Injection
Q6H (every 6 hours) as needed.
14. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
15. Dilaudid 1 mg/mL Solution Sig: 0.5 mg Injection once a day:
may give prior to abd wound pouch change 1-2 times per week.
Discharge Disposition:
Expired
Discharge Diagnosis:
OLT
L trapped lung, s/p thoracotomy [**5-1**]
GI bleed
Discharge Condition:
The patient expired at 8:49am on [**2180-5-26**].
Discharge Instructions:
The family requested an autopsy.
Completed by:[**2180-5-30**]
ICD9 Codes: 5789, 5845, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4335
} | Medical Text: Admission Date: [**2185-6-19**] Discharge Date: [**2185-6-21**]
Date of Birth: [**2126-10-21**] Sex: M
Service: NEUROSURGERY
Allergies:
aspirin / opiates
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 110142**] is a 59 year old man who presents as an OSH
trasnfer for
ICH. Per report from [**Location (un) **], the patient had complained to
his wife for 3 weeks of uncontrollable intermittent twitching
above his R eye. Today ([**6-18**]), the patient went out for a
drive, and on returning, his wife heard a thump outside of their
house,and when she went to look, saw the pt stupourous and
unsteadily walking in circles until he came up to the door,
where he leaned
on it, then slumped on it and hit his head on the way down to
the floor. Per report, he then had a 1 min seizure prior to
EMS's arrival, but we don't have a report of the seizure
semiology. When EMS arrived, he was found to be unresponsive
with a R upward gaze/possible eye deviation. He was brought to
an OSH, where a head CT was completed, showing a ICH (4.9 x 4.2
cm area of hemorrhage within R frontal lobe extending into the R
lateral ventricle, no fx, no c/s fx per OSH rad report). Pt has
no history of antiplatelets or
anticoagulation, but INR was found to be 1.7 at the OSH. Pt was
then intubated with lido 100mg, etomidate 20mg, rocuronium 50mg
and maintained on 30mg propofol. He was then sent to [**Hospital1 18**] for
neurosurgical evaluation.
On presenation to the [**Hospital1 18**] ED, he was intubated, sedated and
minimally responsive, with some spontaneous movement of the RUE
and LLE. While he was being evaluated he had an episode of
eyelid fluttering and mouth twitching with tachycardia to the
130's that was felt to be seizure activity, so he was bolused
with propofol and given 2mg IV ativan. The fluttering/twitching
stopped. He again later in the ED had another episode with R
arm twitching and was again given 2mg IV ativan and it stopped.
He had a CTA that showed extension of the bleed into both
lateral ventricles. His Utox returned positive for amphetamines
but negative for cocaine.
Past Medical History:
chronic LE edema
hypercholesterolemia
Arotic stenosis
Social History:
married, possible EtOH as above
Family History:
unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
O: T: 98.9 BP: 121/61 HR: 114 R 16 O2Sats 100% on ETT
Gen: intubated, sedated, unresponsive
HEENT: C-collar on, ETT in place
Lungs: rhonchourous breath sounds throughout
Cardiac: RRR. S1/S2, mild 2/6 systolic murmur
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused, with 1+ pitting edema at ankles
bilaterally
Neuro:
Mental status: pt intubated and sedated, not following commands,
no opening eyes to voice.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 1.5 to 1
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus passively, but unable to formally test
V, VII: Unable to test
VIII: Unable to test
IX, X: Unable to test
[**Doctor First Name 81**]: Unable to test
XII: Unable to test
Motor: Normal bulk and tone bilaterally. MAEE, but not
vigorously
to noxious.
Sensation: Intact to noxious as above
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes downgoing bilaterally
Coordination: Unable to test
On discharge: expired
Pertinent Results:
ADMISSION LABS:
[**2185-6-18**] 11:40PM BLOOD WBC-8.8 RBC-3.76* Hgb-12.4* Hct-39.5*
MCV-105* MCH-33.1* MCHC-31.5 RDW-14.7 Plt Ct-141*
[**2185-6-18**] 11:40PM BLOOD Neuts-61.1 Lymphs-23.3 Monos-10.5
Eos-4.2* Baso-0.9
[**2185-6-18**] 11:15PM BLOOD PT-16.8* PTT-33.1 INR(PT)-1.6*
[**2185-6-18**] 11:15PM BLOOD Fibrino-166*
[**2185-6-18**] 11:40PM BLOOD Glucose-149* UreaN-13 Creat-1.1 Na-136
K-4.9 Cl-98 HCO3-22 AnGap-21*
[**2185-6-18**] 11:15PM BLOOD Lipase-33
CXR [**2185-6-18**]:
Endotracheal tube and enteric tube appear in position. Mild
increased central venous pressure with no acute cardiopulmonary
process
otherwise identified.
CT C-spine [**2185-6-18**]
1. No evidence of acute fracture or alignment abnormality.
2. Moderate degenerative changes, most severe at C5-C6 and
C6-C7, with
moderately severe spinal canal and bilateral neural foraminal
narrowing.
NOTE ADDED IN ATTENDING REVIEW: The severe degenerative disease
at C5/6 and C6/7, with associated angular kyphosis at the
former, and likely underlying dextroscoliosis, result in
relatively severe canal stenosis with flattening of the ventral
thecal sac. If there is appropriate mechanism of trauma, and
suspicion of cord injury (e.g. new myelopathic symptoms),
consideration should be given to MRI, if feasible.
ECHOcardiogram [**2185-6-19**]
Left ventricular wall thicknesses are normal. There is mild
global left ventricular hypokinesis (LVEF = 50 %). Right
ventricular chamber size and free wall motion are normal. There
is an anterior space which most likely represents a prominent
fat pad.
IMPRESSION: Suboptimal image quality. Mildly depressed left
ventricular function. Good right ventricular systolic function.
Anterior fat pad.
CTA head [**6-19**]..wet read
CXR [**2185-6-19**]
Mild increased right lobe opacities suggesting mild atelectasis
versus new aspiration.
CXR [**2185-6-19**] no read
LENS [**2185-6-19**]
No evidence of deep vein thrombosis in the right or left leg.
ECHO [**6-20**]
The left atrium is dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. There is mild to moderate global left ventricular
systolic dysfunction with 35-40%. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets are
severely thickened/deformed. There is mild to moderate aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Liver US [**6-20**]
Cirrhosis, with sluggish and reversed flow within the main
portal
vein.
CXR [**6-21**]
Right lower lung consolidation further resolved and mild
asymmetric pulmonary edema has significantly improved over last
24 hours.
Brief Hospital Course:
EU Critical [**Doctor First Name **] (first name [**Known firstname **] per report), is a 59 yo
male with an unconfirmed PMHx who presented as an OSH transfer
for ICH then found to have extension of the hemorrhage into both
lateral ventricles with a positive Utox for amphetamines. He
was admitted to the neuro ICU. He was given 2 units of FFP for
his INR of 1.6. He was loaded with fosphenytoin in the ED to
prevent seizures, and continued on PRN ativan in addition.
Phenytoin level was 11.1 on [**2185-6-19**].
In am on [**6-19**], he was hypotenisve and pressors were started. He
was up to three agents in the afternoon with persistant
hypotension. He was having respiratory issues on the ventilator
and he had to be paralyzed.
Prior to this, he localized and was spontaneously moving his
upper extremities. HE WD his lower extremities to noxious
stimuli. Pupils were equal and reactive.
His chest X-ray revealed right sided pneumonia consistent with
aspiration. He was started on Vancomycin and Zosyn. LENS were
done and ruled out DVT, he was unsafe for travel for CTA to rule
out PE. He developed sepsis and [**Last Name (un) **] monitor was place. MAP was
50-60 and fluid blouses were given.
Echocardiogram revealed LVEF 50%. Cardiac enzymes were sent.
They showed a trop of 0.07. The patient was then paralyzed as
his ventilation was difficult to maintain. His INR climbed to
2.6 and his PTT to 77 without any anticoagulation, and likely
[**3-3**] liver failure.
A family meeting was held which determined that the patient
would be aggressively managed for 24 hours then if he had no
response, the decision would be made for likely terminal
extubation.
On [**6-21**] it was noted that his right pupil was 4mm and very
minimally reactive and his left pupil was 2mm and minimally
reactive. After discussion with family it was determined that
they would progress towards comfort measures once they arrived.
they were contact[**Name (NI) **] later in the morning as his condition began
to deteriorate most likely secondary to herniation. His family
was told to come in to see him as soon as possible and care was
aggressively maintained and he was on 3 vasopressors for BP
management and had multiple fluid boluses to sustain his
pressure. the family arrived at his bedside and aggressive
measures utilizing medications and ventilatory support were
ceased. He passed away with his family at his bedside within
minutes of the cessation of ventilatory and circulatory support
at 1330.
Medications on Admission:
1. Lasix [**Hospital1 **]
2. KCl
3. Ibuprofen
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Right IPH
Hypotension
Sepsis
Pneumonia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
None, expired
Completed by:[**2185-6-21**]
ICD9 Codes: 431, 0389, 4280, 5070, 5845, 2762, 496, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4336
} | Medical Text: Admission Date: [**2171-3-18**] Discharge Date: [**2171-3-25**]
Date of Birth: [**2112-11-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Chest pain
Shortness of breath
Major Surgical or Invasive Procedure:
1. CABG x3 (free LIMA-LAD, SVG-OM, SVG-diag)
History of Present Illness:
58M c h/o CAD, now with increasing chest pain and dyspnea on
exertion. Cardiac cath showed 2-vessel disease. Clinical
course has been medical management vs. surgery.
Past Medical History:
1. HTN
2. Hyperlipidemia
3. CAD
4. Diabetes mellitus, type 2
5. Cataracts
Social History:
25 pack-year tobacco (quit)
No EtOH
Family History:
Brother: CAD
Father: MI
Mother: CHF
Physical Exam:
Afebrile, VSS
Neck: no JVD, no bruits
RRR, no murmurs
CTAB, no R/R
Abd: soft, NT, ND
Ext: no edema
Brief Hospital Course:
58M c 2-vessel disease and worsening symptoms presenting to the
cardiac surgery service for surgical treatment. CABG x3 (free
LIMA-LAD, SVG-OM, SVG-diag) [**2171-3-18**]. For more details, please
see operative report. Post-op, she was transferred to the CSRU
where she was extubated on POD 1. Chest tubes and PA catheter
were removed on POD 2. Vasopressors were weaned off on POD [**2-7**].
She was then transferred to the floor on POD 3. She failed to
void after foley removal on POD 5 and 7. Foley was replaced and
GU was consulted. She was 4 kg over her pre-op weight and lasix
was continued. Pt discharged to home with services, with foley
leg bag and Urology f/u.
Medications on Admission:
1. Avandomet 1/500 mg PO BID
2. Atenolol 25 mg PO QD
3. Lisinopril 5 mg PO BID
4. Lipitor 40 mg PO QD
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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Rosiglitazone Maleate 2 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
1. Coronary artery disease
2. Diabetes mellitus
3. Hypertension
4. Urinary retention
Discharge Condition:
Good
Discharge Instructions:
1. Resume medications as directed.
2. See cardiologist in 2 weeks.
3. Please call office or go to ER if fever/chills, drainage from
sternal incision, chest pain, shortness of breath.
4. Foley leg bag care as directed. Measure QD urine output.
Followup Instructions:
[**Hospital 159**] clinic, 1 week, call for appointment.
Cardiologist, 2 weeks, call for appointment.
Dr. [**Last Name (STitle) 70**], 4-6 weeks, call for appointment.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4337
} | Medical Text: Admission Date: [**2155-9-15**] Discharge Date: [**2155-9-22**]
Date of Birth: [**2075-3-16**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5378**]
Chief Complaint:
Altered consciousness, right arm shaking.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The pt. is an 80 year-old right-handed gentleman who presented
on [**2155-9-15**] with several hours of decreased responsiveness. Per
the pt's wife, the patient awoke around 6:00 on the morning of
admission and was mumbling, seemed to have trembling of lips. He
sat at the side of the bed and at 6:30 wife asked him to take
his medications and he has not responsive to her. He kept
repeating "chip and chip and chip..." At that time the pt's wife
noted that the pt had trembling of his right arm and he seemed
to be elevating the right arm. He was not responding to her
questions. His wife thinks that the whole episode lasted
approximately 30 minutes. She became concerned and called EMS.
On their arrival he was unresponsive to stimuli, his SBP was as
high as 220mmHg systolic and fingerstick was 222. His pupils
were noted to be unreactive and he seemed to have a right gaze
preference. He was brought to [**Hospital1 18**]. En route he developed
tonic-clonic activity of his right upper and lower extremities.
This activity continued upon his arrival to the ED. He was
subsequently intubated for airway protection. He was admitted
to the intensive care unit overnight. He was loaded with
phenytoin. He was successfully weaned off of sedation and
extubated this morning, the second hospital day.
There is no history of antecedant illness. He has been
compliant with his medication (keppra) and has not missed any
doses per his wife. [**Name (NI) **] did admit to alcohol consumption on the
night prior to presentation but not in excess.
Past Medical History:
-HTN
-type 2 diabetes mellitus
-Hyperlipidemia
-coronary artery disease
-hx of L MCA territory stroke, per the pt's wife, he has no
residua in terms of weakness, vision, language as a result of
stroke
-L ICA stenosis 80-99%, pt has refused intervention
-seizure in setting of urosepsis in [**1-25**], had been on dilantin
and then switched to keppra earlier this year due to concern
over medicine noncompliance (phenytoin levels of < 0.6)
Social History:
His a retired laborer who used to work in a shipyard. He lives
at home with his wife in [**Name (NI) 2268**]. He quit smoking roughly 20
years ago after roughly 40 years of use (1ppd). He uses alcohol
occasionally, but he does have a history of significant use in
the past. There is no history of illicit drug use.
Family History:
There are no other family members with seizures.
Physical Exam:
Vitals: T: 100.7F P: 82 R: 14 BP: 119/54 SaO2: 100% 4L
General: Awake, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Lethargic, intermittently fell asleep but easily
arousable to voice. He is able to state his name and birthdate.
He stated that he was in [**Location (un) 86**] but also thought that he was
"home." He denied being in a hospital. He did not know the
date and stated that the year was "1880." He was not able to
register that the year was actually [**2154**], despite multiple
attempts. Able to name days of week forward, but only got as
far as Friday going backward before he stopped. Language is
fluent with intact repitition and comprehension. There were no
paraphasic errors. Pt. was only able to name both high
frequency objects, and demonstrated perseveration when naming.
Speech was not dysarthric. He intermittently followed commands.
He recognized his wife. [**Name (NI) **] was unable to tell us how many
children he had or their names. This is not his baseline per
his wife.
-cranial nerves: Pupils irregularly shaped and surgical; were
minimally reactive to light bilaterally. He attended to all
visual fields bilaterally. EOMI without nystagmus. No facial
droop, facial musculature symmetric. Palate elevates
symmetrically in midline. 5/5 strength in trapezii and SCM
bilaterally. Tongue protrudes in midline.
-motor: Normal bulk throughout. Prominent paratonia in all four
extremities. No adventitious movements noted. No asterixis
noted. No myoclonus noted.
The pt would not participate with formal strength testing. He
would raise his right arm up but was seemingly unable to raise
his left arm against gravity. He would grip the examiner's
hands bilaterally. He would raise both legs and wiggle his toes
bilaterally.
-sensory: Intact to light touch over all four extremities. He
extinguished on the left arm and leg to DSS.
-coordination: pt would not cooperate.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was extemsor bilaterally.
-gait: deferred.
Pertinent Results:
Laboratory Data:
7.4 > 9.7 < 131
28.4
PT: 14.1 PTT: 27.3 INR: 1.3
139 | 106 | 19/161
3.3 | 24 |1.2\
Ca: 8.6 Mg: 1.2 P: 2.7
Phenytoin: 9.6
Alb: 3.4
7.38 |42| 141
Radiologic Data:
CT head: Multiple chronic infarcts (left temporal and right
frontal lobes, as well as the left cerebellar hemisphere)
without definite evidence for intracranial hemorrhage.
CXR: Extensive mediastinal and hilar lymphadenopathy (noted on
CT torso in [**2-22**]), mild congestive heart failure.
MRI: Allowing for this limitation, the well-defined wedge-shaped
area of chronic encephalomalacia at the left parietal/occipital
region, with dilatation of the ipsilateral lateral ventricle is
stable in appearance since [**2155-2-18**], persistent with chronic
cerebral infarct. No further focal T1 or T2 signal abnormality
within the cerebrum, cerebellum, or brain stem. Ventricular size
and configuration remains stable since [**Month (only) 958**]. No shifting of the
normally midline structures. Basal cisterns are patent. No
evidence of tonsillar herniation on the sagittal images.
The DWI images demonstrate no focal signal abnormality to
suggest new cerebral ischemia.
CONCLUSION:
1. Chronic infarct at the left parietal/occipital region,
probably representing chronic MCA/PCA watershed infarct. This is
stable since [**2155-2-18**].
2. No MR features of acute cerebral infarcts.
Brief Hospital Course:
1. Seizure disorder: The pt is an 80 year-old gentleman with a
history of seizures in the setting of urosepsis who presented
after an episode of altered consciousness and right-sided
seizure activity. This episode is consistent with a complex
partial seizure with a focus in the left frontal lobe. By
report, it lasted over 30 minutes and therefore is an episode of
complex partial status epilepticus. The precipitant was unclear
but may be due to medication noncompliance or antecedant alcohol
use. Keppra was titrated to a dose of 1500mg po bid. He did
have prolonged confusion and left upper extremity weakness
following the seizure. Both his mental status and the weakness
returned to baseline per the pt's wife prior to discharge. He
had no further seizures during the hospital stay. The pt was
told that by law he should refrain from driving an automobile
for 6 months. Given his underlying concomitant underlying
dementia, the pt should probably not drive notwithstanding.
2. Multifactorial gait disorder: Following intubation, the pt
had great difficulty with ambulation which was much worse per
the pt's wife from baseline. He demonstrated marked instability
in a standing position with almost immediate retropulsion. An
MRI with DWI was not suggestive for acute stroke as the etiology
behind either the seizure, weakness or the gait disorder. The
physical therapy service followed the pt. Over the course of
the hospital stay, the pt's gait improved substantially. At the
time of discharge, he was able to initiate gait without
difficulty. It was wide-based, but with normal stride and was
without veering. Nonetheless, he will require physical therapy
for gait training on discharge. His chronic underlying gait
disorder is likely multifactorial and related to cervical spine
disease, peripheral neuropathy and frontal lobe dysfunction.
The acute worsening was likely due to post-ictal weakness and
encephalopathy.
3. Iron deficiency and cyanocobalamin deficiency anemia: The pt
was noted to have low hematocrit values on admission. There was
no evidence of blood loss anemia. A workup revealed evidence of
both iron deficiency and cyanocobalamin deficiency. He was
started on ferrous sulfate 325mg po daily. He was also given
vitamin B12 1000mcg subcutaneously qday for five days and will
continue a reload upon discharge with plans for lifetime
supplementation.
4. Type 2 diabetes mellitus: His fingersticks remained
acceptable on rosiglitazone, metformin and a sliding scale of
regular insulin.
5. Hypertension: His blood pressure remained under acceptable
control on metoprolol and lisinopril.
Medications on Admission:
-ASA 325 mg po daily
-atorvastatin 40 mg qday
-avandia 4 mg qday
-Famotidine 20 mg [**Hospital1 **]
-Keppra 1000 mg [**Hospital1 **]
-Lisinopril 10 mg qday
-Metformin 850 mg [**Hospital1 **]
-Metoprolol 25 mg [**Hospital1 **]
-Plavix 75 mg qday
-Viagra 25 mg prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO QPM
(once a day (in the evening)).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO QAM
(once a day (in the morning)).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
DAILY (Daily) for 2 days: Give daily for the next two days, then
weekly for one month, then monthly thereafter.
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
-seizure disorder
-multifactorial gait disorder
-iron deficiency and vitamin B12 deficiency anemia
-hypertension
-type 2 diabetes mellitus
Discharge Condition:
Afebrile, stable.
Discharge Instructions:
Please continue all medications as prescribed. Please attend
all follow-up appointments. You have had a seizure and by
[**State 350**] state law, you are required to forfeit your
driver's license to the local RMV. You cannot drive for 6
months.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2155-10-30**] 3:00
Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] within 7-10 days after discharge from rehab.
Please call the [**Hospital 878**] Clinic at [**Telephone/Fax (1) 2574**] to schedule a
follow-up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] within the [**12-22**]
months after discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**]
ICD9 Codes: 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4338
} | Medical Text: Admission Date: [**2115-3-31**] Discharge Date: [**2115-4-5**]
Date of Birth: [**2059-11-4**] Sex: F
Service: MEDICINE
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Initially presented with Dyspnea to [**Hospital **] hospital from
nursing home. Transfered to [**Hospital1 18**] ICU because of respiratory
failure requiring intubation and hypotension requiring pressors.
Major Surgical or Invasive Procedure:
Intubation with mechanical ventilation
History of Present Illness:
55 y/o female with breast cancer presented with SOB to [**Hospital **]
Hospital because of dyspnea, fever, tachypnea, and tachycardia.
At [**Hospital **] Hospital, found to have fever to 101.5, tachycardia
to 112, tachypnea of 22, O2 sat of 93% on RA, and transiently
was hypotensive to 70 systolic. She was intubated, given 4L NS,
treated with zosyn, and started on dopamine.
.
At [**Hospital1 18**], a RIJ was placed, norepinepherine started in place of
dopamine, and given vancomycin and 3L NS. Paralysed with
vecuronium for CTA done for back pain to rule out disection.
.
Per her sister, she had a cold for the last few weeks but was
otherwise feeling well until the day before admission.
Past Medical History:
Breast Cancer- Diagnosed 8/[**2114**]. T3 N0, Infiltrating lobular
carcinoma; ER positive, PR positive, and her2neu negative;
status post a left modified radical mastectomy with axillary
lymph node disection on [**2114-12-7**], started [**2115-2-1**] on adjuvant
chemotherapy (cyclophosphamide and adriamycin as well as
dexamethasone) by Dr. [**Last Name (STitle) **].
Hypotension NOS
Schizoaffective Doisorder
Chronic Liver disease with Cirrhosis
History of Seizures
Tobacco Abuse
Mood d/o NOS
h/o alcohol dependence along with drug abuse.
Social History:
Sister [**Name (NI) 2048**] [**Name (NI) 110914**] [**Telephone/Fax (1) 110915**] (health care proxy). Lives
in [**Hospital3 **] facility because of psychiatric history.
Coming in from [**Location (un) 169**] nursing home in [**Location (un) **] after
recent hospitalization four weeks ago. Ambulates with a cane
with supervision because of unsteady gait. Declared incompetent
at nursing home.
Family History:
One sister with breast cancer at 54. 4 other siblings are
healthy.
Physical Exam:
Intubated, sedated, Caucasian female.
T 97.6 HR 93 BP 148/119 (cuff on levo) RR 18 SAT 100%
Vent AC 500x12 FiO2 100% PEEP 5
SKIN: no rashes, cool extremities
HEENT: PERRL. Sclera anicteric. Intubated. OG tube in place.
NECK: R IJ in place. Good carotid pulses. No LAD.
CHEST: Left mastectomy. Bronchial breath sounds over right
posterior lung fields. Left lung fields clear.
HEART: Regular rhythm. No murmurs.
ABD: soft, NT, ND, faint bowel sounds.
EXT: Good femoral pulses, good DP pulses.
NEURO: Repsonds to noxious stimuli. Reflexes 2+ and equal
bilaterally. Toes downgoing.
Pertinent Results:
[**2115-3-31**] 10:32AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2115-3-31**] 10:32AM PT-11.6 PTT-24.9 INR(PT)-1.0
[**2115-3-31**] 10:32AM PLT SMR-NORMAL PLT COUNT-274
[**2115-3-31**] 10:32AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2115-3-31**] 10:32AM NEUTS-61 BANDS-28* LYMPHS-7* MONOS-3 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2115-3-31**] 10:32AM WBC-12.4* RBC-3.91* HGB-11.4* HCT-35.2*
MCV-90 MCH-29.1 MCHC-32.3 RDW-15.1
[**2115-3-31**] 10:32AM LITHIUM-0.9
[**2115-3-31**] 10:32AM CRP-56.9*
[**2115-3-31**] 10:32AM AMMONIA-23
[**2115-3-31**] 10:32AM CALCIUM-8.3* PHOSPHATE-4.8* MAGNESIUM-1.5*
[**2115-3-31**] 10:32AM ALT(SGPT)-20 AST(SGOT)-20 CK(CPK)-46 ALK
PHOS-74 AMYLASE-151* TOT BILI-0.3
Urine culture no growth
Blood cultures no growth to date
.
CTA: IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Right upper and right lower lobe pneumonia.
3. Consolidation in the left lower lobe.
4. Sideports of the NG tube located at the level of GE junction.
.
TTE: Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a trivial/physiologic pericardial effusion.
.
Abd xray: FINDINGS: One vew of the abdomen on spine position
demonstrates no evidence of bowel loop dilatation. No evidence
of obstruction. Unremarkable bowel gas pattern.
.
PORTABLE CHEST: Endotracheal and NG tube have been removed. A
right internal jugular line is unchanged in position. Previously
noted asymmetric increased interstitial opacity diffusely
throughout the right lung may be slightly any improved compared
to three days prior. Left lung appears grossly clear. There is
no evidence of effusion. Cardiomediastinal silhouette is
unchanged.
Brief Hospital Course:
A/P: 55 y/o female with breast cancer and new right middle and
lower lobe PNA.
.
#. Hypoxia/Right Lower Lobe PNA: Patient admitted to MICU and
intubated, required pressors briefly. Was extubated on [**4-1**] and
did well. No PE on CTA. No evidence post obstructive disease.
Treated with vancomycin and zosyn with azithromycin on admission
and received 6 days here (3 days azithro). On room air at time
of discharge. Intubated. Hypoxia likely due to airspace disease
(PNA) on top of poor lungs (smoking history). No PE on CTA.
Negative cardiac enzymes. TTE repeated and unchanged from
previous (normal). At time of discharge plan to change to
levofloxacin for 14 day course total. Patient should get repeat
CXR to see resolution of infiltrates in [**3-10**] weeks. Seen by
swallow specialists here and no abnormality found; can continue
regular diet. Still unclear why two recent episodes of
pneumonia, although in different locations by report. Can
continue to investigate as outpatient.
.
#. Hypotension: Combination sepsis and hypovolemia. Had [**Last Name (un) 104**]
stim test with appropriate bump and appropriate am cortisol.
This can be repeated in outpatient setting if desired. TFTs
also normal and normal TTE.
.
#. Breast Cancer: No evidence of lung metastasis. D/w patient's
oncologist and will get outpatient follow up. Continued on
aromasin while here. Patient did complain of lower back pain
but appears to be chronic issue with negative bone scan last
fall.
.
#. Schizoaffective Disorder and Mood Disorder: Followed by
psychiatry here and medications adjusted as outlined. Initially
in ICU patient very agitated when extubated but became calm and
redirectable (with bouts of yelling) after transfer to floor.
No prolonged QTc on EKG on haldol. Lithium level 0.9. Also on
depakote so LFTs should be followed as outpatient.
.
#. h/o Liver disease: Labs show preserved synthetic function and
LFT's not elevated.
.
# h/o chronic constipation: Continued zelnorm and miralax.
.
#. CODE: Full
.
#. CONTACT: Sister [**Name (NI) 2048**] [**Name (NI) 110914**] [**Telephone/Fax (1) 110915**] (health care
proxy)
Discharge back to [**Hospital 169**] Center/[**Location (un) **].
Medications on Admission:
Zelnorm 6 mg Oral [**Hospital1 **]
Lyrica 150 mg Oral [**Hospital1 **]
Miralax 17 gm daily
Lithium Carbonate 300 mg PO QAM and 600 mg PO QHS
Prilosec 20 mg daily
Melatonin 3 mg QHS
Multivitamin daily
Aromasin 25 mg daily
Cogentin 0.5 mg [**Hospital1 **]
Stelazine 10 mg [**Hospital1 **]
Seroquel 400 mg QHS
Buspar 15 mg [**Hospital1 **]
Discharge Medications:
1. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day) as needed for constipation.
2. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day) as needed for Seizure Disorder.
3. Polyethylene Glycol 3350 17 g (100%) Powder in Packet Sig:
One (1) Powder in Packet PO DAILY (Daily) as needed for
COnstipation.
4. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO QAM
(once a day (in the morning)).
5. Lithium Carbonate 300 mg Capsule Sig: Two (2) Capsule PO QHS
(once a day (at bedtime)).
6. Exemestane 25 mg Tablet Sig: One (1) Tablet PO Daily () as
needed for Breast Cancer.
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
12. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
14. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 8 days.
16. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center/ [**Location (un) **]
Discharge Diagnosis:
Community acquired pneumonia, multilobar pneumonia
Severe sepsis
Schizoaffective disorder
Discharge Condition:
Good
Discharge Instructions:
You had a very severe pneumonia requiring intensive care unit
care. This has improved. If you develop worsening cough,
fevers, difficulty breathing please see your doctor.
.
You have now had two hospitalizations with serious pneumonias.
We did not find a clear reason that you are at higher risk for
these but will recommend to your physicians to continue this
work up as an outpatient.
.
We also have made some adjustments to your psychiatric
medications. We recommend close follow up with your
psychiatrist to continue to make adjustments as needed.
Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2115-4-30**] 10:00
.
2. You have an appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 31446**] [**Name (STitle) 8521**], on
Wednesday [**2115-4-10**] at 11:00. [**Telephone/Fax (1) 54268**]
.
3. Please follow up with your psychiatrist for continued
management of your schizoaffective disorder.
ICD9 Codes: 0389, 486, 5715, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4339
} | Medical Text: Admission Date: [**2153-7-9**] [**Month/Day/Year **] Date: [**2153-8-21**]
Date of Birth: [**2089-12-13**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / Indomethacin / Actonel / Reglan
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
GI bleeding.
Major Surgical or Invasive Procedure:
[**2153-7-22**]: liver and kidney [**Month/Day/Year **]
History of Present Illness:
The patient is a 63 year old female iwth a history of NASH
cirrhosis awaiting [**Month/Day/Year **], complicated by portal vein
hypertension, grade 2 esophogeal varices s/p TIPS,
encephalopathy, recurrent pleural effusions, ESRD on HD awaiting
[**Month/Day/Year **] was was transfered from [**Hospital1 **] Care with GIB
unresponsive to multiple transfusions. The patient was recently
hospitalized at [**Hospital1 18**] from [**Date range (1) 19159**] for altered mental status
believed secondary to hepatic encephalopathy. During the
admission the patient had a large melanotic stool, and an EGD
showed which showed portal hypertensive gastropathy vs. GAVE
syndrome without varices. On day of [**Date range (1) **], the patient had
a hct of 26.9. While at [**Hospital1 **], patient describes having
melena for a couple of days, without BRBPR. She reportedly
received 4units of PRBC over the weekend, without improvement of
HCT. When checked at [**Hospital1 **], hct was less than 21, and she was
transfered to [**Hospital1 18**] for further evaluation. Of note, the
patient has questioning of clotting of her AV graft, with an
inability to dialyze on the day of presentation.
.
On presenation ot [**Hospital1 18**], initial vitas were 98.5, BP 102/39, HR
56, 94% on RA. Her vitals remained stable, and hct was 23.3.
She was transfused with 1 unit of PRBC, cipro for SBP ppx, IV
protonix, started on an octreotide gtt, and given 1 L of NS.
She was noted to have a melanotic, guaic positive stool. She
was admitted to the MICU for further manegment.
.
Past Medical History:
- NASH cirrhosis: Liver bx [**2152-9-6**] = Stage IV cirrhosis, Grade 2
inflammation, complicated by portal HTN
- Esophageal varicies (grade I and II, s/p banding), s/p TIPS
[**8-15**]
- History of encephalopathy
- History of ascites
- Anemia
- Thrombocytopenia
- ESRD on HD due to diabetes and contrast-induced nephropathy
- Type 2 diabetes with retinopathy, nephropathy, and neuropathy
- History of C. difficile infection
- History of seizures
- Small left frontal meningioma
- Hypertension
- GERD
- OSA
- Leg cramps/? RLS
- DJD of neck
- History of dermoid cyst
- Right adrenal mass
.
Past Surgical History: (per OMR)
- Status post cholecystectomy followed by tubal ligation
- Status post left oopherectomy
- Status post appendectomy
.
Past Psychiatric History: (per OMR)
Depression first experienced in high school. First
hospitalization in [**2131**] (after husband's death). History of
cutting and burning self. History of overdose. One course of ECT
in past that was helpful.
.
Social History:
Widowed, lived in [**Hospital3 **] although most recently has
been at rehab. Has 4 children, several in MA. Smoking: None;
EtOH: Never; Illicits: None
Family History:
Family History:
Mom: CAD, stroke
Dad: HTN, DM
Physical Exam:
On presentation to the MICU:
VS: T 97.9 BP 104/40 HR 83 RR 20 97% 2L
GENERAL: NAD, lethargic but opens eyes to voice and follows
commands
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. dryMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 3/6 SEM
best heard at RUSB, no rubs or [**Last Name (un) 549**]. JVP=7cm.
LUNGS: decreased BS at right base but poor effort, no wheezing
or rhonchi
ABDOMEN: +BS, Soft, NT, obese, distended, negative fluid wave
but Dullness to percussion throughout all 4 quadrants, No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Lethargice CN 2-12 grossly intact. Preserved
sensation throughout grossly. Moves all 4 extremities(unable to
interact for strength exam) but b/l arms contracted. Increased
tone with all extremities. [**2-9**]+ reflexes, equal BL. Unable to
assess coordination. Gait assessment deferred. +asterixis
PSYCH: unable to assess
.
Pertinent Results:
On Admission: [**2153-7-9**]
WBC-3.3* RBC-2.54* HGB-8.0* HCT-23.3* MCV-92 MCH-31.4 MCHC-34.3
RDW-18.3*
NEUTS-67.5 LYMPHS-26.4 MONOS-5.4 EOS-0.3 BASOS-0.4 PLT COUNT-65*
PT-16.4* PTT-32.4 INR(PT)-1.5*
GLUCOSE-150* UREA N-55* CREAT-5.4*# SODIUM-134 POTASSIUM-4.5
CHLORIDE-101 TOTAL CO2-24 ANION GAP-14
LIPASE-40 ALT(SGPT)-11 AST(SGOT)-17 ALK PHOS-98 TOT BILI-1.0
.
Hct Trend:
[**2153-7-10**] 02:12AM BLOOD Hct-23.0*
[**2153-7-10**] 09:04AM BLOOD Hct-20.9*
[**2153-7-10**] 12:42PM BLOOD Hct-23.4*
[**2153-7-10**] 05:22PM BLOOD Hct-22.7*
[**2153-7-11**] 12:27AM BLOOD Hct-26.8*
[**2153-7-11**] 05:52AM BLOOD Hct-25.8*
.
At [**Month/Day/Year **]: [**2153-8-20**]
WBC-12.1* RBC-3.30* Hgb-10.0* Hct-31.2* MCV-94 MCH-30.2
MCHC-32.0 RDW-16.2* Plt Ct-893*
Glucose-96 UreaN-19 Creat-0.6 Na-139 K-5.1 Cl-105 HCO3-26
AnGap-13
ALT-20 AST-10 AlkPhos-116 TotBili-0.3
Albumin-2.9* Calcium-8.3* Phos-3.5 Mg-1.5*
tacroFK-6.9
Brief Hospital Course:
63 y/o female with NASH cirrhosis, c/b portal hypertension,
grade [**2-9**] esophageal varices s/p TIPS, encephalopathy, recurrent
pleural effusions requiring weekly thoracentesis, and ESRD on HD
who was admitted with GI Bleed.
.
# UGIB: Has h/o NASH cirrhosis c/b varicies s/p banding and EGD
2 weeks prior with severe portal hypertensive gastropathy vs.
GAVE syndrome. Presented with melenotic stools and hematocrit
drop unresponsive to transfusion. EGD showed clotted blood and
known varices/gastropathy with no active bleeding. ? oozing from
gastropathy. Hct stablelized after 2 units pRBCs and was called
out of the ICU to the medicine floor. PPI was continued.
.
Dyspnea: Likely related to reaccumulating pleural effusion.
Required 2 thoracentesis procedures on the medicine service
prior to [**Month/Day (2) **]. Fluid was exudative by lights criteria and
cultures were negative. Likely related to underlying liver
disease. She received one tap for 1 liter post op and has
otherwise been stable.
.
# Fever: Patient was intermittently febrile while on the
medicine service prior to [**Month/Day (2) **]. Culture data and c diff
toxin were unrevealing. She was placed on Vanco and Zosyn
empirically from [**7-15**] to [**7-21**] until [**Month/Year (2) **] for presumed HAP,
but no adequate sputum could be obtained. She had one episode of
fever post [**Month/Year (2) **] that was related to a Klebsiella UTI which
was treated with Zosyn x 5 days, she remained afebrile through
the rest of hospitalizations.
.
# ESRD: Prior to [**Month/Year (2) **], was on TTS HD schedule. Received
liver/kidney [**Month/Year (2) **].Because she was highly sensitized, she
received plasmapheresis and thymoglobulin. The creatinine was
down to 0.6 by time of [**Month/Year (2) **].
.
# NASH Cirrhosis: On the medicine service, patient was continued
on lactulose, rifaximin, midodrine, ursodiol, nadolol and
bactrim DS for SBP prophylaxis prior to [**Month/Year (2) **]. She received
a combined liver and kidney [**Month/Year (2) **] on [**7-21**] (extending
into [**7-22**]) She was taken to the OR with Drs [**Last Name (STitle) **] and [**Name5 (PTitle) 816**].
The liver surgery consisted of Orthotopic deceased donor liver
[**Name5 (PTitle) **], piggyback,
portal vein to portal vein anastomosis, common hepatic artery
donor to proper hepatic artery recipient, common bile duct to
common bile duct anastomosis with no T-tube. Splenectomy was
also done to assist with increased PRA for the kidney.
Post operatively her liver enzymes returned to [**Location 213**] very soon
after surgery and remained stable throughtout the
hospitalization. She received routine immunosuppression to
include Cellcept and Prograf as well as the induction Thymo and
solumedrol with plasmapheresis for the highly sensitzed kidney.
She also received IVIg x 3 doses.
.
Nutrition: Patient will continue on tube feeds. Her appetite has
improved over the course of the hospitalization but is still
requiring some supplementation via [**Location 40056**].
.
# DM2: Continue glargine and SSI.
.
# History of seizure: Leviticetam is continued post op.
.
# Depression/Anxiety: Continue on citalopram (dose increased to
40 mg daily on [**8-19**]) and ativan PRN
.
Medications on Admission:
Albuterol Sulfate (0.083 % nebs inhaled q(4) hours prn
Allopurinol 100 mg Tablet PO QOD
Nephrocaps daily
Citalopram 60 mg Tablet by mouth daily
Gabapentin 300 mg Capsule PO QOD
Hydroxyzine HCl 25 mg Tablet PO q8hr prn pruritis
Novolog SS
Lantus 18 units at bedtime
Ipratropium Bromide (0.02 %) q(6) prn
Lactulose 45 CCs by mouth qid
Lamotrigine 100 mg Tablet by mouth at bedtime
Keppra 1,000 mg Tablet by mouth once a day after HD on HD days
Lorazepam 1 mg Tablet by mouth q (8) prn anxiety
Midodrine 5 mg by mouth QTUTHSA (TU,TH,SA)
Nadolol 20 mg Tablet by mouth once a day
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) by mouth every
q12
Rifaximin 400 mg Tablet PO TID
Renagel 800 mg Tablet by mouth TID
Bactrim DS 800 mg-160 mg Tablet by mouth daily
Ursodiol 600 mg Capsule PO BID
OTC:
Calcium Carbonate-Vitamin D3 [Caltrate-600 Plus Vitamin D3]
600 mg-400 unit Tablet 2 Tablet(s) by mouth once a day
Multivitamin 1 Tablet(s) by mouth once a day (OTC)
.
[**Month/Year (2) **] Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Hold for diarrhea.
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for peri area.
8. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed for diarrhea.
10. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Follow [**Month/Year (2) **] clinic taper.
11. Insulin Glargine 100 unit/mL Solution Sig: Thirty Two (32)
units Subcutaneous at bedtime.
12. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection four times a day.
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
14. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO twice a
day.
15. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for agitation/anxiety.
[**Month/Year (2) **] Disposition:
Extended Care
Facility:
[**Hospital1 **]
[**Hospital1 **] Diagnosis:
NASH cirrhosis
ESRD
s/p combined liver/kidney [**Hospital1 **]
[**Hospital1 **] Condition:
Stable/Good
[**Hospital1 **] Instructions:
Please call the [**Hospital1 **] clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, diarrhea, inability to take or
keep down food, fluids or medications.
Labs to be drawn every Monday and Thursday to include CBC, Chem
10, AST, ALT, t bili, Alk Phos, trough Prograf level and U/A
Continue cycled tube feeds via [**Name (NI) 40056**]
PT
Abdominal wound normal saline moist to dry dressing daily
Sacral dressing q 72 hours and PRN
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2153-8-29**]
3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2153-9-5**]
11:00
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2153-9-14**]
11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2153-8-21**]
ICD9 Codes: 5856, 5789, 5119, 486, 5990, 4271, 4275, 5715, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4340
} | Medical Text: Admission Date: [**2199-7-13**] Discharge Date: [**2199-7-19**]
Date of Birth: [**2137-7-28**] Sex: F
Service: MEDICINE
Allergies:
aspirin / NSAIDS / Haldol
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Chief Complaint: AMS
Reason for MICU transfer: hypoxia
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
The patient is a 61 yo F with hx of Schizophrenia, DM2, COPD
last FEV1 60% predicted [**4-18**](with recent hospitalization at
[**Hospital1 18**] [**Date range (1) 70311**] with hypoxemia and UTI). The patient was
reportedly called by her family this AM - when she did not
answer, they were alarmed and called the police who went to her
home. The police found her confused, reportedly "frothing" at
the mouth, incontinent. EMS brought her to [**Hospital1 18**].
In the ED, initial VS were T103.4 P138 BP117/57 RR34 Sat88% nrb.
Her sats eventually improved on high flow/NRB to mid-90s. Then
placed on Bipap with O2 Sat 94%. On exam, she was responsive to
voice, slowed. answering questions appropriately. CXR showed
low lung volumes and previously seen retrocardiac/RLL opacities
due to atelectasis versus infection. She had a urinalysis,
which was floridly dirty. She was given CTX, vanco, azithro and
4 L IVF. On transfer, BP reportedly in the 90s systolic.
On arrival to the MICU, her VS were T100.8 HR110 Sat90 on
60%Hi-Flow, RR22. She is answering all questions. She is fully
oriented to person, place, time, purpose, and can recite phone
numbers for her next of [**Doctor First Name **]. She complains of pain in the right
lower leg which has been ongoing for several weeks. She also
notes dysuria, urinary frequency, and malodorous urine since
[**2199-7-8**]. She did finish a course of cefpodoxime for a recent UTI
several weeks ago. She actually denies shortness of breath
currently, as well as chest pain, chest pressure, pleurisy. She
notes cold-like symptoms of congestion, scant cough, sore
throat, malaise since her last discharge about 3 weeks ago. She
finished her azithromycin and prednisone from her last COPD
exacerbation about a month ago. She remains compliant with home
COPD regimen per her report. She continues to smoke cigarettes
but denies recent marijuana use. No recent sick contacts.
She recently presented similary to [**Hospital1 18**] [**Date range (1) 70311**] with
hypoxemia and UTI and was immediately weaned to 2LNC on arrival
to the MICU. She was treated for a COPD exacerbation with a
prednisone taper and azithromycin course, as well as
Ceftriaxone/cefpodoxime for urinary tract infection that grew
out klebsiella pneumoniae. Note was made at that time of
numerous medication reconciliation issues. She was admitted in
[**3-/2199**] with a fall, possibly secondary to psychiatric
medications and UTI (coag- staph), and had established pulm care
with Dr. [**Last Name (STitle) 575**] since that time.
Spoke with her friend [**Name (NI) 71549**] who speaks with her regularly- she
mentions that her respiratory status has been OK recently.
Past Medical History:
-COPD, exacerbation [**6-/2199**]
-Schizophrenia
-Diabetes mellitus type 2
-Overactive bladder
-HTN
-marijuana/tobacco abuse
-bilateral ureteritis [**6-/2198**]
-s/p fall [**3-/2199**]
-right hand numbness
-resting tachycardia of unclear source
Social History:
Tobacco: 1.5ppd x 50 years
- Alcohol: quit 15 years ago
- Illicits: smokes marijuana frequently (son died of heroin od
2 years ago)
- Housing: Lives alone. PCA visits twice daily
Other son is in and out of jail- patient requested that we do
not contact him.
Family History:
HTN
Physical Exam:
Admission exam
Vitals: T100.8 HR110 Sat90 on 60%Hi-Flow, RR22
General: sleepy but fully oriented to person place time
president purpose
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: tachycardic without MRG
Lungs: Diffuse inspiratory and expiratory wheezing and rhonchi
heard throughout the anterior and posterior fields. Abdominal
breathing but no other accessory muscles used.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. Umbilical surgical scar.
Ext: warm, well perfused, 2+ pulses. There is a diffuse patch of
erythema along the right shin that is not well marked, mild TTP.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally
Discharge exam
PHYSICAL EXAM:
VITALS: 97.3, 100s-120s/70s-80s, 90s-100s, 20, 94% RA i/o
1680/3500
Gen - non-toxic appearing elderly female in NAD
HEENT: PERRL, EOMI, MMM and pink, sclera anicteric
NECK: Supple, no carotid bruits, no JVD
LUNGS: crackles in lung bases more on L than R
HEART: Tachycardic, normal S1/S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: RLE discoloration medial to the anterior tibia, not
erythematous or swollen. Violaceous in color, non-erythematous,
non-warm, no edema.
NEUROLOGIC: A&Ox3, CNs II-XII intact, strength and sensation
grossly intact
[**Name (NI) 3687**] pt is anxious at baseline and has had panic attacks in
past
Pertinent Results:
Admission labs
[**2199-7-13**] 09:00AM WBC-11.1* RBC-4.93 HGB-14.5 HCT-44.4 MCV-90
MCH-29.4 MCHC-32.7 RDW-16.1*
[**2199-7-13**] 09:00AM NEUTS-85.3* LYMPHS-11.0* MONOS-2.5 EOS-0.9
BASOS-0.3
[**2199-7-13**] 09:00AM GLUCOSE-98 UREA N-11 CREAT-0.9 SODIUM-140
POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14
[**2199-7-13**] 09:15AM URINE BLOOD-MOD NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2199-7-13**] TYPE-ART PO2-78* PCO2-55* PH-7.24* TOTAL CO2-25 BASE
XS--4
Relevant labs:
[**2199-7-19**] 05:40AM BLOOD WBC-10.4 RBC-4.87 Hgb-14.3 Hct-43.6
MCV-90 MCH-29.4 MCHC-32.8 RDW-15.9* Plt Ct-283
[**2199-7-19**] 05:40AM BLOOD Glucose-86 UreaN-14 Creat-0.7 Na-141
K-3.8 Cl-100 HCO3-35* AnGap-10
[**2199-7-19**] 05:40AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.9
[**2199-7-18**] 06:10AM BLOOD TSH-4.3*
[**2199-7-16**] 09:45AM BLOOD freeCa-1.15
[**2199-7-16**] 12:41PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2199-7-16**] 12:41PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Pertinent Micro/path:
URINE CULTURE (Final [**2199-7-16**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Legionella Urinary Antigen (Final [**2199-7-14**]):
TESTING NOT PERFORMED: SPECIMEN RECIEVED IN THE
PRESERVATIVE.
TEST CANCELLED, PATIENT CREDITED.
Reported to and read back by [**First Name4 (NamePattern1) 3347**] [**Last Name (NamePattern1) **] #[**Numeric Identifier 86830**] @1210,
[**2199-7-14**].
[**2199-7-13**] 9:00 am BLOOD CULTURE
**FINAL REPORT [**2199-7-19**]**
Blood Culture, Routine (Final [**2199-7-19**]): NO GROWTH.
[**2199-7-13**] 9:26 am BLOOD CULTURE
**FINAL REPORT [**2199-7-19**]**
Blood Culture, Routine (Final [**2199-7-19**]): NO GROWTH
[**2199-7-13**] 1:49 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2199-7-15**]**
MRSA SCREEN (Final [**2199-7-15**]): No MRSA isolated
[**2199-7-16**] 12:41 pm URINE Source: Catheter.
**FINAL REPORT [**2199-7-17**]**
URINE CULTURE (Final [**2199-7-17**]): NO GROWTH.
2 Pending Blood cultures
Pertinent Imaging:
CXR [**2199-7-13**]: lung volumes low, left retrocardiac consolidative
opacity and rihgt lower lung patchy opacities are increased
compared to prior study, maybe atelectasis though infection
possible. Pulm congestion without frank pulmonary edema. Heart
size WNL. Small bilateral pleural effusions. No pneumothorax.
CXR [**2199-7-16**]: Portable semi-upright AP view of the chest was
provided. The endotracheal tube tip resides 4.7 cm above the
carina. Tip of the NG tube is visualized in the left upper
abdomen. There is diffuse pulmonary edema with probable small
bilateral pleural effusions and hilar engorgement. No
pneumothorax.
CTA CHEST [**2199-7-18**]:
1. No evidence of PE or acute aortic syndrome.
2. Enlarged main trunk, right and left pulmonary arteries are
consistent with chronically increased pulmonary artery pressure.
3. Interval increase of bilateral pleural effusions with
resolution of
bibasilar consolidations from exam performed one month ago.
4. Enlarged multinodular right thyroid lobe is noted and
unchanged with prior
exam from [**2199-6-17**]. Correlation with ultrasound is
recommended.
Brief Hospital Course:
Ms. [**Known lastname **] is a 61yoF with moderate COPD, schizophrenia, DM2,
hypertension and recent hospitalization for COPD exacerbation
and UTI presenting with fevers, hypoxia, and UTI symptoms.
.
Active Diagnoses
# Sepsis of urinary origin: She was hospitalized for COPD
exacerbation last month and presented this admission with cough,
fever, U/A positive for infection and SIRS criteria. CXR with
bibasilar opacities and pleural effusions, however these changes
have been present for several weeks. Improving with Vancomycin
and Zosyn IV starting [**2199-7-13**]. Blood cx pending, but unable to
obtain sputum cx. She was initially on the MICU, but then
transferred to the medicine floor, where she was transitioned to
Levaquin from the other antibiotics. The opacities noted on
chest imaging quickly resolved from admission suggesting against
an infectious process. She was continued on Levaquin to complete
an 8 day course as she was noted to have a UTI this admission.
# COPD Exacerbation: Pt with diffuse wheezing suggesting COPD
exacerbation in setting of possible PNA. Likely triggers
include cigarette smoking versus URI versus ?med noncompliance
(prior compliance issues). Pt was treated with IV solumedrol
and albuterol/ipratropium nebs x1 day. Switched to prednisone
40mg po, spiriva, advair on [**7-13**]. The patient was transferred
from the ICU to the medicine floor, where she had acute dyspnea,
requiring intubation (see below). She was transferred back to
the MICU, where she was treated with Lasix for flash pulmonary
edema and successfully extubated. We continued to wean
supplemental 02 as she is not O2 dependent at home. Albuterol
was changed to Xopenex for tachycardia. She was discharged on a
10 day taper of Prednisone.
.
# Respiratory Distress/Hypoxia: On [**7-17**], the patient was on the
medicine floor and was found by the nurse to be not moving air
well. BP 180s/110s. She sounded wheezy, crackly. She was
given diltiazem and Lasix 20 mg IV, but didn't put out much. She
was hypoxic to the low 80s on NRB and the came up to 87% O2
saturation. A code blue was called. She was intubated with
succinylcholine and propofol. She was transferred back to the
MICU, where she was treated with Lasix for flash pulmonary edema
and successfully extubated. This was likely in the setting of
hypertension so lisinopril restarted at home dose of 20 mg daily
and lasix was started as well at 20 mg daily. She was then
transferred back to the floor. A repeat echo showed new basal
inferolateral hypokinesis but improvement in her Pulmonary HTN.
She was dischared on 20mg of Furosemide daily. F/u with
cardiology was arranged
.
# Urinary tract infection: Pt presented with dysuria and hx of
mult UTIs. UA grossly positive. Antibiotic coverage Vanc/Zosyn
(for HCAP) initially covered this, but these were discontinued
on the floor as described above. Cultures showed Klebsiella,
and for this she was treated with levoquin to complete an 8 day
course.
.
# Right lower leg venous stasis changes: History of frequent
right lower leg cellulitis and chronic venous insufficiency
changes. Presented with tender, erythematous right lower leg.
Treated with Vancomycin initially. Area responded quickly after
1 day abx. Vicodin was used for pain control.
.
# Tachycardia: The patient has a resting heart rate that is
borderline tachycardic (documented in OMR), and this was
worsened by the albuterol. Therefore, the patient was
transitioned from albuterol to levalbuterol, which decreased the
tachycardia. A CTPA was performed which was negative for PE a
TSH was also checked an shown not to be the cause of her
Tachycardia.
.
# HYPERTENSION: Pt remained normotensive during initial MICU
stay. Antihypertensives were held. On the floor the patient was
hypertensive (see Respiratory Distress above). When she was
back in the MICU, she was restarted on her home antihypertensive
lisinopril.
.
Chronic Issues
# SCHIZOPHRENIA: Stable, Continued home meds: risperidone,
buspirone, mirtazipine, clonazipine.
.
# Pulmonary hypertension: Pt with known pulm HTN. Monitored
fluid status to prevent fluid overload. We monitored fluid
status and diuresed as needed.
.
# DIABETES MELLITUS: Pt did have elevated sugars to the 400s in
the setting of solumedrol. We continued to monitor FSG.
Metformin was held, and the patient was placed on ISS while
hospitalized.
.
# TOBACCO ABUSE: Pt counseled on the importance of smoking
cessation. Recommend ordering nicotine patch.
.
Transitional Issues
# Continue to address need for smoking cessation
# Cautious use of drugs that suppress the respiratory drive.
# Close FSG monitoring in the setting of current prednisone use.
# U/S of her thyroid should be performed to re-evaluate
multi-nodular goiter that was incidentally found on CT of chest
Medications on Admission:
MEDICATIONS- could not confirm
1. Lisinopril 20 mg PO DAILY
hold for sbp<100
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Advair Diskus (250/50) 1 INH IH [**Hospital1 **]
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
5. Clonazepam 1 mg PO QID PRN anxiety
hold for oversedation or rr<10
6. Mirtazapine 30 mg PO HS
hold for oversedation or rr<10
7. Risperidone 4 mg PO TID
8. Fluoxetine 80 mg PO DAILY
9. Baclofen 20 mg PO BID
10. BusPIRone 30 mg PO TID
11. Gabapentin 600 mg PO TID
hold for oversedation or rr<10
12. HydrOXYzine 10 mg PO Q6H:PRN itching
13. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q6H:PRN pain
hold for oversedation or rr<10
14. Nicotine Patch 21 mg TD DAILY
15. Tolterodine 2 mg PO BID
16. Ranitidine 150 mg PO BID
17. Clobetasol Propionate 0.05% Cream 1 Appl TP [**Hospital1 **]
18. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg twice daily Disp #*30 Capsule Refills:*0
19. PredniSONE 40 mg PO DAILY Duration: 3 Days Start: In am
to be taken through [**6-21**].
RX *prednisone 20 mg daily Disp #*6 Tablet Refills:*0
20. Azithromycin 250 mg PO Q24H Duration: 3 Days
to be taken through [**6-21**].
RX *azithromycin 250 mg daily Disp #*3 Tablet Refills:*0
21. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days
to be taken through [**6-23**].
RX *cefpodoxime 200 mg twice daily Disp #*10 Tablet Refills:*0
Discharge Medications:
1. Tolterodine 2 mg PO BID
2. Baclofen 20 mg PO BID
3. Gabapentin 600 mg PO Q8H
4. BusPIRone 30 mg PO TID
5. Risperidone 1 mg PO BID
6. Risperidone 4 mg PO HS:PRN agitation
7. Fluoxetine 80 mg PO DAILY
8. Mirtazapine 30 mg PO HS
9. Clonazepam 1 mg PO QID anxiety
Hold for sedation, rr<10
10. Hydrocodone-Acetaminophen (5mg-500mg [**1-7**] TAB PO Q6H:PRN pain
11. GlyBURIDE 10 mg PO BID
12. Lisinopril 20 mg PO DAILY
Hold for SBP<100
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
14. Docusate Sodium 100 mg PO BID
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
16. Ranitidine 150 mg PO BID
17. Zolpidem Tartrate 10 mg PO ONCE Duration: 1 Doses
18. MetFORMIN (Glucophage) 1000 mg PO BID
19. HydrOXYzine 10 mg PO Q6H:PRN itching
20. Tiotropium Bromide 1 CAP IH DAILY
21. PredniSONE 40 mg PO DAILY
RX *prednisone 10 mg 2 tablet(s) by mouth daily for five days
Disp #*15 Tablet Refills:*0
22. Levofloxacin 500 mg PO DAILY Duration: 2 Days
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
23. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Sepsis of urinary origin
COPD exacerbation
Pulmonary Hypertension
respiratory failure requiring intubation/mechanical ventilation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with altered
mental status and difficulty breathing. You were initially
admitted to the ICU where your breathing was stabilized and your
mental status cleared. We determined that the cause of your
shortness of breath was due to both fluid in your lungs and
inflammation from your COPD. We have started you on steroids to
decrease the inflammation in your lungs and a diurectic
medication to keep the fluid out of your lungs. We would like
you to follow up with cardiology to help you manage the fluid in
your lungs.
The following changes have been made to your medications:
START:
Prednisone 20mg for 5 more days then 10mg for the following 5
days then stop this medication
Levofloxacin for two more days
Furosemide for the fluid in your lungs
We have made you follow up appointments with both your primary
care physician and [**Name Initial (PRE) **] heart physician as well. It is very
important that you keep these appointments. Also please weigh
yourself daily and alert your doctor if your weight increases by
more than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2199-7-22**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (un) 86831**],HABIBULLAH
Address: [**Location (un) **], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 86832**]
Phone: [**Telephone/Fax (1) 71517**]
Appt: [**7-24**] at 2:45pm
ICD9 Codes: 0389, 5990, 4280, 4168, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4341
} | Medical Text: Admission Date: [**2180-6-3**] Discharge Date: [**2180-6-12**]
Date of Birth: [**2134-3-21**] Sex: F
Service: MEDICINE
Allergies:
vancomycin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
fever, sputum production, shortness of breath, stomach pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname **] is a 46-year-old with a history of intracranial
hemorrhage secondary to AVM s/p evacuation in [**2179-8-27**],
complicated by hydrocephalus requiring VP shunt, brought in from
[**Hospital3 2558**] nursing home. She has a tracheostomy and PEG. She
has undergone rehabilitation at [**Hospital3 **] [**Hospital1 8**] and
[**Location (un) 1036**] [**Location (un) 620**]. During her time at [**Location (un) 1036**], she was
hospitalized at [**Hospital1 18**] [**Location (un) 620**] and found to have a mucous plug
with sputum culture positive for MRSA, as well as E. faecalis
urinary tract infection (sensitive to linezolid, vancomycin, and
furantoin) treated with nitrofurantoin x 6 days. She was
transferred from [**Location (un) 1036**] to [**Hospital3 2558**] on [**2180-5-30**]. Per a
[**Hospital3 2558**] employee who spoke with the patient's respiratory
therapist, the patient was noted to have increasingly voluminous
secretions requiring increasingly frequent sunctioning (every
four hours -> every two hours -> every hour -> every 30
minutes). She was febrile to 101.2 with a heart rate in the
120s.
.
In the [**Hospital1 18**] ED, VS were HR 126, BP 90/68, RR 26, O2 99% on ?
O2. She was thought to have suprapubic tenderness on exam. Chest
X-ray revealed no acute intrathoracic process. Urinalysis was
leukocyte- and nitrite-positive with many bacteria. Sputum
Gram-stain and culture, blood culture, and urine culture went
sent. She received cefepime 2g IV x 1 and linezolid 600mg IV x 1
for possible healthcare-associated pneumonia and urinary tract
infection, plus acetaminophen and fluids.
.
On the floor she is noted to be hypotensive to 82/palp and is
triggered in the setting of losing her IV access. She is
admitted to the MICU for closer monitoring. In the MICU she
denies complaints.
.
In the MICU pt received fluid boluses (6.5L total) to treat
hypotension, but did not receive pressors. Linezolid and
cefepime were continued [**12-29**] vanc allergy. CXR revealed
questionable pneumonia with retrocardiac opacity vs atelectasis,
and current abx should treat for any HAP as well. On hospital
day 3, pt's hypotension stabilized, with SBPs in the 100s. At
time of txfr, sputum culture taken is growing GNR, which will
need to be followed. Urine Cx revealed E. coli sensitive to
cefepime. Pt's lactate trended down with condition improvement.
Pt was transferred to the floor.
.
On the floor, pt remained stable, with SBPs in the 100s.
Midodrine was added to pt's regimen, with resumption of normal
blood pressures in the 110s to 120s. Pt remained afebrile on the
floor, with no adverse events. Cefepime and Linezolid were
continued. Pt was restarted on her normal cycled tube feeding
regimen from continuous feeds, which she tolerated well.
.
Review of systems:
(+) Per HPI; she has had ongoing hyperthermia thought to a
"central fever"/reset thermostat, though she was afebrile on
discharge from [**Location (un) 1036**] (T 98.0); husband also notes that she
has complained of intermittent headache recently; she is
constipated at baseline
(-) Denies sinus tenderness, rhinorrhea or congestion. Denied
chest pain or tightness, palpitations. Denied arthralgias or
myalgias
Past Medical History:
Intracranial hemorrhage in [**2179-8-27**]
s/p VP shunt
Enterococcus faecalis UTI ([**2-4**])
Mucous plug ([**2-4**])
MRSA colonized
Situational depression
Social History:
Cared for by husband, who is her guardian. Currently [**Name2 (NI) 546**] at
[**Hospital3 2558**] ([**Location (un) **]), a nursing facility, but has spent
the last ~9 months at [**Hospital3 **] [**Hospital1 8**] and [**Location (un) 1036**]
[**Location (un) 620**]. [**University/College **] grad [**First Name8 (NamePattern2) **] [**Doctor First Name **] note.
Family History:
non-contributory
Physical Exam:
On Admission:
VS: T 97.3, BP 95/60, HR 79, RR 24, SpO2 100% on 50%
GA: somnolent and uncommunicative
HEENT: PERRL. eyes with strabismus. oropharynx exam limited but
there are visible secretions. no LAD. trach with visible
secretions.
Cards: Faint S1 and S2, no MRG, pulses full but faint
Pulm: Diffusely rhonchorous breath sounds with scattered
background wheezes
Abd: soft, deep palpation did not elicit grimace
Extremities: WWP
Skin: warm with no rashes, PEG site clean and non-draining
Neuro/Psych: strabisus as above. CN IV-XII, UE/LE strength,
coordination, reflexes, and gait not assessed.
On Discharge:
VS: T 98.8, BP 116/75, HR 82, RR 24, SpO2 99% on 35% humidified
through trach mask
GA: alert and responsive.
HEENT: eyes with strabismus, left anisocoria. oropharynx without
lesions. no LAD. trach clean and well-cushined with no leaking
secretions.
Cards: normal S1 and S2, no MRG, pulses 2+
Pulm: Good air entry b/l throughout. Transmitted upper airway
sounds from trach heard throughout.
Abd: soft, non-tender, non-distended.
Extremities: WWP 2+ PT/DP pulses
Skin: warm with no rashes, PEG site clean and non-draining
Neuro/Psych: strabisus as above, left anisocoria unchanged
during course on floors.
Pertinent Results:
ADMISSION LABS:
DISCHARGE LABS:
STUDIES:
cxr [**2180-6-3**]:
IMPRESSION: No acute intrathoracic process.
CT abd/pelvis:
IMPRESSION:
Mild amount of subcutaneous air in the anterior abdominal wall
inferiorly is likely related to injections.
Trace pelvic free fluid, could be physiologic (if patient
pre-menopausal), or could relate to VP shunt.
MICRO:
Blood Cx [**2180-6-3**]: pending
Urine Cx [**2180-6-3**]: pending
Sputum Cx [**2180-6-3**]:
[**2180-6-3**] 11:45 am SPUTUM
GRAM STAIN (Final [**2180-6-3**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND IN SHORT
CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
[**2180-6-8**] 06:15AM BLOOD WBC-8.8 RBC-3.24* Hgb-10.0* Hct-30.7*
MCV-95 MCH-30.9 MCHC-32.6 RDW-14.9 Plt Ct-378
[**2180-6-7**] 05:55AM BLOOD WBC-7.5 RBC-3.19* Hgb-9.8* Hct-30.3*
MCV-95 MCH-30.8 MCHC-32.4 RDW-14.6 Plt Ct-333
[**2180-6-6**] 06:14AM BLOOD Hct-30.9*
[**2180-6-6**] 04:02AM BLOOD WBC-7.4 RBC-2.68* Hgb-8.2* Hct-24.9*
MCV-93 MCH-30.8 MCHC-33.1 RDW-14.5 Plt Ct-322
[**2180-6-5**] 05:46AM BLOOD WBC-8.0 RBC-3.20* Hgb-9.9* Hct-29.8*
MCV-93 MCH-30.8 MCHC-33.1 RDW-14.4 Plt Ct-264
[**2180-6-4**] 04:25AM BLOOD WBC-7.1# RBC-2.98*# Hgb-9.2*# Hct-28.0*#
MCV-94 MCH-30.9 MCHC-32.9 RDW-14.4 Plt Ct-280
[**2180-6-3**] 11:12AM BLOOD WBC-16.8* RBC-4.34 Hgb-13.3 Hct-39.0
MCV-90 MCH-30.6 MCHC-34.0 RDW-14.5 Plt Ct-421
[**2180-6-3**] 11:12AM BLOOD Neuts-82.2* Lymphs-10.4* Monos-5.8
Eos-0.7 Baso-0.8
[**2180-6-8**] 06:15AM BLOOD Plt Ct-378
[**2180-6-5**] 05:46AM BLOOD PT-11.1 PTT-26.3 INR(PT)-0.9
[**2180-6-8**] 06:15AM BLOOD Glucose-117* UreaN-6 Creat-0.4 Na-137
K-4.0 Cl-98 HCO3-32 AnGap-11
[**2180-6-7**] 05:55AM BLOOD Glucose-103* UreaN-4* Creat-0.3* Na-138
K-3.9 Cl-101 HCO3-30 AnGap-11
[**2180-6-6**] 04:02AM BLOOD Glucose-87 UreaN-6 Creat-0.4 Na-141 K-3.8
Cl-107 HCO3-27 AnGap-11
[**2180-6-5**] 05:46AM BLOOD Glucose-139* UreaN-6 Creat-0.4 Na-136
K-4.0 Cl-105 HCO3-24 AnGap-11
[**2180-6-4**] 04:25AM BLOOD Glucose-117* UreaN-11 Creat-0.4 Na-137
K-3.9 Cl-108 HCO3-22 AnGap-11
[**2180-6-3**] 11:12AM BLOOD Glucose-128* UreaN-19 Creat-0.7 Na-132*
K-5.1 Cl-95* HCO3-20* AnGap-22*
[**2180-6-7**] 05:55AM BLOOD ALT-74* AST-50* AlkPhos-78 TotBili-0.1
[**2180-6-5**] 05:46AM BLOOD ALT-33 AST-22 LD(LDH)-242 AlkPhos-69
TotBili-0.1
[**2180-6-3**] 11:12AM BLOOD ALT-53* AST-38 LD(LDH)-309* AlkPhos-98
Amylase-47 TotBili-0.2
[**2180-6-7**] 05:55AM BLOOD Lipase-24
[**2180-6-5**] 05:46AM BLOOD Lipase-29
[**2180-6-3**] 11:12AM BLOOD Lipase-42
[**2180-6-8**] 06:15AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.4
[**2180-6-7**] 05:55AM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.6 Mg-2.4
[**2180-6-6**] 04:02AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.3
[**2180-6-5**] 05:46AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.2 Iron-20*
[**2180-6-4**] 04:25AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.2
[**2180-6-3**] 11:12AM BLOOD Albumin-4.3 Calcium-9.5 Phos-3.1 Mg-2.8*
[**2180-6-5**] 05:46AM BLOOD calTIBC-218* Ferritn-290* TRF-168*
[**2180-6-4**] 04:56AM BLOOD Type-[**Last Name (un) **] pO2-76* pCO2-43 pH-7.37
calTCO2-26 Base XS-0
[**2180-6-4**] 04:56AM BLOOD Lactate-1.2
[**2180-6-3**] 11:21AM BLOOD Lactate-2.3*
Brief Hospital Course:
Pt is a 46 yo F w PMH of AVM intracerebral bleed c/b cerebral
edema in [**2178**] requiring a trach and PEG who presents with
increased respiratory secretions, increased lethargy,
hypotension and fever concerning for severe sepsis. She was
transferred to the MICU for hypotension and closer monitoring.
She was treated with Linezolid and Cefepime. Cultures were sent
and showed e coli in the urine sensitive to cefepime.
# Severe sepsis: Patient's vitals in the ED were temp 102, HR
126, RR 26, with a WBC count of [**Numeric Identifier 2686**]. Patient met all 4
criteria for SIRS. Patient also has a UA concerning for UTI. Pt
also has a trach aspirate growing Moraxella from an OSH and a
sputum culture pending here; however, clear lungs, lack of
increased sputum or O2 requirement here, lack of infiltrate
makes HAP unlikely. CT abdomen unrevealing. Pt was bolused with
IVF's and hypotension resolved. She would become intermittently
hypotensive 1-2x/day throughout her MICU course thought to be
secondary to autonomic dysfunction secondary to her stroke.
Sepsis was thought to be resolved, and the hypotension would
quickly recover on its own or with small fluid bolus. She was
started on Linezolid given history of Vanc allergy & VRE
positive per report, in addition to Cefepime to cover for GNR's
on [**2180-6-3**] for day 1. C. diff was ordered; however, pt was not
stooling while in the MICU. KUB was sent and revealed
constipation. She remained hemodynamically stable with no
pressor requirement while in the MICU. Cultures were sent and
showed e coli in the urine sensitive to cefepime.
OUTPATIENT ISSUES:
-- Continue cefepime next 4 days to complete 14d course,
midodrine
# Abdominal pain: Unclear origin but most likely [**12-29**] UTI,
possible pyelonephritis. LFTs showed only mildly elevated ALT.
CT abd unrevealing. Abdomen remained soft. VP peritonitis
considered, but only minimal ascites on imaging in addition to
benign abdomen on exam. KUB revealed constipation and she
improved with suppositories and laxatives. Once on floor s/p
MICU stay, pt no longer complained of abdominal pain.
# Anion gap acidosis: Likely [**12-29**] lacate. Lactate downtrended and
acidosis resolved.
# Anemia: normocytic, previous baseline ~ 30-32. Likely dry on
admission, and Hct fell to 28, likely dilutional in setting of
volume resuscitation. Patients hematocrit monitored daily. HCTs
remained stable.
.
# Hypotension. Per report patient with baseline SBPs in
90s-100s. In MICU patient received a total of 6.5L in 500cc
boluses to maintain pressures. With treatment of infection SBPs
stabilized to 100s. Decision made to start patient on standing
midodrine to treat possible component of autonimic dysfunction
secondary to known intracranial pathology.
# S/P Intracerebral bleed: Baseline neuro status according to
husband. On trach and PEG. Has [**2-29**] R sided strength, left sided
weakness. No acute issues.
# Depression: Wellbutrin held on Linezolid due to initial
concern for serotonin syndrome. Patient continued on ambien.
Medications on Admission:
-Jevity tube feeds @ 85 cc/hr via NG tube at 8pm off at 6am
-Azocranberry 150 mg NG [**Hospital1 **]
-Lactulose 15 mL NG [**Hospital1 **]
-Ritalin 2.5 mg NG daily
-Clonidine 0.1 mg NG [**Hospital1 **]
-Vitamin B complex 1 tab NG daily
-Lovanox 40 mg subQ daily
-Zantac 150 mg/10 mL syrup NG daily
-Senna 2 tabs NG daily
-Wellbutrin 100 mg NG daily
-Ambien 5 mg NG qHS
-Tylenol 650 mg NG q4h PRN:pain, fever
-Simethicone 80 mg NG QID PRN:gas pain
-Acetylcysteine [Mucomyst] 600 mg NEB [**Hospital1 **]
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day): [**Month (only) 116**] decrease by half if pt has more than 2 bowel
movements per day.
2. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily).
3. ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg
PO DAILY (Daily).
4. senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
6. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
8. nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day) as needed for thrush.
9. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
12. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day). Disp:*180 Tablet(s)* Refills:*2*
13. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours): For the next four days through [**2180-6-16**].
14. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once
a day.
15. bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed: for constipation. Tablet(s)
16. mucomyst Neb Sig: 600mg twice a day: give acetylcysteine
600mg Neb [**Hospital1 **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Urosepsis
Discharge Condition:
Level of Consciousness: Alert and interactive, though
neurologically limited.
Activity Status: Bedbound.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Ms. [**Known lastname **]: It was a pleasure participating in your care at
[**Hospital1 69**]. You were treated here for
Urosepsis, which is a severe infection of the bladder. You need
4 more days of antibiotics through your veins. You were also
treated for a likely infection of your lungs, you already
completed antibiotics for that. You should continue your
medications as you had previously, and take the antibiotics as
prescribed in the medicine list.
.
CHANGES TO YOUR MEDICATION:
START: To treat infection, please take your cefepime twice per
day for the next 4 days.
START: Please continue your bowel regimen (laxatives) as
prescribed on the medication sheet to avoid constipation and
belly pain.
START: To treat low blood pressure please take the midodrine as
prescribed on your medication sheet.
STOP: Ritalin 2.5mg daily, you did not seem to need this. You
are now getting midodrine.
STOP: Clonidine, your blood pressures were low during this
admission.
HOLD: Wellbutrin 100mg daily. You can discuss with your rehab
doctor when you resume this medication.
To avoid future urinary tract infections, you should have your
diapers changed very regularly. Your institution may want to
straight-cath collect urine every 4 hours if diaper changes are
not frequent enough.
Followup Instructions:
Please follow up with the doctors at rehab this week.
Completed by:[**2180-6-12**]
ICD9 Codes: 0389, 5990, 2762, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4342
} | Medical Text: Admission Date: [**2176-4-17**] Discharge Date: [**2176-4-22**]
Date of Birth: [**2176-4-17**] Sex: F
Service: Neonatology
HISTORY: [**Female First Name (un) **] is a 2220 gram 33 [**11-29**] week female born to a
45 year old gravida II, para I, now III white female.
Prenatal screens revealed blood type A positive, antibody
negative, Rubella immune, RPR nonreactive, Hepatitis B
surface antigen negative, Group B strep unknown. Pregnancy
was uncomplicated until she presented in labor with breech-
breech presentation prompting cesarean section. Apgars were
7 at one minute and 8 at five minutes. She was brought to
the Neonatal Intensive Care Unit after visiting with her
parents.
PHYSICAL EXAMINATION: Revealed a pink, active, non-
dysmorphic infant who is well saturated and perfusing well in
room air. Skin is without lesions. Head, eyes, ears, nose
and throat examination is within normal limits. Heart had
normal S1 and S2, no murmur. Lungs have crackly breath
sounds. There is mild grunting, flaring and retracting.
Neurologically she has a nonfocal and age appropriate
examination. Her hips are intact without click or clunk.
Her anus is patent. Her spine is intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. Respiratory: She initially had mild respiratory distress
characterized by grunting, flaring and retracting. She
had no oxygen requirement. Her course was consistent with
transient tachypnea of the newborn. She has had no apnea
of prematurity.
2. Cardiovascular: She has been hemodynamically stable with
heart rates in the 120s to 150s and mean arterial blood
pressures in the 40s to 50s.
3. Fluid, electrolytes and nutrition: Initially she was
n.p.o. Her initial Dextrostix was 31. She received a
D10W bolus and then D10W intravenous infusion and corrected
her hypoglycemia. Once her respiratory distress resolved
she was started on feedings on day of life one and advanced
to full feedings without difficulty. She reached 150 cc
per kilogram per day of Premature Enfamil or breast milk
feedings on the day of transfer. She is fully fed by
gavage. Her weight on transfer is 2070 grams.
4. Gastrointestinal: She had physiologic jaundice with a
peak bilirubin of 12.6 total, 0.3 direct. She was treated
with phototherapy. On the day of transfer her bilirubin
is 9.0 total, 0.3 direct.
5. Hematology: Her initial hematocrit was 53.1. She has
required no transfusions. Her platelet count was 251,000.
6. Infectious disease: On admission she had a CBC and blood
culture for rule out sepsis. Her white blood cell count
was 11.4 with 36 polys, 0 bands, 47 lymphs. She was
started on Ampicillin and Gentamicin for 48 hour rule out
sepsis course. When blood cultures returned negative at
48 hours, antibiotics were discontinued.
7. Neurology: She has had a normal neurologic examination.
As she is greater than 32 weeks no head ultrasound was
performed.
8. Sensory: (1) Audiology: Hearing screening was not done
and will be needed prior to discharge, (2)
Ophthalmology: Eye was not required as she is greater
than 32 weeks.
9. Psychosocial: [**Hospital1 69**] Social
Work is involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **].
10.Hip ultrasound will be required at four to six weeks
since she was breech presentation.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: The infant is being transferred to
[**Hospital6 4620**] level 2 Neonatology Intensive Care
Unit for continuing care.
Pediatrician will be Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38807**].
CARE RECOMMENDATIONS:
A) Feedings at discharge are Premature Enfamil or breast milk
20 at 150 cc per kilogram per day by gavage.
B) Medications none.
C) Car seat positioning screening will be required prior to
discharge.
D) State Newborn Screening was sent on [**4-20**].
E) She received hepatitis B vaccination on [**4-18**].
F) Immunizations recommended: 1) Synagis RSV prophylaxis
should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants
who meet any of the following three criteria: (1) born at
less than 32 weeks. (2) born between 32 and 35 weeks with
two of three of the following: Day care during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings, or (3) With chronic
lung disease. 2) Influenza immunizations should be
considered annually in the fall for preterm infants with
chronic lung disease once they reach six months of age.
Before this age the family and other care-givers should be
considered for immunization against influenza to protect the
infant.
FOLLOW UP APPOINTMENT: Should be scheduled with Dr. [**Last Name (STitle) 38807**]
at the time of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 33 1/7 weeks.
2. Twin number two.
3. Sepsis ruled out.
4. Transitional respiratory distress.
5. Status post breech delivery.
6. Hyperbilirubinemia, treated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern4) 55464**]
MEDQUIST36
D: [**2176-4-22**] 16:22:28
T: [**2176-4-22**] 22:36:46
Job#: [**Job Number 55466**]
cc:[**Last Name (NamePattern1) 55465**]
[**Hospital6 4620**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4343
} | Medical Text: Admission Date: [**2112-10-15**] Discharge Date: [**2112-11-21**]
Date of Birth: [**2035-3-21**] Sex: M
Service: SURGERY
Allergies:
Ancef
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Right abdominal and flank pain x 8days.
Major Surgical or Invasive Procedure:
[**2112-10-15**]:
Exploratory laparotomy, lysis of adhesions, right colectomy,
ileal colostomy retroperitoneal abscess drainage, drain
placement, transgastric feeding jejunostomy.
[**2112-10-19**]:
Right flank abscess incision and drainage, complex debridement
of full-thickness skin, subcutaneous tissue, fascia, pulse
lavage.
[**2112-10-20**]:
Extensive incision and drainage of subfascial intramuscular
right thigh abscess.
[**2112-10-28**]:
Exploratory laparotomy, lysis of adhesions, right
retroperitoneal drain removal, intra-abdominal drain placement,
subcutaneous drain placement.
[**2112-11-11**]:
1. Ultrasound-guided puncture of left brachial artery.
2. Second-order catheterization of superior mesenteric artery.
3. Abdominal aortogram.
4. Selective superior mesenteric arteriogram.
5. Primary stenting of superior mesenteric artery for stenoses.
History of Present Illness:
77 year-old gentleman with CAD, CHF, HTN, chronic renal
insufficiency presented to [**Hospital3 3583**] in the morning of
[**2112-10-15**] with complaints of 8 days of right back/flank pain, and
eventually skin redness that developed 24 hours ago. The patient
has never had pain like this before. He has not been nauseated
or vomiting. No reported fevers at home. He has had no
dysuria. He states he has had pain in his abdomen that began a
few days after the back pain began. At the current time, he
reports the most pain on his right side. At [**Hospital3 3583**], his
WBC was noted to be 35.6, and he was found to be in acute renal
failure with a BUN/Creatinine of 101/5.1, respectively.
Abdominal/pelvic CT scan
demonstrated (R) retroperitoneal fascial gas extending into
psoas muscles, intraperitoneal air in (R)LQ appearing to be
stemming from TI area. The patient received vancomycin and zosyn
at [**Hospital3 3583**]. The patient was transferred to [**Hospital1 18**] to
evaluate for necrotizing fasciitis.
Past Medical History:
1. HTN
2. GERD
3. Nephrolithiasis
4. s/p cholecytectomy
5. s/p (R) THR
6. 3+ MR on [**2108**] TTE
7. CHF with EF 25%
8. CAD
Social History:
Retired plumber. Drinks 2 beers per night. Denies history of
tobacco or illicit substance use.
.
Health care by proxy: [**Name (NI) **] [**Last Name (NamePattern1) **] Home: [**Telephone/Fax (1) 63478**]. Work M-F
7:00am to 4:30pm [**Telephone/Fax (1) 63479**].
Son: [**Name (NI) **] [**Name (NI) 63480**] Home [**Telephone/Fax (1) 63481**]. Cell: [**Telephone/Fax (1) 63482**].
Family History:
Non-contributory.
Physical Exam:
On Admission:
VS: T 96.9, HR 120, BP 96/45, RR 16, 97%2L
GEN: NAD, A&Ox3
HEENT: No scleral icterus
LUNGS: Clear B/L
CV: sinus tach, nl S1 and S2
ABD: Soft, TTP in RLQ, ND, no guarding, no rebound, no hernias,
abdominal diastasis, cholecystectomy scar well-healed; (R) flank
erythema extending to (R) back - shiny and well-defined without
active drainage or crepitus.
GU: Scrotal erythema also present without drainage or crepitus
EXT: Patches of (R) erythema extend to (R) iliac area and
anterolateral-anteromedial (R) thigh. Feet cool B/L; femoral and
poplitleal pulses palpable B/L
.
At Discharge:
VS: 98.6 PO, 110, 110/52, 18, 97% RA
GEN: Thin, frail male in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **]. No JVD.
LUNGS: CTA(B)
COR: RRR; nl S1/S2 with 3/6 SEM @(L)SB.
ABD: Well-approximated, well-healed midline incision c/d/i. G-J
Tube patent/intact. Both ports flush w/o problem. Insertion site
clean, dry. BSx4. Soft/NT/ND.
EXTREM: WWP. No c/c/e
NEURO: A+Ox3. Deconditioned, otherwise non-focal.
SKIN/INTEG: Wound #1 (right flank/back) Description: 16cm x 5cm
x 2cm, beefy red, healthy granulation tissue. Wound #2 (right
groin/thigh) Description: 10cm x 3cm x 1.5cm, beefy red, healthy
granulation tissue. Both healing well with VAC dressings.
Pertinent Results:
On Admission:
[**2112-10-15**] 11:59PM TYPE-ART PO2-165* PCO2-34* PH-7.38 TOTAL
CO2-21 BASE XS--3
[**2112-10-15**] 11:59PM LACTATE-1.9
[**2112-10-15**] 11:59PM freeCa-1.12
[**2112-10-15**] 11:50PM CK(CPK)-98
[**2112-10-15**] 11:50PM CK-MB-NotDone cTropnT-<0.01
[**2112-10-15**] 09:15PM PO2-205* PCO2-27* PH-7.34* TOTAL CO2-15* BASE
XS--9 COMMENTS-UNLABELED
[**2112-10-15**] 09:15PM LACTATE-1.7
[**2112-10-15**] 09:15PM freeCa-1.04*
[**2112-10-15**] 09:03PM CREAT-2.7* SODIUM-135 POTASSIUM-4.4
[**2112-10-15**] 09:03PM CALCIUM-7.8* PHOSPHATE-5.5* MAGNESIUM-2.4
[**2112-10-15**] 04:40PM GLUCOSE-155* UREA N-70* CREAT-2.9*#
SODIUM-135 POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-16* ANION
GAP-14
[**2112-10-15**] 04:40PM ALT(SGPT)-64* AST(SGOT)-89* CK(CPK)-175* ALK
PHOS-73 TOT BILI-1.4
[**2112-10-15**] 04:40PM CK-MB-6 cTropnT-<0.01
[**2112-10-15**] 04:40PM ALBUMIN-1.5* CALCIUM-7.9* PHOSPHATE-6.2*#
MAGNESIUM-1.6
[**2112-10-15**] 04:40PM WBC-28.4* RBC-3.17*# HGB-10.1*# HCT-30.8*#
MCV-97 MCH-31.7 MCHC-32.7 RDW-14.3
[**2112-10-15**] 04:40PM NEUTS-91* BANDS-1 LYMPHS-3* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2112-10-15**] 04:40PM PLT SMR-NORMAL PLT COUNT-323
[**2112-10-15**] 04:40PM PT-16.3* PTT-30.8 INR(PT)-1.4*
[**2112-10-15**] 11:45AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2112-10-15**] 11:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-TR
[**2112-10-15**] 11:45AM URINE RBC-[**3-24**]* WBC-[**3-24**] BACTERIA-0 YEAST-MANY
EPI-0
[**2112-10-15**] 11:25AM cTropnT-<0.01
[**2112-10-15**] 11:25AM CK-MB-7
.
PATHOLOGY:
[**2112-10-15**] SPECIMEN SUBMITTED: right colon, retro-peritoneal
tissue, section transverse colon, omemtum.
DIAGNOSIS:
I. Right ileocolectomy specimen (A-Q): Subacute/interval
appendicitis with severe periappendicitis, periappendiceal/cecal
abscess formation, and fecal material consistent with
perforation. Adenoma, 2.5 cm. Multiple hyperplastic polyps. One
focus of distorted but crowded glands with cytologic and
architectural atypia and focal intraluminal necrotic debris
identified at the distal colonic resection margin consistent
with dysplasia/adenoma, cannot exclude high grade. Unremarkable
segment of ileum and proximal resection margin. Eleven
unremarkable lymph nodes.
II. Retroperitoneal tissue (R): Fibroadipose tissue with acute
and chronic inflammation, necrosis, and granulation tissue and
abscess formation.
III. Omentum (S): Unremarkable adipose tissue.
IV. Transverse colon resection (T-V): Hyperplastic polyp.
Unremarkable mucosa. Three unremarkable lymph nodes.
.
[**2112-10-20**] SPECIMEN SUBMITTED: right thigh tissue.
DIAGNOSIS:
Soft tissue, right thigh, excision: Fibroadipose tissue with
acute and chronic inflammation, fat necrosis, and granulation
tissue. See note.
Note:
Although no organisms were identified on special stain (GMS,
PAS-D, Gram), the findings, along with the clinical history,
favor a diagnosis of panniculitis, most likely due to infectious
etiologies. Alternatively and less likely, this process could
be a secondary inflammatory response (e.g. "id reaction") to a
primary trigger such as an abscess at a distant site. Clinical
correlation recommended.
.
IMAGING:
[**2112-10-16**] ECHO:
The left atrium is moderately dilated. The estimated right
atrial pressure is 10-20mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated.
Regional left ventricular wall motion is normal. There is
considerable beat-tobeat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. There are three aortic valve
leaflets. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**1-22**]+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is no pericardial effusion.
.
[**2112-10-17**] Portable AP CXR:
Indwelling devices remain in standard position.
Cardiomediastinal contours are difficult to assess due to marked
leftward patient rotation. There has been apparent interval
increase in a moderate left effusion as well as adjacent left
retrocardiac opacity, likely atelectasis. Additionally, a small
right pleural effusion has developed.
.
[**2112-10-18**] ABD/PELVIC CT W/O CONTRAST:
1. Resolution of the retroperitoneal gas/fluid collections and
no retroperitoneal abscess. New perihepatic gas and fluid
collections are likely post-operative sequelae.
2. Bilateral pleural effusions with bibasilar pulmonary
consolidations, new since three days earlier.
3. New placement of a transgastric feeding jejunostomy tube in
good position as well as a right retroperitoneal drain.
4. Decrease in volume of subcutaneous gas overlying the right
flank.
5. Large scrotal edema.
6. Diverticulosis
7. Staghorn right renal calculus and inadequately characterized
exophytic right lower pole lesion, likely a cyst. This could be
clarified with a non- urgent renal son[**Name (NI) **].
.
[**2112-10-19**] (R)UQ U/S:
1. status post cholecystectomy. No intrahepatic biliary ductal
dilatation. The visualized portion of the common duct is not
dilated.
2. Small right pleural effusion.
.
[**2112-10-20**] US EXTREMITY NONVASCULAR RIGHT:
Two fluid collections in the deep subcutaneous tissues of the
medial thigh as described above. The more superior fluid
collection may have been present on the prior CT of the abdomen
and pelvis.
.
[**2112-10-24**] UNILAT UP EXT VEINS US RIGHT: No evidence of DVT.
.
[**2112-10-28**] ABD/PELVIC CT W/O CONTRAST:
1. Portal venous gas and extensive small bowel pneumatosis
features consistent with bowel ischemia. These findings were
verbally discussed at the time of the study with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **].
2. Right renal cyst, likely representing simple cysts, however,
incompletely characterized in the non-contrast setting.
3. Unchanged right renal staghorn calculus with associated mild
right hydroureteronephrosis.
4. Near complete resolution of the right retroperitoneal
collection with a small residual fluid pocket in the anterior
infrahepatic region measuring 3.8 x 2.9 cm.
5. Indeterminant left adrenal lesion.
.
[**2112-11-7**] CTA ABD W&W/O C & RECON:
1. Patent mesenteric vasculature without evidence of embolic
filling defects. Extensive atherosclerotic disease is present,
though without evidence of critical stenoses.
2. Resolution of previously described portal venous gas.
3. Small bilateral pleural effusions.
4. Unchanged left adrenal nodule, inadequately characterized.
5. Staghorn right renal calculus as well as right renal cyst and
other right renal hypodensities, too small to characterize.
6. Right hepatic arterial enhancing focus. This finding could be
followed with MRI on a non-emergent basis.
.
[**2112-11-7**] CXR:
A right-sided PICC has been repositioned, with a wire seen in
the distal subclavian vein and not beyond that location. Tip of
the catheter is not definitely visualized, repeat PA and lateral
radiographs are recommended to assess position of the PICC.
There is increase in left basal opacity, likely representing
atelectasis, given rapid interval change. The remainder of the
examination is unchanged, with stable cardiomediastinal
silhouette, right basal atelectasis and low lung volumes. There
is no evidence of pulmonary edema. Left subclavian catheter ends
in the distal left brachiocephalic vein.
.
MICRO:
[**2112-11-17**] c diff negative
[**2112-11-8**] c diff negative
[**2112-11-6**] c diff negative
[**2112-10-30**] sputum negative
[**2112-10-29**] MRSA negative
[**2112-10-28**] MRSA negative
[**2112-10-25**] C. diff negative
[**2112-10-25**] MRSA negative
[**2112-10-23**] cath tip negative
[**2112-10-20**] tissue 4+ PMN, GNR sparse, strep viridans rare
[**2112-10-20**] R thigh 3+ PMNs
[**2112-10-19**] Flank GNR X 2
[**2112-10-18**] Sputum no growth final
[**2112-10-18**] UCx no growth final
[**2112-10-18**] BCx x2 no growth final
[**2112-10-15**] UCx no growth final
[**2112-10-15**] BCx x2 no growth final
[**2112-10-15**] Abscess B. frag rare growth
Brief Hospital Course:
The patient was transferred from [**Hospital3 3583**] and admitted to
the General Surgical Service on [**2112-10-15**] for evaluation of right
back, flank, and groin necrotizing fasciitis likely secondary to
an intraperitoneal process. The patient was septic upon
presentation. Given the emergent nature of the patient's
presentation, he was taken to the Operating Room on [**2112-10-15**],
where the patient underwent exploratory laparotomy, lysis of
adhesions, right colectomy, ileal colostomy retroperitoneal
abscess drainage, drain placement, transgastric feeding
jejunostomy, which went well (reader referred to the Operative
Note for details). After a brief, uneventful stay in the PACU,
the patient was transferred to the TICU NPO with an NG tube,
intubated on mechanical ventilation, on IV fluids and IV Zosyn,
Vancomycin, and Fluconazole; with a foley catheter, JP drains
x2, CVL, A-Line, and a G-J tube in place; and a Fentanyl drip
for pain control. The patient was hemodynamically stable.
.
NEURO/PAIN: Post-operatively when in an ICU setting, the patient
initially received Fentanyl by IV infusion or IV PRN with good
effect. He was transitioned to Dialudid IV PRN, and when
tolerating oral intake, to Dilaudid 2-4mg PO Q3-4Hours PRN with
continued good pain control. Prior to VAC dressing changes, the
patient was given Dilaudid 2mg IV, which worked well.
Discounting times of intentional sedation, the patient remained
neurologically intact during the admission.
.
CV: Patient with baseline history of CAD, CHF with an EF 25-30%,
3+ Mitral regurgitation, systolic ventricular dysfunction, and
mild pulmonary hypertension. At the time of admission, ECG
revealed afib with PACs successfully treated with Metoprolol 5mg
IV Q6Hours PRN, which also controlled hypertension. On [**2112-11-5**],
the patient experienced [**11-5**] abdominal pain, nausea and
vomiting,he was made NPO and tubefeeds were stopped, he was
triggered for a sustained heart rate in 130s, an EKG revealed
Afib with RVR. He was transferred to the SICU. Symptoms were
believed secondary to hypovolemia. He received 1 unit PRBCs for
a HCT of 22 and IV fluid rescusitation with good effect. The
patient was returned to the floor on [**2112-11-9**].
[**Date Range **] Surgery was consulted to evaluate for possible SMA
stenosis/mesenteric ischemia. A CTA Abdomen on [**2112-11-7**]
demonstrated patent mesenteric vasculature without evidence of
embolic filling defects, and extensive atherosclerotic disease
is present, though without evidence of critical stenoses. On
[**2112-11-11**], the patient underwent ultrasound-guided puncture of
left brachial artery, second-order catheterization of superior
mesenteric artery, abdominal aortogram, selective superior
mesenteric arteriogram showing 70-80% stenosis of SMA, and
primary stenting of superior mesenteric artery for stenoses for
chronic mesenteric ischemia, which went well without
complication. Plavix was restarted. A statin and ASA were
started prior to discharge. The patient will follow-up with the
[**Date Range **] Service as an outpatient.
.
PULMONARY: Post-operatively, the patient was maintained on
mechanical ventilation until [**2112-10-30**], at which time he was
extubated after being weaned and placed on supplemental oxygen
by face mask. He was transitioned to supplemental oxygen by
nasal cannula and subsequently weaned off supplemental oxygen
entirley. Early chest x-rays in late [**Month (only) **] revealed a
moderate left effusion as well as a small right pleural
effusion. Over the hospital course, these resolved with later
CXR only revealing changes consistent with atelectasis. The
patient remained stable from a pulmonary standpoint. Good
pulmonary toilet, early ambulation and incentive spirrometry
were encouraged and adhered to throughout the hospitalization.
Albuterol and Atrovent nebulizer treatments were administered as
needed with good effect.
.
GI/FEN: For the majority of the hospital admission, the patient
was NPO. Overall, the patient's metabolic needs were met by
tubefeeds and TPN. Nutrition was consulted, and followed the
patient throughout this admission. The patient received TPN via
a PICC line starting from [**2112-10-31**] until [**2112-11-15**], afterwhich it
was discontinued. Tubefeeds via the J-port of the G-J tube were
initiated as early as [**2112-10-18**], and progressively advanced to
cycled tubefeeds with Replete with Fiber Full Strength at
100mL/Hr by [**2112-10-27**]. By this time, his diet had been advanced to
regular with only fair but improving intake.
On [**2112-10-28**], however, the patient developed abdominal pain,
nausea, vomiting. Abdminal/pelvic CT revealed portal venous gas
and extensive small bowel pneumatosis features consistent with
bowel ischemia. Tubefeeds were stopped, the G-tube vented, and
the patient was made NPO. The patient was emergently brought to
the Operating Room, where he underwent exploratory laparotomy,
which was negative, lysis of adhesions, right retroperitoneal
drain removal, intra-abdominal drain placement, and subcutaneous
drain placement (see Operative Note). Post-operatively, trophic
tubefeeds were gently re-initiated using 1/2 strength Replete.
Slowly, the rate was increased to goal, and formulation stength
and content updated. Due to loose stools, banana flakes were
added, and the administration route changed to the G-port from
the J-port of the G-J tube, with the J-port clamped. Loose
stools improved. The patient was discharged on Replete with
Fiber 3/4 Strength with Banana Flakes as an additive at a goal
of 60mL/Hr over 24 hours via the G-Tube. The J-Tube was clamped.
By discharge, the patient was tolerating a low sodium, heart
healthy regulr diet, albeit with only fair intake. During
hospitalization, he patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary. He received IV fluid boluses when needed, including a
1 liter LR fluid bolus on [**2112-11-18**] and maintenence IV fluid over
[**11-19**] and [**11-20**] for poor oral intake. By [**2112-11-21**], the patient was
tolerating the tubefeeds via the G-tube, was tolerating his diet
with improved intake, and no longer required IV fluids.
.
GU/RENAL: At the time of admission, the patient was experiencing
acute renal failure on chronic renal insufficiency. Initial
BUN/Creatinine was 98/4.5, respectively. He required pressors
after his frst surgery on [**2112-10-15**]. He responded well to IV fluid
rescusitation on a number of occassions during this admission
with good urine output. After his multiple surgical
interventions, he required placement of a foley catheter. The
last foley was discontinued on [**2112-11-12**]. He was subsequently
able to void on his own without problem. By discharge, his renal
functions had essentially normalized with a BUN/creatinine of
19/0.9, respectively.
.
INFECTIOUS DISEASE/INTEG: After surgery on [**2112-10-15**], the patient
had a midline incision with staples which remained clean and
intact. Staples were removed, and steri-strips placed after 2
weeks. Post-operatively, the patient developed progressively
worsening erythema and tenderness over his right flank. On
[**2112-10-19**], the patient was brought to the OR for right flank
abscess incision and drainage, complex debridement of
full-thickness skin, subcutaneous tissue, fascia, and pulse
lavage for a right flank abscess with soft tissue necrosis. He
was again taken to the OR on [**2112-10-20**] for extensive incision and
drainage of subfascial intramuscular of a right thigh abscess.
At this time, separate continuous VAC dressing systems with
black granufoam to a target pressure of 125mmHg were placed at
both of these extensive I&D sites. The dressings were changed
every third day with progressive improvement and development of
new granualtion tissue. All JP drains were discontinued. VAC
dressings were continued when the patient was discharged to a
rehabilitation facility.
After surgery on [**2112-10-15**], the patient was started on IV
Fluconazole in addition to IV Zosyn an Vancomycin, which were
continued from [**Hospital3 3583**]. The Infectious Disease Service
was consulted. Peritoneal fluid culture revealed polymicrobial
gut flora with gram negative rods and anaerobes. Other cultures
from the thigh and flank abscesses revealed only sparse growth
of mixed bacterial types. IV Fluconazole was discontinued on
[**2112-10-21**] as preliminary findings revealed no fungus. IV Zosyn and
Vancomycin were continued until [**2112-11-8**]. Vancomycin trough
levels and renal functions were monitored closely during the
admission, and IV Zosyn and Vancomycin dosages adjusted
accordingly.
.
ENDOCRINE: The patient's blood sugar was monitored throughout
his stay; sliding scale insulin was administered accordingly,
particularly when the patient received TPN. Exogenous insulin
was not required at discharge.
.
HEMATOLOGY: The patient's complete blood count was examined
routinely. Over the course of this long hospitalization, the
patient required the transfusion of a total of 6 units of PRBCs.
He remained hemodynaically stable. By discharge, his hematocrit
was greater than 31. Also, he received 2 units of FFPs prior to
incision, drainage, and complex debridement of the right flank
abscess on [**2112-10-20**].
.
PROPHYLAXIS: The patient received subcutaneous heparin and
venodyne boots were used during this stay; he was encouraged to
get up and ambulate as early as possible with assistance. He was
discharged on Plavix and ASA.
.
ACTIVITY: During this admission, the patient was followed
closely by Physical Therapy. He required assistance getting out
of bed and ambulating. As recommended, he was discharged to a
rehabilitation facility.
.
At the time of discharge on [**2112-11-21**], the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
low sodium regular diet with improved intake and tubefeeds at
goal via the G-port of the G-J tube with the J-port clamped,
ambulating with assistance, voiding without assistance, and pain
was well controlled. Prior to discharge, the VAC dressings were
taken down, and moist-to-dry dressings placed for transport. VAC
dressings to the right flank/back and right thigh/groin will be
replaced at the rehabilitation facility and continued. He was
discharged to an extended care facility for continued nursing
care and rehabilitation. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Home Medications:
Lisinopril 20mg PO daily
Zoloft 50mg PO daily
Omeprazole 20mg PO daily
MVI 1 tab PO daily
Tylenol prn
.
At [**Hospital3 3583**]:
Vancomycin 1250 mg IV Q 24H
Piperacillin-Tazobactam 2.25 g IV Q6H
Discharge Medications:
1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. HYDROmorphone (Dilaudid) 1-2 mg IV Q4H:PRN Prior to VAC
change or for breakthrough pain
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-25**]
hours as needed for fever or pain.
13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO once
a day.
15. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
16. Trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO HS (at bedtime)
as needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Perforated cecum with retroperitoneal extension of
inflammation and abscess
2. Right flank abscess with soft tissue necrosis.
3. Right thigh subfascial intramuscular abscess.
4. Portal venous gas with small bowel pneumatosis.
5. Chronic mesenteric ischemia.
6. HTN
7. CAD/CHF
8. Chronic renal insufficiency
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-29**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Adhere to 2 gm sodium diet.
.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Wash the area gently with 1/2 Strength H2O2, then rinse with a
saline soaked Q-tip, pat dry, and place a drain sponge daily and
as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
VAC dressings will be performed by Nursing or Medical Staff.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2112-12-14**] 10:15. Location: [**Last Name (un) 6752**] 3, [**Last Name (NamePattern1) 8028**], [**Hospital Ward Name 517**], [**Hospital1 18**] [**Location (un) 86**]
.
[**Location (un) **] Service Follow-up Appointments:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2112-12-19**]
8:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2112-12-19**] 9:50. Location: [**Last Name (NamePattern1) 439**], [**Last Name (un) 2577**]
Building [**Location (un) **], [**Hospital Unit Name **] for both appointments above.
Completed by:[**2112-11-21**]
ICD9 Codes: 0389, 5849, 5180, 4280, 5859, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4344
} | Medical Text: Admission Date: [**2187-5-31**] Discharge Date: [**2187-6-4**]
Date of Birth: [**2118-2-22**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Motrin / Advil / Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Coffee ground emesis.
Major Surgical or Invasive Procedure:
[**2187-6-1**] Paracentesis
[**2187-6-1**] EGD
History of Present Illness:
Ms. [**Known lastname **] is a pleasant 69 year old female with past medical
history of cirrhosis and scleroderma who presents with coffee
ground emesis. On 6/23PM, she vomited 500cc dark brown material
with several clots on a car ride from [**Location (un) 86**]. She denies
wrenching and bright red blood.
.
Prior to this event, she denies any recent history of
nausea/vomiting, dysphagia or GERD. She denies NSAID use and
other anticoagulation medications. She does report melanotic
stools the past week and occasional BRBPR which she attributes
to her external hemorrhoids. She denies any episodes of syncope
or dizziness. She has felt weak the last few weeks, but
attributed this to her worsening scleroderma and cirrhosis
(unknown etiology).
.
Of note, her symptoms of ascites began in [**2187-2-5**]. Since
[**2187-3-8**], she has had two paracentesis since for removal of
fluid. Per her report, neither have demonstrated evidence of
infection. Her most recent paracentesis was roughly two weeks
ago, at which time her daughter reports 5 liters were removed.
She reports worsening lower extremity edema. She was seen in
liver clinic [**5-30**] by Dr. [**Last Name (STitle) **].
.
She presented to [**Hospital3 **] Hospital, where she was initiated on
octreotide and pantoprazole drips. During her time there,
reported to be hypotensive (unknown how low BP was), for which
she received 2 liters of IVF. She was then transferred to [**Hospital1 18**]
for further management.
.
In the [**Hospital1 18**] ED, initial vtial signs were: temperature of 97.6,
blood pressure 111/86, heart rate 10, respiratory rate of 16,
and oxygen saturation of 100%. NG lavage was completed and
notable for dark coffee ground material that did not clear;
there was no bright red blood. Pantoprazole and octreotide drips
were continued.
.
She was transfered to the MICU where she received 2U pRBC (Hct
22.9-currently stable at 35.1) and started on ciprofloxacin. She
was evaluated for upper GI bleed via NGL and EGD. On EGD showed
no signs of active bleeding, 2 cords of non-bleeding grade I
varices, gastritis, and severe esophagitis. She was started on
sucralafate. RUQ ultrasound showed evidence of cholelithiasis
with no evidence of cholecystitis, but no portal vein
thrombosis. She was note to have a leukocytosis to 23 which was
attributed to steriods, stress response, and possible infection.
CXR showed no consolidations and diagnostic paracentesis showed
no signs of infection.
.
On the floor, she appears comfortable, although complains of
sharp lower extremity and lower back pain. Of note, her bed
sheets are soaked around her abdomen which could be due to
recent paracentesis. She denies any recent episodes of vomiting,
diarrhea, (has been NPO), dysuria.
.
Review of systems:
(+) Per HPI. + Abdominal distension, + lower extremity and back
pain
(-) 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 constipation, abdominal pain, dysphagia. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- Scleroderma
- Cirrhosis of unknown etiology: Status-post two paracentesis,
last one several weeks ago, with 5L fluid withdrawal. No
episodes of SBP, encephalopathy, or bleeding. She saw Dr.
[**Last Name (STitle) **] [**5-30**] for the first time. Liver biopsy has not been
completed. History of positive [**Doctor First Name **] 1:640
- Hypothyroidism
- Anemia of chronic disease
- Coagulopathy
- Cellulitis (multiple infections in lower extremities)
- Sinus tachycardia
- Mitral regurgitation (patient unaware)
- External hemorrhoids
- 'Heart burn' but no diagnosis of GERD
.
Social History:
Retired, lives with 84 yo husband in [**Name (NI) **] [**Hospital3 **]. Husband
disabled with dementia. VNA and PT visits 1-2 times per week.
Daughter and son provide additional care. Feels safe at home,
but overwhelmed by husband's health and own health problems.
- [**Name2 (NI) 1139**]: Never
- Alcohol: Very rarely, none in the last few years.
- Illicits: Denies
Family History:
No family history of liver disease, auto-immune disease. Lung
cancer history related to smoking, grandmother with type two
diabetes mellitus.
Physical Exam:
General: Alert, oriented, pleasant, no acute distress,
cachectic.
HEENT: Sclera anicteric, PERRL, EOMI. MMM and oropharnyx clear,
Neck: Flat neck veins. No lymphadenopathy.
Lungs: scant bibasilar inspiratory crackles, no wheeze.
CV: Tachycardic. RR. Normal S1 + S2. No murmurs, rubs, or
gallops,
Abdomen: Soft, distended, no fluid wave. tympanic to percussion
in LLQ, non-tender w/o rebound or guarding.
Ext: Warm, well perfused, 2+ pulses. 2+ pitting edema to upper
shin.
NEURO: CN II-XII intact. Upper and lower extremity sensation
intact bilaterally
SKIN: Per nurses report, patient has two 1-2cm lesions on
gluteus
Pertinent Results:
[**5-31**] Dupp Abd/Pelvis
IMPRESSION:
1. Massive ascites, with the largest collection marked in the
right lower
quadrant.
2. Shrunken cirrhotic liver.
3. 4 mm hypoechoic hepatic lesion within segment VI. In the
absence of any
available comparison studies at [**Hospital1 18**], a three month followup is
recommended.
4. Cholelithiasis with no evidence of cholecystitis.
5. Patent portal veins, hepatic veins, and hepatic arteries,
with appropriate
flow directions and waveforms.
[**5-31**] US IMPRESSION:
1. Massive ascites, with the largest collection marked in the
right lower
quadrant.
2. Shrunken cirrhotic liver.
3. 4 mm hypoechoic hepatic lesion within segment VI. In the
absence of any
available comparison studies at [**Hospital1 18**], a three month followup is
recommended.
4. Cholelithiasis with no evidence of cholecystitis.
5. Patent portal veins, hepatic veins, and hepatic arteries,
with appropriate flow directions and waveforms.
[**6-1**] Therapeutic/diagnostic paracentesis:
GRAM STAIN (Final [**2187-6-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2187-6-4**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Micro:
Blood cultures ([**5-31**]): pending
[**2187-5-31**] 08:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2187-5-31**] 10:15PM HCT-22.9*#
[**2187-5-31**] 08:00AM HGB-10.0* calcHCT-30
[**2187-5-31**] 07:51AM WBC-23.3*# RBC-3.08* HGB-9.8* HCT-31.6*
MCV-103* MCH-31.9 MCHC-31.1 RDW-17.4*
[**2187-5-31**] 06:54AM ALT(SGPT)-31 AST(SGOT)-46* ALK PHOS-181* TOT
BILI-0.5
[**2187-5-30**] 04:55PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-NEGATIVE
[**2187-5-30**] 04:55PM AMA-NEGATIVE
[**2187-5-30**] 04:55PM IgG-1429 IgA-1180* IgM-258*
[**2187-5-30**] 04:55PM HCV Ab-NEGATIVE
At time of discharge
HCT: 33.7
WBC13.8
Brief Hospital Course:
MICU [**2102-5-31**]: Patient is a 69yo female with past medical
history of cirrhosis and scleroderma who presents with coffee
ground emesis
-Hematemesis: Coffee ground emesis secondary to likely upper GI
bleed. Upper endoscopy performed on day of admission notable
for old blood in stomach/small intestine, but no active
bleeding; non-bleeding grade I varices were seen. Severe
esophagitis and gastritis were observed. Sucralafate and PPI
were started. Pt had stable H/H. Liver team provided further
recommendations, including investigating possible hepatic
process, however, this was ruled out by abdominal US which
demonstrated patent portal veins, hepatic veins, and hepatic
arteries, with appropriate
flow directions and waveforms.
.
-Cirrhosis: Per report, unknown etiology. Unlikely alcohol
related given history. No clear offending medications on initial
review of her home list, though per yesterday's liver note,
prior use of minocycline (for scleroderma) is a consideration.
Ciprofloxacin was started as prophylaxis in setting of acute
ascites with plan for 5days of treatment. Diagnostic and
therapeutic IR-guided paracentesis (3L) revealed no SBP, and
patient was given 25g albumin. GRAM STAIN (Final [**2187-6-1**])NO
POLYMORPHONUCLEAR LEUKOCYTES SEEN, NO MICROORGANISMS SEEN. Fluid
culture with no growth. The paracentisis site continued to drain
ascitic fluid. Ostomy care was provided. Liver Team saw patient
prior to discharge and reported that bag could be left in place
to drain ascitic fluid at time of discharge. Spironolactone was
continued to aid in diuresis. Lasix was discontinued secondary
to side effect of persistent diarrhea.
.
-Hypoechoic lesion in liver: Seen on [**5-31**] RUQ US, and may
represent HCC vs other process. AFP was 3.0. Plan to follow-up
lesion as out-patient.
.
-Leukocytosis: Marked increase at admission that was normalizing
without intervention. Possible stress response secondary to
bleed as no obvious source of infection. No localizing symptoms.
No vital sign instability. However, blood and urine cx ordered
with results pending; paracentesis did not reveal source of
infection.
.
-Scleroderma: Followed by Dr. [**Last Name (STitle) 6426**] in rheumatology, but not
currently on tx. Minocycline was discontinued while in house and
at time of discharge due to concern that it may have contributed
to cirrhosis.
.
-Hypothyroidism: Continued home dose of levothyroxine
Medications on Admission:
- Calcium with vitamin D
- Nyastatin swish and swallow [**Hospital1 **] (currently not taking)
- Acetaminophen 500 mg [**Hospital1 **]
- Calan SR 60 mg daily (Verapamil)
- Levothyroxine 50 mcg daily
- Fluconazole 200 mg Q72 hr (currently not taking)
- Acidophilus 500 million cell [**Hospital1 **]
- Millipred 10 mg daily (prednisolone)- Stopped [**5-30**]
- Hydrocodone 1 tab q6-8 hours
- Lactulose -- prescribed [**5-30**]
- Spironolactone 50 mg -- prescribed [**5-30**]
- Furosemide -- prescribed [**5-30**]
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Verapamil 40 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Hold for sedation, RR<12, SBP<95. Do
not take when driving or when operating heavy machinery.
11. Lactulose 10 gram/15 mL Solution Sig: Three (3) ML PO TID (3
times a day) as needed for prn for confusion: Take if patient
becomes confused, unsteady.
Discharge Disposition:
Extended Care
Facility:
Eagle [**Hospital **] Rehabilitation Center - [**Location 23723**]
Discharge Diagnosis:
Primary diagnosis:
Gastritis
Esophagitis
Blood loss anemia secondary to upper GI bleed
Malnutrition
Cryptogenic cirrhosis
.
Secondary diagnosis:
Scleroderma
Tachycardia
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 presented to the hospital after vomiting blood. You were
admitted to the intensive care unit (ICU) and monitored
overnight and received two units of blood. You underwent
endoscopy which revealed inflammation of your esophagus and
stomach. This inflammation was likely due to your underlying
scleroderma and your recent use of steroids. Your steroids were
discontinued and you were started on medications to help protect
your stomach. You had been collected fluid in your belly and a
procedure was performed to both help your symptoms as well as
test the fluid for any sign of infection. You were started on
antibiotics to cover for any intra-abdominal infections. Your
bleeding resolved and were transferred to the medicine floor. On
the medicine floor your blood counts remained stable. Physical
Therapy saw you and thought it would be beneficial to discharge
to a rehabiliation facility prior to returning home.
.
The following changes were made to your home medications:
STOP minocycline
STOP prednisone
START Ciprofloxicin 500mg taken by mouth once in the morning,
once at night - to be taken through [**6-6**].
START Pantoprazole 40mg taken by mouth once in the morning, once
at night
START Sucralfate 1gm taken by mouth four times a day.
START Oxycodone 2.5mg every four hours as needed for pain
management. Do not take this medication if driving or operating
heavy machinery as it has the potential for sedation.
START Lactulose 30ml as needed three times a day for increasing
confusion, unsteadiness.
Followup Instructions:
Department: LIVER CENTER
When: WEDNESDAY [**2187-6-27**] at 3:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2187-6-6**]
ICD9 Codes: 2851, 2449, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4345
} | Medical Text: Admission Date: [**2112-9-3**] Discharge Date: [**2112-9-12**]
Date of Birth: [**2033-4-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
hypotension,respiratory failure,IMI
Major Surgical or Invasive Procedure:
emergency CABG x3/[**First Name3 (LF) **] with IABP [**2112-9-3**]
(29mm [**Company 1543**] Mosaic Porcine valve, LIMA to LAD, SVG to OM,
SVG to PDA)
History of Present Illness:
79 yo male admitted from OSH with hypotension, respiratory
failure and IMI. Arrived already intubated with IABP in place
for acute MR. [**First Name (Titles) **] [**Last Name (Titles) 74846**] to [**Hospital **] Hosp. on [**9-1**] with angina
and acute MI. Cath there revealed ramus 90%, RCA 95%, 80% PDA,
and 3 bare metal stents were placed in the RCA. Dopamine drip
started for hypotension at that time. Recurrent angina the next
day led to a repeat cath and echo showed severe MR. [**Name13 (STitle) **] also was
shocked 4 times for VTach. Transferred to [**Hospital1 18**] with IABP for
further management and surgery.
Past Medical History:
HTN
IMI
rheumatoid arthritis
prostate Ca [**2095**]
bladder Ca [**2101**]
Social History:
retired and lives with wife
no tobacco use
occ. ETOH
no recr. drugs
Family History:
non-contributory
Physical Exam:
84/65 HR 111 RR 14 ventilated, intubated and sedated
IABP in place left femoral
anicteric, PERRL, EOMI, OP unremarkable
neck supple, no JVD appreciated
[**2-16**] holosystolic murmur
coarse BS, bibasilar rales
soft, NT, ND, no HSM or abd. bruits
bil. art. and venous sheaths in place
no carotid bruits
bil. DPs/PTs dopplerable
Pertinent Results:
[**2112-9-12**] 06:15AM BLOOD WBC-11.9* RBC-3.52* Hgb-10.5* Hct-30.3*
MCV-86 MCH-29.8 MCHC-34.7 RDW-15.0 Plt Ct-223
[**2112-9-8**] 05:50AM BLOOD PT-13.6* PTT-44.9* INR(PT)-1.2*
[**2112-9-12**] 06:15AM BLOOD Plt Ct-223
[**2112-9-12**] 06:15AM BLOOD UreaN-14 Creat-0.8 K-4.9
[**2112-9-10**] 05:10AM BLOOD Glucose-75 UreaN-24* Creat-0.7 Na-135
K-4.7 Cl-100 HCO3-26 AnGap-14
[**2112-9-3**] 03:48PM BLOOD ALT-31 AST-126* LD(LDH)-573* CK(CPK)-846*
AlkPhos-49 TotBili-0.7
[**2112-9-7**] 04:10AM BLOOD Mg-2.2
Cardiology Report ECHO Study Date of [**2112-9-3**]
PATIENT/TEST INFORMATION:
Indication: cabg,[**Date Range **]
Status: Inpatient
Date/Time: [**2112-9-3**] at 21:09
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 Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: *3.2 cm (nl <= 2.5 cm)
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; basal inferolateral - hypo; mid inferolateral - hypo;
basal
anterolateral - hypo; mid anterolateral - hypo; anterior apex -
hypo; lateral
apex - hypo; apex - hypo; remaining LV segments contract
normally.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Mildly dilated ascending aorta. Mildly dilated descending
aorta. Simple
atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Torn
mitral chordae.
Severe (4+) MR.
TRICUSPID VALVE: 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 patient
received antibiotic
prophylaxis. The TEE probe was passed with assistance from the
anesthesioology
staff using a laryngoscope. No TEE related complications.
Conclusions:
Pre-CPB: The patient is in extremis, with IABP well-positioned,
on high-dose
inotropes, very low cardiac output.
No spontaneous echo contrast is seen in the left atrial
appendage. The LV
septum, infero-septal and antero-septal walls contract normally.
The anterior,
inferior and lateral walls are hypokinetic. . There is mild
global right
ventricular free wall hypokinesis. The ascending aorta is mildly
dilated. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic
valve leaflets are mildly thickened. Trace aortic regurgitation
is seen. The
mitral valve leaflets are moderately thickened. Torn mitral
chordae are
present. Severe (4+) mitral regurgitation is seen. Flow is
directed
anteriorly. There appears to be a rupture of the antero-lateral
papillary
muscle. There is no pericardial effusion.
Post-CPB: Patient is on epinephrine and milrinone. RV systolic
fxn is
preserved. LV EF = 30-35%. Mild improvement of anterior wall.
There is a
well-seated and functioning mitral valve prosthesis. No leak, no
MR, no AI.
Aorta intact.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD on [**2112-9-3**] 23:06.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 74847**])
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2112-9-9**] 7:22 PM
CHEST (PA & LAT)
Reason: r/o eff, inf
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with
REASON FOR THIS EXAMINATION:
r/o eff, inf
CHEST PA LATERAL
HISTORY: Evaluate for effusion or infiltrate.
FINDINGS: Frontal and lateral views of the chest compared to
prior study [**2112-9-6**]. Post-surgical changes of median sternotomy
are again noted. Right internal jugular Swan-Ganz catheter has
been removed. Bilateral pleural effusions persist. There is also
bibasilar airspace density, likely atelectasis in the
post-operative setting. There is no pneumothorax. Bony
structures are unchanged.
IMPRESSION: Small bilateral pleural effusions and associated
bibasilar airspace opacity, likely atelectasis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Brief Hospital Course:
Admitted [**9-3**] and seen by cardiology. Continued on dopamine drip
with IABP in cardiogenic shock and referred to Dr. [**Last Name (STitle) **] for
urgent surgery after echo showed 4+ MR. [**First Name (Titles) **] [**Last Name (Titles) **]/cabg x3
that evening and transferred to the CVICU in fair condition on
titrated epinephrine, milrinone, and insulin drips.IABP
removed.Extubated on POD #2 and transferred to the floor on POD
#4 to begin increasing his activity level.Chest tubes and pacing
wires removed without incident. He was gently diuresed toward
his preoperative wieght and continued amiodarone for postop
Afib.Continued to make good progress and was cleared for
discharge to home with services on POD #9. Pt. to make all
followup appts. as per discharge instructions.
Medications on Admission:
meds on transfer:
amiodarone drip
heparin drip
dopamine drip
plavix
ASA
omeprazole
tylenol
zocor
plaquenil
atenolol
enalapril
meds at home:
plaquenil
atenolol
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
MR/CAD s/p emergency [**Location (un) **]/CABG x3 with IABP
acute IMI
RCA stents
HTN
RA
prostate Ca/bladder Ca
postop Afib
Discharge Condition:
Good.
Discharge Instructions:
SHOWER DAILY and pat incisions dry
no lotions, creams, or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**12-15**] weeks
see Dr. [**Last Name (STitle) 2232**] in [**1-16**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2112-9-13**]
ICD9 Codes: 4240, 9971, 4280, 5990, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4346
} | Medical Text: Admission Date: [**2103-8-9**] Discharge Date: [**2103-8-17**]
Date of Birth: [**2033-11-28**] Sex: F
Service: CT [**Doctor First Name 147**]
ADMISSION DIAGNOSIS:
Coronary artery disease requiring revascularization.
HISTORY OF PRESENT ILLNESS: This is a 69-year-old female
with coronary artery disease and a history of chest pain on
medical management, who underwent a cardiac catheterization
at the request of her primary care physician [**Last Name (NamePattern4) **] [**2103-7-12**],
which demonstrated significant left anterior descending
artery and right coronary artery disease with an ejection
fraction of 65% and aortic stenosis with an aortic valve area
of 1.0 cm and a peak pressure gradient of 23 mm. The patient
was referred to Dr. [**Last Name (STitle) 1537**] for surgery.
PAST MEDICAL HISTORY: The past medical history was
significant for peripheral vascular disease, hypertension,
transient ischemic attacks, carotid disease and
hypercholesterolemia.
PAST SURGICAL HISTORY: The past surgical history included a
right femoral-popliteal bypass graft at [**Hospital6 **].
MEDICATIONS ON ADMISSION:
Aggrenox two p.o. b.i.d.
Norvasc 2.5 mg p.o. q.d.
Lipitor 10 mg p.o. q.d.
Zestril 10 mg p.o. q.d.
Aspirin 81 mg p.o. q.d.
Folic acid p.o. q.d.
Vitamins over-the-counter.
Atenolol 50 mg p.o. q.d.
ALLERGIES: The patient had a penicillin allergy.
SOCIAL HISTORY: The social history was significant for a 100
pack year history of smoking.
PHYSICAL EXAMINATION: The head, eyes, ears, nose and throat
examination revealed a positive bruit on the left. The chest
was clear to auscultation with decreased breath sounds at the
bases. The heart was a regular rate and rhythm with a IV/VI
systolic ejection murmur radiating to the neck. The abdomen
was obese, soft, nontender and nondistended with active bowel
sounds. The extremities showed an old right thigh incision
with no clubbing, cyanosis or edema. The neurological
examination was nonfocal.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2103-8-9**], at which time she
underwent coronary artery bypass grafting times three as
follows: a left internal mammary artery graft to the left
anterior descending artery, a saphenous vein graft to the
first diagonal artery and a saphenous vein graft to the
posterior descending artery as well as a #23 pericardial
aortic valve replacement. Her postoperative ejection
fraction was 55%. The patient was transferred to the cardiac
surgery recovery unit, where she required some nitroglycerin
intravenously to control her hypertension. Otherwise, she
did very well and was begun on Lopressor, aspirin and
Captopril as well as Lasix diuresis.
The patient was transferred to the regular floor on
postoperative day #2 and was doing well, ambulating and with
a good level of activity, until she had a low grade fever on
postoperative day #5. At that time, a white blood cell count
and urine cultures were sent off. The urine demonstrated
moderate bacteria and her white blood cell count was 11,200.
The patient was begun on ciprofloxacin for this and an
infectious disease consultation was obtained, given the fact
that she had a new valve. Blood cultures were also obtained
at the time of the fever that grew out gram negative rods.
Given the fact that she had recently undergone valve
replacement, the patient was continued on ciprofloxacin and
tobramycin and Flagyl were added.
The patient also underwent a chest x-ray that demonstrated a
left sided effusion without any other significant
abnormalities at the request of the infectious disease
consultant. She also underwent an ultrasound of the
genitourinary system to rule out any abnormalities of such
that would lead to recrudescence of her urinary tract
infection. The report was not available at the time of
discharge.
The blood cultures subsequently grew out pansensitive
Escherichia coli and the urine cultures grew out pansensitive
Proteus mirabilis as well as Escherichia coli. It was felt
that her bacteremia was secondary to seeding of the blood
from her urinary tract infection and, after consultation with
infectious disease, her antibiotics were tapered back to
ciprofloxacin, which she should receive for two weeks.
Otherwise, the patient remained afebrile for the rest of her
hospital course. Her white blood cell count dropped and on
the day of discharge was 10,300. She was ambulating well and
tolerating a regular diet. Of note, she was also placed on
amiodarone postoperatively for an episode of atrial
fibrillation that resolved spontaneously and never recurred.
CONDITION/DISPOSITION: The patient was felt to be stable for
discharge and was discharged on postoperative day #8 to
rehabilitation.
DISCHARGE MEDICATIONS:
Amiodarone 400 mg p.o. t.i.d. for three days, then 400 mg
p.o. b.i.d. for one week, then 400 mg p.o. q.d.
Lisinopril 5 mg p.o. q.d.
Ciprofloxacin 500 mg p.o. b.i.d. until [**2103-8-31**].
Lipitor 10 mg p.o. q.d.
Percocet p.r.n.
Albuterol metered dose inhaler two puffs every four hours and
p.r.n.
Atrovent metered dose inhaler two puffs every four hours and
p.r.n.
Lopressor 25 mg p.o. b.i.d.
Colace 100 mg p.o. b.i.d.
Zantac 150 mg p.o. b.i.d.
Aspirin 81 mg p.o. q.d.
FOLLOW UP: The patient was instructed to follow up with the
infectious disease clinic; an appointment was scheduled for
[**2103-9-3**] at 1:30 PM with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15474**] on the sixth
floor of the [**Doctor Last Name 780**] Building at [**Hospital1 190**].
DISCHARGE DIAGNOSES:
1. Hypertension.
2. Peripheral vascular disease.
3. Coronary artery disease, status post coronary artery
bypass grafting on [**2103-8-9**].
4. Aortic stenosis, status post aortic valve replacement on
[**2103-8-9**] with a tissue valve.
5. Transient ischemic attacks with episodes of monocular
blindness.
6. Carotid artery disease with 100% occlusion of the right
carotid artery.
7. Left leg claudication.
8. Status post right femoral-popliteal bypass graft.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2103-8-17**] 14:03
T: [**2103-8-17**] 16:12
JOB#: [**Job Number 108546**]
ICD9 Codes: 4241, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4347
} | Medical Text: Admission Date: [**2186-1-18**] Discharge Date: [**2186-2-14**]
Service: MEDICINE
Allergies:
Penicillins / Metoprolol
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation
Central Line placement
History of Present Illness:
HPI: 89 male with PMH sig for Parkinson's disease, AF, CHF (EF
35-40%), hx of aspiration requiring close monitoring during
feeding pureed substances, presented to ED with CC of dyspnea.
He was in his usual state of health until end of last week. His
family noted that he had slightly increased wheezing and SOB.
The course was intermittent and did not worsen immediately. His
respiratory status stablized over the weekand. He continued to
do well until this afternoon around 4-5pm. He had increased
wheezing and dyspnea. He also had increasing cough as well. He
was fed some ice cream and subseuqently developed respiratory
distress and cough. His respiratory status settle down a little
bit. He then went to the bathroom, where he was found later by
his family to have much worsened respiratory status.
.
The family (including daughters and wife) denied that he had
other complaints over the last several days. Denies fever,
chills, nausea, vomiting, headache, chest pain, exertional
dyspnea, abdominal pain, diarrhea or dysuria.
.
Of note, he was admitted in [**2185-12-31**] w/ cellulits of left leg
ulceration with [**Date Range 109815**] exposure. His leg film was negative for
osteomyelitis. He was seen by plastics, who felt that pt. should
have evaluation of vascularity to area of wound. Then, he was
seen by vascular surgery. Vascular surgery recommeded MRA to
determine feasibility of revascularization procedure. After
discussion within family, decided to defer MRA. He was treated
with vancomycin. His erythema, warmth, and tenderness to
palpation improved. On discharge. He was discharged w/ vascular
and plastic f/u. He was d/c on [**1-9**] w/ 4 more doses of vanco
over next 8 days. He finished vancomycin course on [**1-17**].
.
In [**Name (NI) **] pt was given dose of IV metoprolol 5 mg which caused some
resultant hypotension. However the hypotension persisted hours
after the single dose of metoprolol infusion. He did not respond
to IVF challenge and was transferred to [**Hospital Unit Name 153**] on Dpamine drip.
Past Medical History:
PMHx:
1) Parkinson's disease
2) BPH
3) Large left hernia
4) s/p appy
5) s/p hernia repair 20 yrs ago
6) atrial fib: dx [**1-1**], not on Coumadin, Rate 80-100
7) h/o CHF: TTE [**1-1**] EF 35-40%, [**11-28**]+ AR, [**11-28**]+ MR, 3+ TR, global
hypoK w/ distal lateral and inferolateral hypokinesis and apical
akinesis.
8) Fe def anemia
9) Hypothyroidism
10) CRI: baseline Cr 1.5-1.7
Social History:
Pt lives at home with his wife and daughter. [**Name (NI) **] is retired
construction/ engineer/ realestate man. No ETOH, tobaccol, or
drugs. Did occasionally smoke a pipe but quit greater than 20
years ago.
Family History:
[**Name (NI) 1094**] father had DM. Mother died of heart disease /rythm
problems. She was over 90 at her death. Daughter (alive at 47)
had Hodgkins many years ago.
Physical Exam:
VS: Temp 95.4 HR 115 BP 117/60 (Dop 6) RR27 Bipap 5/5
Gen: lying in bed in mod distress on non rebreather mask
HEENT: NC/ AT, PERRL, MMM
Neck: + JVD to jam, supple, no LAD
CV: irregularly irregular, ii/vi SM @ LSB
Chest: diffuse ant ronchi, bibasilar rales
Abd: Soft, NT, +BS
Ext: L foot with ulcer, [**Name (NI) 109815**] visible, no abcess/puss/erythema.
1+ LE edema
Neuro: A/O x 0, withdrwas to pain, opens eyes randomly, moves
all 4 extr spontanously
Pertinent Results:
Portable AP chest x-ray was obtained and compared to the
previous film from [**2186-1-18**], and [**2186-1-17**].
The ETT tube is inserted with its tip projecting 2.6 cm above
the carina. The cuff of the ETT tube looks to be overinflated
with distention of the proximal trachea.
The NG tube is in good position. The right subclavian catheter
is inserted with its tip projecting over the superior vena cava.
The extensive consolidation seen in the right lung as well as in
the left lower lobe may represent an overlying pneumonia in
addition to a known congestive heart failure. No significant
change in the lung opacification is present except for slight
improvement of the left lower lung consolidation.
IMPRESSION:
1. Status post insertion of the ETT tube with overinflation of
cuff. These findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
during dictating the exam.
2. Satisfactory position of NG tube and right subclavian
catheter.
3. Slight improvement of the left lower lobe consolidation.
Otherwise, no significant changes in comparison to the previous
study.
.
Echo
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm)
Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.1 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
TR Gradient (+ RA = PASP): *>= 31 mm Hg (nl <= 25 mm Hg)
This study was compared to the report of the prior study (images
not
available) of [**2185-1-14**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Suboptimal technical quality, a focal LV wall motion
abnormality cannot be fully excluded. Mild global LV
hypokinesis. Mildly depressed LVEF.
RIGHT VENTRICLE: Markedly dilated RV cavity. [Intrinsic RV
systolic function likely more depressed given the severity of
TR]. Abnormal septal motion/position consistent with RV
pressure/volume overload.
AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**11-28**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate to severe [3+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. There is mild global left ventricular
hypokinesis. Overall left ventricular systolic function is
mildly depressed (estimated ejection fraction ?45%). The right
ventricular cavity is markedly dilated. [Intrinsic right
ventricular systolic function is likely more depressed given
the severity of tricuspid regurgitation.] There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**11-28**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2185-1-14**], no definite segmental wall motion
abnormalities were identified in the current study. Left
ventricular systolic function may now be more rigorous but
prior images not available for comparison. Right ventricular
size and function were not described in the [**2185-1-14**] report
(depressed RV function was noted in the [**2185-6-7**] TEE report).
.
Cxr
[**Hospital 93**] MEDICAL CONDITION:
89 year old man s/p doboff tube placement via NG, in GE junction
by initial Xray, now s/p advancement.
REASON FOR THIS EXAMINATION:
Eval placement of Dobhoff tube
STUDY: AP chest.
FINDINGS: Compared to the prior study from two hours earlier.
The Dobbhoff tube has been advanced few centimeters, however the
tip still remains just at the gastroesophageal junction.
Nasogastric tube, endotracheal tube, and right-sided central
line are in unchanged position. There is bilateral airspace
opacities, right greater than left. There is a developing
opacity seen along the right lateral chest wall which may
represent some loculated fluid. The right side pleural effusion
is seen. There is likely an underlying _____ pulmonary edema as
well.
.
[**2186-1-18**] 11:00PM GLUCOSE-167* UREA N-39* CREAT-1.9* SODIUM-135
POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-19* ANION GAP-16
[**2186-1-18**] 11:00PM CALCIUM-7.8* PHOSPHATE-4.4 MAGNESIUM-2.0
[**2186-1-18**] 03:48PM O2 SAT-49
[**2186-1-18**] 03:46PM TYPE-ART PO2-71* PCO2-34* PH-7.39 TOTAL
CO2-21 BASE XS--3
[**2186-1-18**] 03:46PM LACTATE-1.8
[**2186-1-18**] 10:25AM CORTISOL-108.3*
[**2186-1-18**] 09:39AM CORTISOL-107.9*
[**2186-1-18**] 08:48AM CORTISOL-100.4*
[**2186-1-18**] 07:43AM TYPE-ART RATES-/28 O2-100 PO2-55* PCO2-33*
PH-7.39 TOTAL CO2-21 BASE XS--3 AADO2-641 REQ O2-100
INTUBATED-NOT INTUBA
[**2186-1-18**] 06:26AM GLUCOSE-113* UREA N-33* CREAT-1.9* SODIUM-139
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-20* ANION GAP-18
[**2186-1-18**] 06:26AM CK(CPK)-63
[**2186-1-18**] 06:26AM CK-MB-6 cTropnT-0.05*
[**2186-1-18**] 06:26AM CALCIUM-8.1* PHOSPHATE-3.2 MAGNESIUM-1.7
[**2186-1-18**] 06:26AM WBC-5.5 RBC-3.30* HGB-9.6* HCT-28.6* MCV-87
MCH-29.2 MCHC-33.6 RDW-19.5*
[**2186-1-18**] 06:26AM NEUTS-76* BANDS-15* LYMPHS-6* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2186-1-18**] 06:26AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
TARGET-OCCASIONAL BURR-OCCASIONAL STIPPLED-OCCASIONAL
[**2186-1-18**] 06:26AM PLT SMR-NORMAL PLT COUNT-294
[**2186-1-18**] 06:26AM PT-13.6* PTT-27.3 INR(PT)-1.2*
[**2186-1-18**] 12:20AM cTropnT-0.02*
[**2186-1-18**] 12:10AM GLUCOSE-145* UREA N-32* CREAT-2.0* SODIUM-141
POTASSIUM-5.0 CHLORIDE-109* TOTAL CO2-22 ANION GAP-15
[**2186-1-18**] 12:10AM LIPASE-15
[**2186-1-18**] 12:10AM LIPASE-15
[**2186-1-18**] 12:10AM CK-MB-NotDone proBNP-[**Numeric Identifier 109816**]*
[**2186-1-18**] 12:10AM ALBUMIN-3.0* CALCIUM-8.2* PHOSPHATE-3.8
MAGNESIUM-2.0
[**2186-1-18**] 12:10AM TSH-4.4*
[**2186-1-18**] 12:10AM WBC-4.6 RBC-3.36* HGB-9.5* HCT-29.7* MCV-88
MCH-28.4 MCHC-32.2 RDW-19.0*
[**2186-1-18**] 12:10AM NEUTS-85.3* BANDS-0 LYMPHS-11.6* MONOS-2.0
EOS-0.8 BASOS-0.3
[**2186-1-18**] 12:10AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-1+ ELLIPTOCY-1+
[**2186-1-18**] 12:10AM PLT SMR-NORMAL PLT COUNT-260
[**2186-1-18**] 12:10AM PT-12.7 PTT-23.7 INR(PT)-1.1
[**2186-1-18**] 12:10AM FIBRINOGE-351#
[**2186-1-18**] 12:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2186-1-18**] 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2186-1-18**] 12:10AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2186-1-17**] 11:54PM TYPE-ART RATES-/36 PEEP-10 O2-100 PO2-74*
PCO2-36 PH-7.37 TOTAL CO2-22 BASE XS--3 AADO2-619 REQ O2-99
INTUBATED-NOT INTUBA VENT-SPONTANEOU
[**2186-1-17**] 11:54PM GLUCOSE-157* LACTATE-1.9 NA+-140 K+-4.8
CL--108
[**2186-1-17**] 11:54PM freeCa-1.13.
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2186-2-2**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
[**2186-2-7**] 4:10 pm BLOOD CULTURE
**FINAL REPORT [**2186-2-13**]**
AEROBIC BOTTLE (Final [**2186-2-13**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2186-2-13**]): NO GROWTH.
Brief Hospital Course:
89 yo M PMH of Parkinson's, AF not on Coumadin, CHF presents
with 1 week of progressive SOB in addition to an acute episode
of aspiration in respiratory distress and acute or chronic renal
failure, his hospital course is discussed by problem:
.
1. CHF: Initially, the patient had a CXR consistent with
pulmonary edema, secondary to CHF, a known LVEF of 40% and BNP
of 10,000. He was carefully diuresed in the acute setting, but
his hypotension, as described below, made it a difficult
balance. An echocardiogram indicated right heart failure, and
he required pressors for blood pressure control. He was
eventually weaned off the pressors, and successfully diuresed
with IV Lasix, which were eventually changed to oral. Upon
transfer to the medicine floor, he was initially continued on
the Lasix regimen, with a fluid goal of negative 500 cc to even
balance on a daily basis. After his foley was removed, however,
it was more difficult to measure strict Is/Os as the patient was
incontinent of urine. He had one episode of hypotension with
his systolic pressure dropping to the 80's. It improved and
stabilized with a gentle fluid bolus, and the Lasix was held for
the remainder of his hospitalization. His lung exam did not
demonstrate new rales or crackles, and his oxygen requirements
remained stable. Therefore, the Lasix was discontinued and may
be restarted as an outpatient depending on the patient's fluid
balance once he is on a regular schedule with his tube feeds.
In addition, it was felt that with a depressed ejection
fraction, the patient would likely benefit from an ACE
inhibitor. However, this was not initiated given his history of
hypotension, but may be considered in the future.
.
2. Hypotension: The patient was hypotensive and pressor
dependent while in the [**Hospital Unit Name 153**]. It was felt that this was most
likely multifactorial. The patient had been in A-fib with a rate
of 110's, leading to decreased filling time. In addition, the
patient may have been septic given the pulmonary process on CXR,
hypothermia, and sputum/cough. He was administered broad
spectrum antibiotics and treated with an approximately two week
course of antibiotics for likely aspiration pneumonia. He was
initially started on a dopamine drip at maximum doses, but given
poor urine output, he was changed to levophed; and then
secondary to tachycardia it was changed to Neo-Synephrine for
blood pressure stabilization. Upon transfer to the medicine
floor, his blood pressure remained stable other than one episode
of hypotension that responded to a gentle fluid bolus.
.
3. Resp distress: This was thought to be due to CHF with resp
pneumonitis/ PNA. He was initially on a nonrebreather,
alternated with bipap. As the patient respiratory status
continued to decline, discussions were made the family regarding
goals of care, and his HCP decided intubation was in the goals
of care. He was intubated and later successfully extubated on
[**1-30**]. He completed an approximately two week course of
antibiotics for pneumonia, although there was likely a component
of chemical pneumonitis from aspiration as well.
.
4. Afib: The patient was found to be in atrial fibrillation with
hr into 100's. Given that he had become hypotensive in the ED
after receiving nodal agents and had a history of sinus arrest
on metoprolol, nodal agents were avoided. His tachycardia
resolved with treatment of underlying factors (sepsis/ CHF). On
transfer to the medicine floor, he was in sinus rhythm at a
normal rate by EKG. It was decided not to put the patient on
anticoagulation given his fall risk.
.
5. Anemia: The patient had a history of iron deficiency anemia,
and also had recent blood loss from elbow after falling. His
hematocrit was monitored, and remained stable throughout his
admission, was 30 at the time of discharge. He did not have any
guaiac positive stools while on the medicine floor.
.
6. ARF: This was thought to be secondary to a decreased
intravascular volume and poor forward flow due to CHF. With
diuresis and subsequent fluid mobilization resulting in
increased intravascular volume, the patient's acute renal
failure resolved, and his creatinine normalized to .9. He
maintained a good urine output, and upon transfer to the floor
his foley was successfully removed.
.
7. Chronic RLE ulcer: The patient was initially treated with IV
Vanco given his history of MRSA. He was evaluated by wound care
nursing, with recommendations followed. In addition, the
patient was seen by the plastics service. They recommended
resection of the [**Month (only) 109815**], but the family was against any type of
surgical intervention. The patient has also been seen by
vascular as an outpatient, but the family refused to have an MRA
of the leg. Upon transfer to the floor, the patient was seen by
both the plastic service and wound care nursing, and the family
was provided the number to Dr.[**Last Name (STitle) 17650**] clinic for follow-up within
one-two weeks as an outpatient.
.
8. ID- Upon transfer to the medicine floor, the patient
remained afebrile, without a leukocytosis. Blood cultures were
negative and was found to be c-diff negative on three separate
occasions. He was maintained on contact precautions for history
of MRSA bacteremia ([**5-31**]). His central line was carefully
monitored on the floor, without any evidence of infection. It
was removed on the day of discharge.
.
9. Asymmetric Lower extremity edema: The patient was found to
have increased edema of the right lower extremity when compared
to the left. He was ruled out for a DVT, no evidence of
infection or cellulitis. It was thought that this may be
dependency related from lying on R side. This was carefully
monitored, the patient was repositioned frequently, and
continued to work with PT to increase mobility as much as
possible.
.
10. Mental Status/Parkinson's disease: He was restarted on his
home medications. Speech therapy worked with the patient on
multiple occasions, and PT/OT followed the patient as well. The
family will follow-up with Dr. [**Last Name (STitle) **] as instructed on an
outpatient basis, as he does not do inpatient consults when he
is not on service. Given that there were no acute neurological
issues, it was felt that a [**Last Name (STitle) **] consult was not necessary.
After he failed a speech and swallow eval, a discussion was had
with the family regarding access to nutrition and the aspiration
risks. A Dobhoff tube was placed under IR and the patient was
started on tube feeds. Dr. [**Last Name (STitle) 349**] and the GI service
discussed PEG tube placement with the family, and a PEG tube was
eventually placed. Nutrition service followed for tube feeding
recommendations, and the patient was started on a 14 hour
cycling (overnight) schedule. The family underwent
education/instruction regarding PEG tube care and use, and home
VNA services were arranged.
.
The patient will follow-up with his PCP, [**Name10 (NameIs) 878**], and Plastics
as instructed.
Medications on Admission:
1. Carbidopa-Levodopa 25-100 mg Po tid
2. Finasteride 5 mg po qd
3. Terazosin 5 mg po qhs
4. Levothyroxine 25 mcg [**11-28**] po qd
5. Lansoprazole 30 mg po qd
6. Colace 100 mg po bid
7. Aspirin 81 mg Tablet po qd
8. Brimonidine 0.15 % Drops OU [**Hospital1 **]
9. Multivitamin po qd
10. Zinc Sulfate 220 mg po qd
11. Entacapone 200 mg po tid PRN Parkinson's
12. Silver Sulfadiazine 1 % Cream tid
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*qs * Refills:*2*
5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Disp:*qs * Refills:*0*
7. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
Disp:*qs ML(s)* Refills:*2*
8. Pramipexole 1 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day) as needed for Parkinson.
Disp:*90 Tablet(s)* Refills:*0*
9. Entacapone 200 mg Tablet Sig: One (1) Tablet PO tid () as
needed for parkinsons.
Disp:*30 Tablet(s)* Refills:*0*
10. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO TID
(3 times a day).
Disp:*135 Tablet(s)* Refills:*2*
11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily).
Disp:*qs mg* Refills:*2*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
Disp:*60 Capsule(s)* Refills:*0*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
14. Probalance Liquid Sig: as instructed PO at bedtime:
100cc/ hr to be cycled 14 hours overnight.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Sepsis secondary to aspiration pneumonia
congestive heart failure
Parkinson's disease
Left lower extremity ulcer
Paroxysmal atrial fibrillation
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
.
Please continue to take all of your medications as instructed.
Call your doctor or return to the hospital if you develop
fevers/ chills/ chest pain, or difficulty breathing.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2186-4-28**] 12:30
.
Please call [**Telephone/Fax (1) 4652**] and speak with [**Doctor Last Name **] to schedule an
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Surgery) within two weeks to
have his wound evaluated.
ICD9 Codes: 0389, 5849, 5070, 4280, 2761, 4589, 2859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4348
} | Medical Text: Admission Date: [**2185-3-18**] Discharge Date: [**2185-3-28**]
Date of Birth: [**2107-8-21**] Sex: M
Service: MEDICINE
Allergies:
lisinopril / hydrochlorothiazide
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Capsule Endoscopy
Single balloon enteroscopy
History of Present Illness:
This is a 77 year old male with PMH of CAD s/p MI [**04**] years ago,
PVD s/p bilateral lower extremity bypass surgery with Y graft in
[**2171**], claudication, and chronic kidney injury presenting in
transfer from the ICU at [**Hospital6 10353**] for further
evaluation of GI bleeding. He first presented to his primary
care physician for further evaluation of claudication on [**3-14**].
Routine lab work at that time revealed a Hct of 25 and he was
referred for an outpatient EGD/colonoscopy at [**Hospital3 13347**]. He received 1 unit PRBCs as an outpatient on [**3-15**] and
again on [**3-16**]. On [**3-17**], the EGD revealed an irregular Z-line,
suspicious for short segment Barrett's esophagus. He also had a
non-obstructing mild Schatzki's ring with erythematous gastric
mucosa and a normal duodenal bulb. The colonoscopy showed old
tarry blood in his colon and terminal ileum with non-bleeding
initernal hemorrhoids. Following this outpatient procedure, he
was referred for admission to [**Hospital6 10353**] for
observation and received another unit of PRBCs. He received a
total of 3 units that week and remained hemodynamically stable
throughout his hospital course. Given his chronic kidney
insufficiency, there was concern about administering contrast
for a CTA abdomen. He was therefore referred to [**Hospital1 18**] for
further management and potential enteroscopy.
.
On arrival to the MICU, the patient had no acute complaints. He
has not had any bowel movements since his bowel prep for the
colonoscopy on [**3-17**]. He reports that he noticed dark stools at
home over the last couple of weeks, but did not see any frank
blood. He thought that the change in his stool color was
secondary to eating more black olives and chocolate cake
recently.
Past Medical History:
-CAD s/p MI in [**2153**]
-PVD s/p bilateral lower extremity bypass with Y-graft in [**2171**],
on coumadin
-Claudication
-Chronic kidney injury
-CVA
Social History:
Lives with his wife of 53 years in a Senior Living Housing
Complex in [**Hospital1 392**]. He is independent in his ADLs, iADLs. He is
retired since [**2171**] and used to manage a warehouse for a living.
His oldest son just passed away at age 51. Otherwise, he has a
daughter who is a nurse [**First Name (Titles) **] [**Hospital6 10353**] and a son who
is 50. He smoked [**1-10**] PPD for 20 years, but quit 31 years ago
after his MI. He does not have a history of alcohol or IVDU.
Family History:
Positive for CAD, mother passed away at age 52.
Physical Exam:
Vitals: T: 97.9, BP: 169/68, P: 64, R: 11, O2: 93% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple
CV: Regular rate and rhythm, 2-3/6 systolic ejection murmur
noted
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge Exam:
VSS
GEN: Patient lying comfortably in bed nad a+ox3
HEENT: MMM oropharynx clear
NECK: supple no thyromegaly
CV: rrr no m/r/g
RESP: ctab no w/r/r
ABD: soft nt nd bs+
EXTR: no le edema good pedal pulses bilaterally
DERM: no rashes, ulcers or petechiae
neuro: cn 2-12 grossly intact non-focal
PSYCH: normal affect and mood
Pertinent Results:
Admission labs:
[**2185-3-18**] 05:26PM GLUCOSE-101* UREA N-31* CREAT-1.7* SODIUM-142
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-15
[**2185-3-18**] 05:26PM ALT(SGPT)-20 AST(SGOT)-24 LD(LDH)-143 ALK
PHOS-77 TOT BILI-0.5
[**2185-3-18**] 05:26PM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-2.8
MAGNESIUM-2.2 IRON-40*
[**2185-3-18**] 05:26PM calTIBC-298 FERRITIN-47 TRF-229
[**2185-3-18**] 05:26PM WBC-5.5 RBC-3.98* HGB-11.4* HCT-32.8* MCV-82
MCH-28.8 MCHC-34.9 RDW-15.8*
[**2185-3-18**] 05:26PM NEUTS-57.5 LYMPHS-30.1 MONOS-5.7 EOS-5.7*
BASOS-1.1
[**2185-3-18**] 05:26PM PLT COUNT-215
[**2185-3-18**] 05:26PM PT-16.3* PTT-39.0* INR(PT)-1.5*
[**2185-3-18**] 05:26PM RET AUT-3.9*
EKG: Normal sinus rhythm at 83 with PVCs, Q waves in inferior
leads suggestive of prior infarct
.
[**3-17**] EGD- Irregular Z-line, suspicious for short segment
Barrett's esophagus. Non-obstructing mild Schatzki's ring.
Erythematous gastric mucosa. Normal duodenal bulb.
.
[**3-17**] Colonoscopy- Old tarry blood in colon and terminal ileum.
Tortuous colon. Non-bleeding internal hemorrhoids.
.
Capsule Endoscopy ([**2185-3-21**])
1) Fresh blood is seen in a segment of the small bowel
(0:1:46:18), likely in the proximal to mid jejunum. Debris are
seen in the lumen but an underlying mass lesion cannot be
excluded.
2)A single lymphangiectasia is seen in the duodenum.
3) Multiple venous structures are seen throughout the small
bowel.
4)Limited visualization of the stomach due to excessive debris.
.
Single Ballon Enteroscopy ([**2185-3-23**])
Normal esophagus. Normal stomach. Normal duodenum.
The distal jejunum was reached. It was tattooed with Indian Ink.
There was a sharp angulation that prevented further advance of
the scope. otherwise the exam of the jejunum was normal. No
evidence of bleeding or mass was seen .
Otherwise normal single balloon enteroscopy to distal jejunum
under fluoroscopic guidance and with direct endoscopic view.
.
MR enterography [**2185-3-27**]([**First Name9 (NamePattern2) 5692**] [**Location (un) 1131**]):
Preliminary ReportIMPRESSION:
1. No mass lesion identified on this limited study. CTA is more
sensitive
for identifying occult GI bleeds and should be considered in
this patient.
2. Cholelithiasis without evidence of cholecystitis.
3. Prior aortobifemoral bypass with some irregularity of the
left common
iliac graft. This could also be further evaluated at the time of
CTA if required.
Discharge labs:
[**2185-3-28**] 06:35AM BLOOD WBC-7.7 RBC-3.40* Hgb-9.4* Hct-29.0*
MCV-85 MCH-27.7 MCHC-32.5 RDW-15.0 Plt Ct-264
[**2185-3-28**] 01:45PM BLOOD Hct-28.6*
Brief Hospital Course:
77 year old male with PMH of CAD s/p MI [**04**] years ago, PVD s/p
bilateral lower extremity bypass surgery with Y graft in [**2171**],
claudication, and chronic kidney injury presenting in transfer
from the ICU at [**Hospital6 10353**] for further evaluation of
GI bleeding.
On arrival to the MICU the evening of [**3-18**], the patient had no
acute complaints. He has not had any bowel movements since his
bowel prep for the colonoscopy on [**3-17**]. He reports that he
noticed dark stools at home over the last couple of weeks, but
did not see any frank blood. He thought that the change in his
stool color was secondary to eating more black olives and
chocolate cake recently. He remained hemodynamically stable
throughout the MICU course with HCT at 33 and was transferred to
the general medicine service on [**3-19**]. Just before transfer, he
received Vitamin K 5mg PO x1. On arrival, he states that he
feels well.
.
#. GI Bleed. Source is likely small bowel. Patient reports 2
weeks of dark stools prior to presentation, but no BRBPR. EGD
shows gastritis, likely short segment Barrett's esophagus, and
mild Schatzki's ring. Colonoscopy showed old tarry blood in
colon and terminal ileum with a tortuous colon and non-bleeding
internal hemorrhoids. Hct stable on admission at 32.8 after 3
units of pRBC transfusion since admission on [**3-17**] at outside
hospital. Initial Hct was 25. Possibility of [**Last Name (un) 30060**] syndrome
given that he has a murmur suggestive of aortic stenosis. Was
transferred to the [**Hospital Ward Name **] for Capsule endoscopy which on
[**3-21**] revealed a lesion in the jejumum. He received an
additional 2 units PRBCs on [**3-22**] for Hct of 25. He underwent
single balloon enteroscopy, which did not reveal a bleeding
source. Since the enteroscopy, his hematocrit has remained
stable, although he continues to have Guaic + stools. He
underwent an MRE to evaluate for small bowel pathology which
showed no masses although it could not be done with IV contrast.
His hct was slight downtrending on day of discharge (28.6), but
he was asymptommatic and he will have a close PCP follow up and
call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 81451**] for double balloon enteroscopy. He was
discussed with GI who thought he was stable for discharge. The
patient will have a copy of his capsule endoscopy and balloon
enteroscopy when he is discharged. PCP f/u on [**2185-3-31**] and then
with Dr. [**Last Name (STitle) 81451**].
.
#Hx of stroke 14 year ago placed on Coumadin with goal INR [**2-11**]:
Coumadin and ASA were initially held prior to
enteroscopy/capsule endoscopy. After discussion with the GI
team, primary team and family the patient was restarted on his
asa 81mg and coumadin was held. Patient will f/u with PCP [**Last Name (NamePattern4) **]
[**2185-3-31**]. Coumadin should be held until bleeding source can be
found.
#. CKD III -. Patient's admission creatinine is 1.7 which has
decreased slightly to 1.6. After MR enterography a suggestion
to have CTA to evaluate for occult bleed was made by radiology,
but with pt already having enteroscopy and capsule endoscopy,
planned for a double balloon enteroscopy and concern for
worsening his renal disease (contrast induced nephropathy), the
ct scan was deferred. He will follow up with GI for his bleed
and PCP will [**Name Initial (PRE) **]/u with ckd.
.
#. CAD: initially asa was held in setting of bleeding. After
enteroscopy, asa was restarted. Statin was continued throughout
his hospitalization
.
Medications on Admission:
-gemfibrozil 600mg PO QHS
-furosemide 20mg PO daily
-amlodipine 20mg PO daily
-Zetia 10mg PO daily
-clonidine 0.2mg PO BID
-ASA 81 mg
-coumadin 2.5mg [**Doctor First Name **]/Tu/Th, 1.25mg M/W/F/Sat
-pravachol 80mg
- per patient recently started Pletal but has only taken one
dose
Timolol 0.5% 1-2 drops each eye daily
Discharge Medications:
1. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for gout flare.
5. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
6. clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for low blood counts from a gi
bleed. A single ballon enteroscopy was performed but could not
find a source of the bleeding. A capsule endoscopy and MR
enterography were also performed, but no clear source of
bleeding was found. You were transfused 2 units of blood on
[**3-22**] and your blood counts increased appropriately. On the day
of discharge your blood counts had been stable for 4 days and
were slightly downtrending, but you did not have any symptoms.
You will have a follow up with your primary care physician [**Last Name (NamePattern4) **] 2
days and will also follow up with Dr. [**Last Name (STitle) 81451**] for a procedure to
look for a bleeding source(double balloon enteroscopy). Please
stop taking coumadin because it could make your bleeding worse.
Medication change
1. Stop taking coumadin
2. Hold your lasix until you are seen by PCP
Followup Instructions:
Name: NP [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) **]
Location: [**Hospital 20086**] MEDICAL GROUP
Address: [**Street Address(2) 20087**], STE 3A, [**Hospital1 **],[**Numeric Identifier 20089**]
Phone: [**Telephone/Fax (1) 7164**]
Appointment: Thursday [**2185-3-31**] 11:00am
*This is a follow up appointment for your hospitalization. You
will be reconnected with your primary care physician after this
visit.
Please contact Dr.[**Name2 (NI) 92092**] office to set up your followup
procedure(double balloon enteroscopy)
ICD9 Codes: 5789, 2851, 4439, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4349
} | Medical Text: Admission Date: [**2188-8-27**] Discharge Date: [**2188-9-5**]
Date of Birth: [**2120-8-28**] Sex: M
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
male with a 2-week history of nausea and vomiting with
possible coffee-grounds emesis which occurred one time,
history of abdominal pain after eating around his front mid
epigastric area with some radiation to the back (which he
described as sharp) who presented to the Emergency Room with
a pulse of 60 and a blood pressure of 75/48. He was given 3
liters of normal saline with an increase in his blood
pressure to 95/48. He was also given Flagyl and Levaquin for
a question of sepsis secondary to a bandemia on his
laboratories and was subsequently transferred to the Medical
Intensive Care Unit because it was discovered that his
hematocrit had dropped 10 points in two weeks.
At that time, it was thought that the patient had a slow
gastrointestinal bleed secondary to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear or
gastritis rather than an ulcer. He had a lavage which showed
red-colored fluid which cleared with 500 mL of normal saline.
The patient still complained of nausea and vomiting up to 1.5
liters of fluid without blood upon his transfer to the
Medicine Service.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient's vital signs were stable. He was
afebrile. In general, he was a well-appearing thin male in
no apparent distress. His pupils were equally round and
reactive to light. His had dry mucous membranes. Cranial
nerves II through XII were intact. His extraocular movements
were intact but delayed. His neck examination revealed he
had no jugular venous distention. It was supple without
masses. He had good carotid pulses without bruits, and no
thyromegaly. On cardiovascular examination he had a regular
rate and rhythm without murmurs, rubs or gallops. Pulmonary
examination was bilaterally clear to auscultation. Abdominal
examination revealed positive bowel sounds, soft, nontender,
and nondistended. His extremities showed trace edema in both
lower extremities, but no clubbing or cyanosis. His back
showed no midline tenderness. Neurologic examination
revealed cranial nerves II through XII were intact. Altered
sensation in the distal extremities. Psychiatrically, the
patient extremely pleasant and conversant, alert and oriented
times three.
PERTINENT LABORATORY DATA ON PRESENTATION: His laboratories
upon admission revealed he white blood cell count was 11.4,
hemoglobin was 10.3, hematocrit was 30.7 (down from 40.9 on
[**2188-8-8**]), with a platelet count of 455. His
Chemistry-7 revealed sodium was 127, potassium was 7.6
(hemolyzed), chloride was 92, bicarbonate was 23, blood urea
nitrogen was 87, creatinine was 2 (up from 1.8), and blood
glucose was 223. The patient had an ALT of 16, AST was 40.
Creatine kinase was 62. Alkaline phosphatase was 53, albumin
was 2.5.
RADIOLOGY/IMAGING: A chest x-ray was read as normal without
any infiltrates or free air.
His electrocardiogram showed no changes.
HOSPITAL COURSE: On [**2188-8-26**], he had an
esophagogastroduodenoscopy which showed a normal esophagus
and duodenum. The stomach with diffuse friability, edema
with nodularity and alternation of the mucosa, with contact
bleeding in the prepyloric region and antrum. There was
narrowing of the pylori secondary to edema; compatible with
severe gastritis and ulceration. Neoplasia could not be
ruled out. It was recommended that the patient have
inpatient followup.
He was made n.p.o., current intravenous proton pump inhibitor
and was recommended, and was recommended for outpatient
repeat endoscopy in 7 to 10 days with a biopsies at that
time.
His laboratories upon transfer from the Medical Intensive
Care Unit to the Medicine [**Hospital1 **] on [**2188-8-27**] showed a
white blood cell count of 12.1, hemoglobin was 12, hematocrit
was 35.6, and platelets were 329. His electrolytes had been
stabilized to a sodium of 142, potassium was 5, chloride
was 111, bicarbonate was 16, blood urea nitrogen was 25,
creatinine was 1, blood glucose was 105. Calcium was 8, and
magnesium was 2.1.
The patient was transferred to the Medicine Service; and
instead of being discharged to home with outpatient followup,
it was decided that he would have his
esophagogastroduodenoscopy with biopsies done subsequently
during his stay as an inpatient.
These biopsies showed pyloric obstruction. Biopsies were
taken which subsequently showed lymphoma, and various
consultation services were called to see the patient.
Oncology had been following the patient immediately prior to
the findings that there was obstruction between the stomach
and the duodenum, and they did a bone marrow biopsy; the
results of which were pending. The patient was also followed
by Radiology/Oncology. He was followed by Surgery in case it
was necessary to relieve the obstruction, and the patient was
followed by Nutrition because total parenteral nutrition was
begun after a few days of the patient being n.p.o. He was
also followed by the Gastrointestinal Service who had
performed the esophagogastroduodenoscopy with biopsies.
Prior to his transfer to the Oncology Service, the patient
had a peripherally inserted central catheter line placed so
that he could receive total parenteral nutrition. He was
also continued on Zofran and pantoprazole. He had a
nasojejunal tube placed by Interventional Radiology. He was
started on allopurinol intravenously with a baseline uric
acid drawn which was normal.
He had a CT scan of the abdomen done for staging which showed
small bilateral pleural effusions, thickening circumference
of the gastric antrum, large lymph nodes up to 2 cm in the
gastrohepatic ligament, and the peripancreatic gastrosplenic
para-aortic, and autocoidal areas which were worrisome for
metastatic disease. He had no free air or fluid, and it was
also found that he had bilateral adrenal masses with low
attenuation; not consistent with adenoma.
His CT of the pelvis showed no free air or fluid and no bony
lesions.
Given these results, a cortisol level was drawn which was
normal, and the patient was scheduled for a gallium scan. He
was subsequently transferred to the Oncology Service with his
discharge status being good.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES: Lymphoma.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 15575**]
MEDQUIST36
D: [**2188-9-12**] 20:27
T: [**2188-9-20**] 03:52
JOB#: [**Job Number 15576**]
ICD9 Codes: 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4350
} | Medical Text: Admission Date: [**2193-8-14**] Discharge Date: [**2193-8-23**]
Date of Birth: [**2114-5-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 15397**]
Chief Complaint:
Cough, decreased responsiveness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 79 yo [**Location 7972**] male with a hx of DM2, HTN,
HL who presents with cough for several days, as well as
decreased responsiveness. The patient was recently admitted to
[**Hospital1 18**] from [**Date range (1) 12542**] and again [**8-7**]/-[**8-12**] for pneumonia. On the
first admission, was treated with five day course of
levofloxacin, on the most recent was treated with vanc/cefepime
-> narrowed to azithro/cefpodoxime, which he should still be
taking. He is now brought to the ED by ambulance from home with
cough, decreased responsiveness. Per the patient's daughter, he
was intermittently weak and confused during the last
hospitalization, but seemed to be fine and talkative until about
noon today. This morning she gave him breakfast - he ate well
and was communicative, and did not appear to be choking. Around
noon she tried to give him lunch and he refused to open his
mouth, was sleepy and weak appearing. He was not complain of any
nausea or pain.
In the ED, initial VS were 98.6 106 122/60 36 98% 10L. He was
found to have an anion gap of 15, K 5.7, glucose 373. U/A was
notable for 1000 glucose but no ketones, no cells. ABG showed
7.49/28/93/22. CXR was consistent with LLL/retrocardiac opacity
that was also seen on prior xrays last week. He was given
vanco/cefepime, Ca and started on an insulin gtt. Prior to
transfer, repeat chem 7 was drawn and gap had closed to 10. He
was admitted to the micu for further management.
On arrival to the MICU, patient difficult to understand with
soft voice. Not able to speak though phone interpreter because
patient unable to enunciate vs unable to understand vs too
somnolent.
Review of systems: Unable to obtain
Past Medical History:
- type two diabetes (last hemoglobin a1c ~ 10 in [**5-9**])
- hypertension
- hyperlipidemia
- incontinence to urine over past month, cause unknown
- wheelchair bound since last [**Month (only) 216**], cause unknown, reports "i
have a problem with my legs and grab onto my wheelchair"
- question of peripheral neuropathy
- dementia
Social History:
Distant 50 pack year smoking history, distant alcohol history,
lives in [**Location 686**] with one of his daughters, [**Name (NI) **]. [**Name2 (NI) **] has
many sons and daughters. [**Name (NI) **] has been married twice, his new wife
lives in [**Country 3587**].
Family History:
Negative for cardiac disease.
Physical Exam:
On admission:
Vitals: T: 98.3 BP: 117/56 P: 80 R: 23 O2: 96% on 4L
General: ill-appearing, thin elderly male
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
On discharge:
Vitals: T97.6, HR 152-172/78-94, HR 86, RR 18, POx 95%RA
General: thin elderly male, sitting in bed watching television.
Exam somewhat difficult [**2-28**] difficulty communicating
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Keeps it bent to the left, no meningisimal signs this AM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Initial rattle clears with forceful cough; then clear to
auscultation bilaterally, no wheezes, rales, ronchi
Abdomen: soft, nontender, soft distension, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no pedal edema
Neuro: EOMI. strength unable to assess [**2-28**] pt deferred, grossly
normal sensation, 2+ reflexes bilaterally, gait deferred
Pertinent Results:
On admission:
[**2193-8-14**] 02:00PM BLOOD WBC-9.7# RBC-5.38 Hgb-15.1 Hct-46.1
MCV-86 MCH-28.0 MCHC-32.7 RDW-12.8 Plt Ct-230
[**2193-8-14**] 02:00PM BLOOD Neuts-83.8* Lymphs-9.5* Monos-4.7 Eos-1.7
Baso-0.3
[**2193-8-14**] 02:00PM BLOOD PT-15.9* PTT-25.8 INR(PT)-1.5*
[**2193-8-14**] 02:00PM BLOOD Glucose-373* UreaN-18 Creat-1.2 Na-136
K-5.7* Cl-100 HCO3-21* AnGap-21*
[**2193-8-14**] 02:00PM BLOOD ALT-105* AST-71* AlkPhos-73 TotBili-0.7
[**2193-8-14**] 02:00PM BLOOD Albumin-4.2
[**2193-8-14**] 08:08PM BLOOD Calcium-9.5 Phos-3.5 Mg-1.7
ABG [**2193-8-14**] 02:06PM BLOOD pO2-93 pCO2-28* pH-7.49* calTCO2-22
Base XS-0 Comment-GREEN TOP
On discharge:
[**2193-8-21**] 06:20AM BLOOD WBC-4.9 RBC-4.34* Hgb-12.2* Hct-37.5*
MCV-87 MCH-28.1 MCHC-32.5 RDW-12.8 Plt Ct-245
[**2193-8-21**] 06:20AM BLOOD Plt Ct-245
[**2193-8-21**] 06:20AM BLOOD Glucose-141* UreaN-14 Creat-1.3* Na-144
K-3.4 Cl-109* HCO3-24 AnGap-14
[**2193-8-22**] 10:10AM BLOOD Creat-1.2
[**2193-8-21**] 06:20AM BLOOD ALT-93* AST-69* AlkPhos-45
[**2193-8-21**] 06:20AM BLOOD Phos-3.0 Mg-1.7
[**2193-8-20**] 07:30PM BLOOD Vanco-17.5
Radiology:
[**8-15**] CXR
IMPRESSION: Increased left lower lobe opacity, likely
combination of effusion and atelectasis.
[**8-16**] CXR
There is no significant change since the previous exam. There
are bibasilar mild atelectases. Stable left retrocardiac
opacities can be atelectasis, but superimposed infection or
aspiration cannot be excluded in the appropriate clinical
setting.
[**8-15**] CT Head w/o contrast:
No evidence of acute disease. Mild atrophy.
Microbiology:
[**8-14**], [**8-15**], [**8-16**], [**8-17**]: negative except one bottle of
coag-negative staph aureus (likely skin contamination).
====================
VIDEO SPEECH AND SWALLOW EVALUATION [**2193-8-21**]
Mr. [**Known lastname 15655**] presented with a slight improvement in his oral and
pharyngeal swallow with reduced aspiration compared to his
previous study, but he is continuing to intermittently aspirate
both thin and nectar thick liquids. His aspiration remains
silent, or without spontaneous coughing and he could not cough
on
command to try to clear aspirate material. Compensatory
techniques were attempted, but pt could not follow commands to
implement these on the study.
At this time, there continues to be no diet that is free from
risk of aspiration an the safest recommendation is to remain
NPO.
Pt was admitted with lethargy and altered mental status which
are
resolving, and his current swallow function may be baseline
given
his history of PNAs. Agree with discussions with pt and his
family which team is pursuing to determine goals of care. If his
family wishes to accept the risks of aspiration and allow the pt
to eat, suggest a PO diet of thin liquids and moist, ground
solids (no pieces larger than ground beef). Thickening his
liquids did not significantly reduce the risk of aspiration on
today's study. We are happy to follow up and participate in any
family meetings if helpful to relay the above results.
FOIS rating of 1
RECOMMENDATIONS:
1. There are no consistencies that are free from risk of
aspiration at this time
2. Continue discussions regarding goals of care and nutritional
plan (POs accepting the risk of aspiration vs PEG tube)
3. If pt and his family agree to accept the risks of aspiration,
suggest a PO diet of thin liquids and moist, ground solids, as
thickened liquids did not significantly reduce the risk of
aspiration.
4. Regular oral care with mouthwash as able- Q4 during admission
5. Meds crushed with purees
6. We are happy to participate in family meetings if helpful
Brief Hospital Course:
Mr. [**Known lastname 15655**] is a 79y/o gentleman with underlying dementia and
diabetes who was admitted due to lethargy and cough. In the
MICU, he was diagnosed with an aspiration pneumonia for which he
was treated with antibiotics. During his stay, he was evaluated
by Speech and Swallow, and he was shown to silently aspirate.
Based on goals of care, the decision was made to allow him to
eat a modified diet, accepting the risks of aspiration, and he
was discharged home.
#. Lethargy/somnolence: aspiration pneumonia.
He was treated with a full course of antibiotics for aspiration
pneumonia with Vanc ([**Date range (1) 15659**]) and Zosyn ([**Date range (1) 15660**]). His WBC
count decreased (~5 on discharge) and he remained afebrile.
Unfortunately, infection is likely from aspiration and it is
expected that he will develop subsequent aspiration pneumonias.
This was discussed with his daughter (please see "Goals of care"
below).
#. Aspiration: still persists.
He has known pharyngocele but it is unclear if this is
contributing. He might have an esophageal cause for his
aspiration. He was assessed by Speech and Swallow, and indeed,
aspiration was noted. He was initially made NPO and his
coughing resolved, and with food he was noted to cough again.
Repeat video oropharyngeal exam revealed that his swallow
function was improved but that he was still aspirating. He is
being discharged on a [**Hospital1 **] PPI to attempt to prevent aspiration
pneumonia.
#. Goals of care: no invasive measures, goal of being home.
Family meetings was held. Given that he has significant
dementia with poor nutritional status, his overall prognosis is
poor (likely has a life expectancy <6mo or a year). In light of
this, daughter [**Name (NI) **] would not want any aggressive measures with
regards to his aspiration, i.e. would not pursue a GJ-tube. She
believes that he would not want any interventional measures if
he were to decompensate and the decision was made to change his
code status to DNR/DNI. Goals of care also include going home
(she would not want him to be placed in a Nursing home).
Consideration was made to going to acute rehab but per Physical
Therapy evaluation, his functional mobility is unlikely to
improve so he would not be likely to benefit. He should,
however, have a home PT evaluation. In addition to having
visiting Nurse services for diet teaching, med teaching, and
evaluation for other services, he should have a Social Work
referral to initiate discussions about possible "Do not
hospitalize" status in the future, as well as bridge to hospice.
#. Dementia: likely [**Last Name (un) 309**] body dementia.
MRI head from [**2193-5-27**] significant only for chronic small vessel
ischemic disease, but this could be contributing to gait
difficulties. Gerontology was consulted and concluded that pt
most likely suffers from [**Last Name (un) 309**] Body Dementia as pt has a h/o
hallucinations, and recommended nonpharmacologic interventions
to prevent delirium.
***He should not receive antipsychotics such as Haldol and
Seroquel as he likely has [**Last Name (un) 309**] Body dementia.***
#. DM2: stable.
He had stable blood sugars but in light of his decreased oral
intake of food he is being discharged on a lower dose of
Glargine. Will continue on Metformin. Has follow-up planned
with his PCP. [**Name10 (NameIs) **] he develops blood sugars <70 or >300 he should
contact his PCP.
Transitional issues:
-Antipsychotics are discouraged in pt with [**Last Name (un) 309**] Body Dementia.
-Needs home PT evaluation.
-Visiting Nurse services for diet teaching, med teaching, and
evaluation for other services.
-Should have a Social Work referral to initiate discussions
about possible "Do not hospitalize" status in the future, as
well as bridge to hospice.
-Note that if family decides to pursue further workup regarding
his aspiration, could consider an Upper GI series to evaluate
esophageal causes of dysphagia (per GI consult) as well as
possible follow-up of his known pharyngocele with ENT.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 325 mg PO DAILY
2. Gabapentin 100 mg PO TID
3. Lisinopril 5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Glargine 30 Units Bedtime
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Azithromycin 250 mg PO Q24H
10. Cefpodoxime Proxetil 200 mg PO Q12H
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Glargine 20 Units Bedtime
3. Lisinopril 5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Gabapentin 100 mg PO TID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Simvastatin 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg 1 tablet by mouth twice a day Disp #*60 Capsule
Refills:*0
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 17 grams by mouth daily
Disp #*510 Gram Refills:*0
11. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain
RX *oxycodone 5 mg [**1-28**] tablet(s) by mouth every 6 hours Disp
#*50 Tablet Refills:*0
12. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*2
13. Acetaminophen 1000 mg PO TID:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*100 Tablet Refills:*0
14. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
PRIMARY
aspiration
aspiration pneumonia
SECONDARY
dementia
diabetes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 15655**],
It was our pleasure caring for you at the [**Hospital1 18**].
You were admitted to the [**Hospital1 69**]
for being less responsive to your family members, and having a
worsening cough at the same time. You were initially admitted to
the ICU, where you were stable the entire time. You received
antibiotics to treat you for pneumonia (a lung infection) that
you developed from coughing and choking on your food. You were
then transferred to the medical floor.
We held extensive discussions with your family (including your
daughter [**Name (NI) **] who is your healthcare proxy) about your overall
prognosis. The exact cause of your aspiration is unclear, but
your poor nutrition, incontinence, and cognitive issues are due
to your dementia. Your family agreed that your goals of care
include eating by mouth (accepting the risk of aspiration), not
treating you with aggressive measures if your health suddenly
declines or your breathing fails (code status changed to "Do not
resuscitate, Do not intubate." Your goals of care also included
being sent back home to live with your daughter, which we were
able to arrange. You will go home with visiting nurse services.
We made the following changes to your medications:
-START Tylenol and Oxycodone as needed for pain
-START Colace, Senna, and Miralax as needed for constipation
-START Omeprazole because of reflux
-DECREASE Lantus insulin to 20 units at bedtime, since you are
eating less
Please take all other medications as previously prescribed.
Dear Mr. [**Known lastname 15655**],
It was our pleasure caring for you at the [**Hospital1 18**].
You were admitted to the [**Hospital1 69**]
for being less responsive to your family members, and having a
worsening cough at the same time. You were initially admitted to
the ICU, where you were stable the entire time. You received
antibiotics to treat you for pneumonia (a lung infection) that
you developed from coughing and choking on your food. You were
then transferred to the medical floor.
We held extensive discussions with your family (including your
daughter [**Name (NI) **] who is your healthcare proxy) about your overall
prognosis. The exact cause of your aspiration is unclear, but
your poor nutrition, incontinence, and cognitive issues are due
to your dementia. Your family agreed that your goals of care
include eating by mouth (accepting the risk of aspiration), not
treating you with aggressive measures if your health suddenly
declines or your breathing fails (code status changed to "Do not
resuscitate, Do not intubate." Your goals of care also included
being sent back home to live with your daughter, which we were
able to arrange. You will go home with visiting nurse services.
We made the following changes to your medications:
-START Tylenol and Oxycodone as needed for pain
-START Colace, Senna, and Miralax as needed for constipation
-START Omeprazole because of reflux
-DECREASE Lantus insulin to 20 units at bedtime, since you are
eating less
Please take all other medications as previously prescribed.
Followup Instructions:
Department: COGNITIVE NEUROLOGY UNIT
When: FRIDAY [**2193-9-6**] at 2:00 PM
With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) 15661**] [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: COGNITIVE NEUROLOGY UNIT
When: FRIDAY [**2193-9-6**] at 2:00 PM
With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) 15661**] [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: FRIDAY [**2193-9-20**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
ICD9 Codes: 5070, 2762, 5849, 4019, 2724, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4351
} | Medical Text: Admission Date: [**2134-4-5**] Discharge Date: [**2134-4-30**]
Date of Birth: [**2055-2-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Left heart catheterization, Coronary Catheterization [**2134-4-8**]
Aortic valve replacement (19 St.[**Male First Name (un) 923**] Tissue) [**2134-4-26**]
History of Present Illness:
This 79 year old male who is known to cardiac surgery with
critical aortic stenosis, having refused surgical intervention
in the past, s/p valuloplasy x2 [**2132-10-15**]/[**2133-12-15**],
who was transferred from an OSH for acute chest pain with
troponin bump to 4.4. He initially presented to OSH with 1 week
progressive shortness of breath, orthopnea, paroxysmal nocturnal
dyspnea which are distinct from prior shortness of breath
episodes which were attributed to COPD exacerbations and always
accomopanied by cough and wheezing.
He was transfered to [**Hospital1 18**] for further mangangment of aortic
stenosis. He now agrres to valve replacement being referred to
cardiac surgery for re-evaluation for an aortic valve
replacement.
Past Medical History:
Aortic stenosis
s/pvalvuloplasty [**10/2132**], [**12/2133**]
Coronary artery disease: Myocardial infarction [**2118**],
h/o Congestive heart failureprior estimates in the 50's),
possible diastolic component
Paroxsymal atrial fibrillation
s/p ablation for flutter
Arthritis
h/o Pulmonary embolism
Hypertension
Hyperlipidemia
s/p cervical fusion
s/p partial colectomy for ischemic colitis - Status-post
hypospadias repair
s/p fasciotomy of left lower leg for compartment
syndrome after a [**2118**]
s/p Tonsillectomy
chronic obstructive pulmonary disease
Social History:
Lives with wife, quit smoking a few months ago, 60 pack year
hx prior. No ETOH. No drugs.
Family History:
Family History: father deceased 72 from myocardial infarction,
brother had heart surgery and died of heart disease in the
hospital post-operatively
Physical Exam:
VS: temp98.2, BP152/67, HR68, RR20, O2sat 98%RA
GENERAL: WDWN in NAD. Oriented x2 and easily redirectable to
date. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, prominent arcus senilis,
EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma.
NECK: Supple with JVP of 5cm.
CARDIAC: 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. left leg with large
linear bandage covering wound on lateral aspect of leg
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: radial 2+ DP 2+ PT 2+
Left: radial2+ DP 1+ PT 1+
Pertinent Results:
ADMISSION
[**2134-4-5**] 08:00PM BLOOD WBC-12.1*# RBC-3.77* Hgb-11.6* Hct-34.7*
MCV-92 MCH-30.8 MCHC-33.5 RDW-14.2 Plt Ct-286#
[**2134-4-5**] 08:00PM BLOOD PT-21.3* PTT-143.1* INR(PT)-2.0*
[**2134-4-5**] 08:00PM BLOOD Glucose-357* UreaN-35* Creat-1.2 Na-136
K-4.3 Cl-95* HCO3-27 AnGap-18
[**2134-4-6**] 10:40AM BLOOD CK(CPK)-238
[**2134-4-5**] 08:00PM BLOOD Calcium-9.6 Phos-5.2* Mg-2.3
.
PERTINENT
[**2134-4-5**] 08:00PM BLOOD CK-MB-22* cTropnT-1.16*
[**2134-4-6**] 10:40AM BLOOD CK-MB-10 MB Indx-4.2 cTropnT-0.86*
[**2134-4-8**] 06:20AM BLOOD proBNP-1376*
[**2134-4-8**] 12:45PM BLOOD %HbA1c-7.4* eAG-166*
[**2134-4-8**] 12:52PM BLOOD Type-ART pO2-90 pCO2-36 pH-7.49*
calTCO2-28 Base XS-4 Intubat-NOT INTUBA
[**2134-4-8**] 12:45PM BLOOD VitB12-732
[**2134-4-8**] 12:45PM BLOOD ALT-14 AST-19 AlkPhos-85 Amylase-29
TotBili-0.5
[**2134-4-6**] 10:40AM BLOOD CK(CPK)-238
.
ECHO [**2134-4-6**]
The left atrium is elongated. A left-to-right shunt across the
interatrial septum is seen at rest c/w a small secundum atrial
septal defect. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area 0.8
cm2). Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**2-15**]+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild-moderate mitral
regurgitation. Mild aortic regurgitation. Increased PCWP. Small
secundum type atrial septal defect.
Compared with the prior study of [**2133-12-12**], the severity of
aortic stenosis and the estimated PA systolic pressure, and
severity of mitral regurgitation are now lower. A small secundum
type ASD is now seen.
CLINICAL IMPLICATIONS:
The patient has severe aortic valve stenosis. Based on [**2128**]
ACC/AHA Valvular Heart Disease Guidelines, if the patient is
symptomatic (angina, syncope, CHF) and a surgical candidate,
surgical intervention has been shown to improve survival.
.
CARDIAC CATH [**4-8**]
1. Selective coronary angiography of this co-dominant system
demonstrated 1 vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting disease. The LAD had
30%
stenosis . The LCx had 50% stenosis of the OM branch. The RCA
was a
small vessel that was totally occluded at mid-vessel.
2. Resting hemodynamics revealed elevated left-sided filling
pressure
with a PCWP of 18mmHg. There was pulmonary venous hypertension
with a
PA pressure of 42/17mmHg in the setting of an only mildly
elevated PVR.
Cardiac output was decreased at 4.7L/min with an index of
2.6L/min/m2.
3. Selective aortography revealed a calcified aortic root with
no
dilation, patent arch vessels, and patent renal and iliac
arteries with
only mild disease.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Elevated left-sided filling pressures with pulmonary venous
hypertension.
3. Non-dilated and calcified aortic root with patent arch
vessel,
renals, and iliac arteries.
.
[**2134-4-28**] 05:20AM BLOOD WBC-10.4 RBC-3.26* Hgb-9.9* Hct-28.7*
MCV-88 MCH-30.4 MCHC-34.5 RDW-16.2* Plt Ct-104*
[**2134-4-28**] 05:20AM BLOOD Glucose-124* UreaN-20 Creat-1.0 Na-137
K-4.2 Cl-102 HCO3-27 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2134-4-5**] for further
management of his chest pain. Heparin was continued and a
cardiac catheterization was obtained which showed single,
non-occlusive coronary artery disease. An echocardiogram showed
severe aortic stenosis with a normal ejection fraction. (Please
see full report for details.) Given the severity of his disease
and the fact that he has had 2 recent failed valvuloplasty's,
the cardiac surgical service was consulted.
He was worked-up in the usual preoperative manner including a
cartotid duplex ultrasound which showed a <40% stenosis on the
right and a 40-59% stenosis on the left. Pulmonary function
testing was obtained which showed an FEV1 of 1.25L and a
diffusion capacity adjusted for hemoglobin to be 58%. As he had
urinary retention and a worsening renal function
([**2-15**]->1.7->1.2), a renal ultrasound was obtained which was
normal. A nephrology consult was obtained which suspected he
sustained an acute renal injury secondary to to Bactrim. Over
the next few days, his renal function slowly improved.
On [**2134-4-26**], he was taken to the Operating Room where he
underwent an aortic valve replacement using a 19mm St. [**Male First Name (un) 923**]
tissue prosthesis. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. He was slowly weaned from pressors. On postoperative
day one, he awoke neurologically intact and was extubated. On
postoperative day two, he was transferred to the step down unit
for further recovery. He was gently diuresed towards his
preoperative weight.
The Physical Therapy service was consulted for assistance with
his postoperative strength and mobility. Coumadin was resumed
for paroxysmal atrial fibrillation. He continued to have
paroxysmal atrial fibrillation, Insulin was titrated for glucose
control and beta blockers adjusted when he became hypotensive to
the 80s, although he remained assymptomatic.
He remains 12kg above his preoperative weight, with significant
edema and will continue on twice daily Lasix at discharge. This
will need to be titrated at rehab as he diuresis. He was in
sinus rhythm on [**4-29**] at am rounds.
\
He was transferred to the [**Location (un) 11252**] Center for Rehab in [**Location (un) 11252**],
[**Location (un) 3844**] for further recovery on [**2134-4-30**].No Coumadin today
as INR 4.3.
Medications on Admission:
`1. Humulin N insulin 12units [**Hospital1 **] (before breakfast and before
supper)
2. Novolog insulin 8 units [**Hospital1 **] (before breakfast and before
supper)
3. aspirin 325mg QD
4. lisinopril 40mg QDAY
5. Lasix 40mg QDAY
6. Ranitidine 150mg QDAY
7. Metoprolol 25mg [**Hospital1 **]
8. Norflex 100mg [**Hospital1 **]
9. Simvastatin 40mg QDAY
10. Coumadin 2.5mg X6 days/week, 5mg wednesdays
11. Ventolin daily prn sob
12. Atrovent daily prn sob
.
transfer meds:
Albuterol + ipratropium nebs PRN
Aspirin 325mg QD
IV Furosamide 40mg [**Hospital1 **]
Insulin lispro
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atrovent HFA 17 mcg/actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
4. Ventolin HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: [**2-15**]
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. warfarin 1 mg Tablet Sig: as directed Tablet PO once a day:
INR 2-2.5.
11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
12. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
14. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day for 2
weeks.
15. Humulin N 100 unit/mL Suspension Sig: Twelve (12) units
Subcutaneous twice a day.
16. Novolog 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11252**]
Discharge Diagnosis:
s/p aortic valve replacement
chronic obstructive pulmonary disease
s/p aortic valvuloplasty x 2
s/p atrial dysrhythmia ablation-unsuccessful
s/p laparotomy for ischemic colon with resection
h/o remote pulmonary embolism
coronary artery disease
hypertension
hyperlipidemia
benign prostatic hypertrophy
aortic stenosis
insulin dependent diabetes mellitus
paroxysmal atrial fibrillation
congestive heart failure
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema: 1+
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2134-6-2**] at1:15pm
Cardiologist: Dr. [**Last Name (STitle) 11250**] ([**Telephone/Fax (1) 11254**]) on [**2134-5-17**] at 8am
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2-2.5
First draw day after transfer
Dr. [**Last Name (STitle) 11250**] ([**Telephone/Fax (1) 11254**]) will manage Coumadin after rehab
discharge
Completed by:[**2134-4-30**]
ICD9 Codes: 4280, 2875, 2761, 4168, 5990, 4241, 412, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4352
} | Medical Text: Admission Date: [**2117-10-26**] Discharge Date: [**2117-11-6**]
Date of Birth: [**2041-5-30**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Monocular right visual loss
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 76 year-old right-handed, with history of
hypertension, rheumatic heart, RA, dyslipidemia, who presented
with a history of right eye pain at 11:30am today. Patient had
been in her USOH, when she was working at home, when she began
to experience a sudden onset of right eye pain after she leaned
forward. She denies any headache, weakness, numbness, LOC,
nausea/vomiting. Following her right eye pain, within minutes,
she reportedly began to have blurring of vision and then double
vision. She called her eye doctor, who saw her. On examination,
she was noted to have right nasal visual half field loss. Rest
of the ophthalmological exam was unremarkable. Patient denies
any similar symptoms in the past. She denies any recent illness
or bowel/bladder problems.
[**Name (NI) 7092**] stroke was activated at 3:32 pm and she was evaluated per
neurologist including stroke fellow at 3:35pm who found her
reporting ~50% improvement in blurry vision and pain but
complete abatement of diplopia.
NIHSS: At : 3:30 pm ([**2117-10-26**])
Total score 1
F/u NIHSS 0
She was admitted to stroke service for evaluation and treatment
including ESR, MRI/A, optho consult, TTE and carotid ultrasound
plus ASA 325mg. She had no
issues overnight and had normal exam during morning rounds
except for rapid and irregular HR. However at 12:05, she
developed L hemiplegia and neglect with conjugated eye deviation
to the right hence another code stroke code was called. Repeat
CTA showed R ICA occlusion seen previously but also a clot in R
MCA in M1 division. Because her symptoms were improving,
heparin drip was
started rather than IV tPA but another hour later at 1:05 pm,
she again developed L hemiplegia with neglect plus slurred
speech which improved within minutes. Although she again
improved, given fluctuating symtpoms, IV tPA (0.9mg/kg) was
started at 1:52 pm with 10% as bolus over 1 minute and 90% over
the next hour and she was transferred to the ICU. Additionally
given that she
seems more symptomatic when BP decreases, she received NS bolus
and orders were put into start pressor if SBP < 140.
After arriving in the ICU, she had another 5~10 minutes of L
hemiplegia with neglect with SBP ~120~130's which resolved.
Past Medical History:
1. HTN - well controlled with meds per patient
2. Hyperlipidemia
3. Rheumatic heart disease
4. Rheumatoid arthritis
Social History:
Lives with husband with 6 grown children. Remote 30 pack years
and drinks 2 glasses of wine/night.
Family History:
non-contributory
Physical Exam:
Neurological Examination on Admission [**10-26**]:
T 97.3 BP 131/87 HR 120 RR 19 O2Sat 96% with 2L NC
Gen: Lying supine in bed - HOB flat
HEENT: NC/AT, moist oral mucosa
CV: irregularly irregular, no murmurs/gallops/rubs appreciated
Lung: Clear
Abd: +BS, soft, nontender
Ext: 2+ symmetruc dorsalis pedis and no edema.
Neurologic examination:
MSE: Awake and alert, cooperative with exam, normal affect.
Oriented to person, place, and date. Attentive. Speech is
fluent with normal comprehension and repetition; naming
intact.No dysarthria. Intact recent and remote recall. No right
left confusion. No evidence of apraxia or neglect.
Cranial Nerves:
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. L inferior quadranopsia. Fundoscopic exam normal
with sharp disc margins.
III, IV & VI: Extraocular movements intact bilaterally, no
nystagmus.
V: Sensation intact to LT and PP.
VII: Facial movement symmetric.
VIII: Hearing intact to finger rub bilaterally.
X: Palate elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline, movements intact
Motor:
Normal bulk and tone bilaterally. No observed myoclonus or
tremor. Slight drift upward of L arm when testing pronator
drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 4 4+ 5 5 5
Sensation: Intact to light touch, pinprick, vibration, and cold
throughout.
Reflexes:
+2 and symmetric throughout except for Achilles. Toes downgoing
bilaterally
Coordination: Intact FTN bilaterally.
Gait: Deferred
Discharge Physical exam:no-neurological deficits noted, gait was
slow but narrow based.
Pertinent Results:
Labs results:
From latest to early during admission.
[**2117-11-5**] 06:00AM BLOOD WBC-9.7 RBC-3.53* Hgb-12.7 Hct-35.1*
MCV-99* MCH-36.1* MCHC-36.3* RDW-13.1 Plt Ct-399
[**2117-11-4**] 05:50AM BLOOD WBC-11.6*# RBC-3.52* Hgb-12.6 Hct-34.8*
MCV-99* MCH-35.7* MCHC-36.1* RDW-13.1 Plt Ct-334
[**2117-11-3**] 06:45AM BLOOD WBC-7.5 RBC-3.47* Hgb-12.2 Hct-34.8*
MCV-100* MCH-35.1* MCHC-35.0 RDW-13.2 Plt Ct-327
[**2117-10-26**] 03:50PM BLOOD WBC-11.4* RBC-4.16* Hgb-14.6 Hct-41.6
MCV-100* MCH-35.1* MCHC-35.1* RDW-12.5 Plt Ct-330
[**2117-11-4**] 05:50AM BLOOD Neuts-73.4* Lymphs-18.7 Monos-4.5 Eos-3.0
Baso-0.5
[**2117-10-31**] 06:50AM BLOOD Neuts-72.4* Lymphs-18.7 Monos-5.6 Eos-2.6
Baso-0.6
[**2117-10-26**] 03:50PM BLOOD Neuts-85.8* Lymphs-10.7* Monos-2.8
Eos-0.4 Baso-0.3
[**2117-11-5**] 06:00AM BLOOD Plt Ct-399
[**2117-11-5**] 06:00AM BLOOD PT-31.7* PTT-38.6* INR(PT)-3.3*
[**2117-11-4**] 05:50AM BLOOD Plt Ct-334
[**2117-11-4**] 05:50AM BLOOD PT-29.0* PTT-39.0* INR(PT)-2.9*
[**2117-11-3**] 06:45AM BLOOD Plt Ct-327
[**2117-11-2**] 12:40PM BLOOD PT-21.7* PTT-65.4* INR(PT)-2.1*
[**2117-11-2**] 06:00AM BLOOD PT-20.1* PTT-69.2* INR(PT)-1.9*
[**2117-10-26**] 03:50PM BLOOD ESR-6
[**2117-11-5**] 06:00AM BLOOD Glucose-87 UreaN-8 Creat-0.7 Na-140 K-3.4
Cl-106 HCO3-25 AnGap-12
[**2117-11-4**] 05:50AM BLOOD Glucose-82 UreaN-4* Creat-0.7 Na-139
K-3.4 Cl-106 HCO3-26 AnGap-10
[**2117-10-27**] 06:35AM BLOOD Glucose-84 UreaN-9 Creat-0.7 Na-137 K-3.4
Cl-102 HCO3-28 AnGap-10
[**2117-10-26**] 03:50PM BLOOD Glucose-158* UreaN-10 Creat-0.7 Na-132*
K-4.2 Cl-96 HCO3-23 AnGap-17
[**2117-11-4**] 05:50AM BLOOD ALT-18 AST-32 AlkPhos-83 TotBili-0.6
[**2117-10-27**] 07:17PM BLOOD CK(CPK)-44
[**2117-10-31**] 06:50AM BLOOD Lipase-31
[**2117-11-5**] 06:00AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.7
[**2117-11-4**] 05:50AM BLOOD Calcium-8.9 Phos-4.6* Mg-1.7
[**2117-10-27**] 06:35AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8 Cholest-238*
[**2117-10-27**] 06:35AM BLOOD Triglyc-88 HDL-81 CHOL/HD-2.9
LDLcalc-139*
[**2117-10-27**] 07:17PM BLOOD TSH-1.7
[**2117-10-27**] 07:17PM BLOOD T4-5.4
[**2117-10-26**] 03:50PM BLOOD CRP-3.2
[**2117-10-30**] 12:38PM BLOOD Type-[**Last Name (un) **] pH-7.43
[**2117-10-30**] 12:38PM BLOOD freeCa-1.19
OTHER RESULTS:
CARDIOLOGY
EKG [**2117-10-26**] Atrial fibrillation with rapid ventricular
response. No previous tracing available for comparison.
EKG [**2117-10-27**] Atrial fibrillation with rapid ventricular
response. Possible prior inferior myocardial infarction.
Non-specific ST-T wave changes. Compared to the previous tracing
of [**2117-10-26**] no significant change.
Echo: TTE [**2117-10-28**] The left atrium is mildly dilated. The right
atrium is moderately dilated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The aortic valve leaflets (3)
are moderately thickened. There is a minimally increased
gradient consistent with minimal aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**2-3**]+) mitral regurgitation is seen. Moderate to severe
[3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Minimal aortic stenosis. Mild aortic regurgitation.
Mild to moderate mitral regurgitation. Moderate to severe
tricuspid regurgitation. Moderate pulmonary hypertension.
Chest RX [**2117-11-3**] Patient positioning is severely kyphotic.
Moderate bilateral pleural effusion is new. Moderate
cardiomegaly unchanged. Upper lungs clear. No pneumothorax.
Carotid series ([**2117-10-27**])
FINDINGS: There are findings consistent with right ICA occlusion
and
substantial atherosclerotic disease of the external carotid
artery on the
right with intimal thickening. This can be clinically
significant in the
setting of ICA occlusion. Peak systolic flow velocity of the CCA
on the right was measured as 0.27 m/sec.
On the left side, there is intimal thickening consistent with
atherosclerotic plaque formation, but no evidence of significant
stenosis. The following peak systolic flow velocities were
obtained on the left in m/sec.
CCA 0.55, proximal ICA 0.52, mid ICA 0.72 and distal ICA 0.75.
The ICA/CCA
ratio on the left is 0.9.
Antegrade flow was noticed in both vertebral arteries.
IMPRESSION:
1. Findings compatible with right-sided ICA occlusion and
external carotid
artery atherosclerotic plaque formation that can be clinically
significant in the setting of ICA occlusion.
2. No significant ICA stenosis on the left, which is patent.
3. Antegrade flow in both vertebral arteries.
NEUROIMAGINGS:
[**2117-10-26**] HEAD AND NECK CTA:
There is calcified plaque at the origins of the innominate, both
common
carotid, and both subclavian arteries, without evidence of
hemodynamically
significant stenoses. The proximal common carotid and vertebral
arteries are tortuous. There is plaque at the origin of the left
vertebral artery, without evidence of hemodynamically
significant stenosis. Calcified plaque is present at the origin
of the left internal carotid artery, spanning less than 1 cm,
with approximately 30% to 40% stenosis. The distal cervical left
internal carotid artery measures 5 mm in greatest diameter.
Calcified atherosclerotic plaque is present within the cavernous
and
supraclinoid portions of the left internal carotid artery,
without evidence of hemodynamically significant stenosis
There is complete occlusion of the right internal carotid artery
from its
origin through its intracranial bifurcation. The right anterior
and middle
cerebral arteries are patent. Fetal origin of the right
posterior cerebral
artery is noted, a normal variant. There is no evidence of an
aneurysm. There is mild focal narrowing in the P2 segment of the
left posterior cerebral artery.
There is mild emphysema within the lung apices. The right
submandibular gland is atrophic. Degenerative changes are
present in the cervical spine. A developmental venous anomaly is
present in the right frontal lobe.
IMPRESSION:
1. Right internal carotid artery demonstrates complete occlusion
from the
origin to the supraclinoid portion, which is likely chronic
given patency of the anterior and middle cerebral arteries.
2. 30% to 40% stenosis at the origin of the internal carotid
artery, spanning less than 1 cm.
3. Fluid and aerosolized secretions in the left maxillary sinus,
which may be seen in acute sinusitis.
4. Right frontal lobe developmental venous anomaly.
5. Mild emphysema.
[**2117-10-26**] MRI HEAD: There is no evidence of hemorrhage, edema,
masses, mass effect or infarction. No diffusion abnormalities
are detected. Mild prominence of the sulci and ventricles is
consistent with cerebral atrophy. There is no flow void in the
right internal carotid artery, corresponding to the occlusion
demonstrated on the concurrent CTA. A right frontal
developmental venous anomaly is noted. Foci of high T2 signal in
the subcortical, deep and periventricular white matter of the
cerebral hemispheres, and in the right pons, likely correspond
to chronic microvascular ischemic disease in a patient of this
age.
Fluid and aerosolized secretions are present in the left
maxillary sinus.
MRI ORBITS: Coronal postcontrast images are limited by motion,
but axial
postcontrast images are diagnostic in quality. No abnormalities
are detected
in the orbits or cavernous sinuses. The optic nerves are normal
in morphology
and signal intensity.
IMPRESSION:
1. Occlusion of the right internal carotid artery, better
demonstrated on the
concurrent CTA. No evidence of acute infarction.
2. Chronic small vessel ischemic disease.
3. Right frontal lobe developmental venous anomaly.
4. Fluid and aerosolized secretions in the left maxillary sinus,
which may
indicate acute sinusitis.
5. Normal appearance of the orbits.
Carotid Series [**2117-10-27**]
FINDINGS: There are findings consistent with right ICA occlusion
and
substantial atherosclerotic disease of the external carotid
artery on the
right with intimal thickening. This can be clinically
significant in the
setting of ICA occlusion. Peak systolic flow velocity of the CCA
on the right was measured as 0.27 m/sec.
On the left side, there is intimal thickening consistent with
atherosclerotic plaque formation, but no evidence of significant
stenosis. The following peak systolic flow velocities were
obtained on the left in m/sec. CCA 0.55, proximal ICA 0.52, mid
ICA 0.72 and distal ICA 0.75. The ICA/CCA ratio on the left is
0.9.
Antegrade flow was noticed in both vertebral arteries.
IMPRESSION:
1. Findings compatible with right-sided ICA occlusion and
external carotid
artery atherosclerotic plaque formation that can be clinically
significant in the setting of ICA occlusion.
2. No significant ICA stenosis on the left, which is patent.
3. Antegrade flow in both vertebral arteries.
[**2117-10-27**] HEAD CT: There is subtle loss of the normal [**Doctor Last Name 352**]-white
matter differentiation in the territory of the right MCA. Mild
sulcal effacement is present in the right hemisphere (2b:50).
New foci of hyperattenuation are present within the right M1
segment of the MCA both proximally and distally (2b:44), which
were not present on comparison from one day previous. There is
no intracranial hemorrhage, hydrocephalus, or midline shift. An
air fluid level with aerosolized secretions is again noted in
the left maxillary sinus. The remaining visualized paranasal
sinuses and mastoid air cells are clear.
HEAD CTA: New abrupt cutoff is present within the M1 segment of
the right MCA (3:64). Abrupt cutoff is also present with regard
to the right fetal PCA (3:59). The remaining carotid and
vertebral arteries and their major branches are patent without
evidence of stenosis. Attenuated filling of the sylvian branches
of the right MCA are possibly secondary to retrograde
leptomeningeal filling.
Incidental note is made of a right frontal lobe developmental
venous anomaly (3:78).
IMPRESSION:
1. New occlusion of the distal M1 segment of the right MCA and a
segment of the right fetal posterior cerebral artery. Associated
subtle edema and sulcal effacement present in the right MCA
distribution.
[**2117-10-30**] MRA/MRI Brain and neck
FINDINGS: On the diffusion-weighted sequence, there are areas of
restricted diffusion in the vascular territory of the right MCA,
also some scattered hyperintense foci noted on the right
occipital lobe, right basal ganglia and distally on the right
temporal lobe suggesting thromboembolic ischemic changes.
Hyperintensity signal is also demonstrated on the right insular
region and tip of the right temporal lobe. No significant mass
effect is noted, on the left cerebral hemisphere also multiple
areas of hyperintensity signal are noted on T2 and FLAIR
consistent with chronic microvascular ischemic changes. There is
no evidence of hemorrhagic transformation. The orbits, the
paranasal sinuses and the mastoid air cells are unremarkable.
There is persistent mucosal thickening with fluid level on the
left maxillary sinus.
IMPRESSION: Acute/subacute ischemic changes are visualized on
the vascular
territory of the right MCA with heterogeneous distribution
raising the
possibility of thrombolytic ischemic event as described above.
MRA OF THE CIRCLE OF [**Location (un) **]
There is evidence of vascular flow in both internal carotids,
narrowing of the distal branches of the right MCA at the level
of the M2, M3 segments,
hypoplasia of the A1 segment is noted on the right with fetal
pattern, the
right posterior communicating artery apparently is arising from
the right
internal carotid. The anterior communicating artery appears
prominent. No
definite aneurysmatic formation is identified. The previously
described right frontal developmental venous anomaly is not
demonstrated in this examination.
MRA OF THE NECK: In these follow examination apparently there is
recanalization or reconstitution of the right internal carotid
artery and
narrowing at the origin of the right external carotid artery.
The left
cervical carotid bifurcation appear within normal limits. Both
vertebral
arteries are patent.
IMPRESSION: Findings compatible with recanalization of the right
internal
carotid on the right with narrowing of the cervical carotid
bifurcation.
Acute/subacute ischemic changes possibly thromboembolic on the
right MCA as described in detail above.
Brief Hospital Course:
Briefly, 76 year old woman with a h/o RA developed sudden onset
of visual loss accompanied with a right orbital pain yesterday.
Ophthalmology evaluation showed a
left nasal field cut only in the right visual filed but no optic
disc abnormalities. Initial neck CTA showed a R-ICA occlusion in
neck. Overnight she developed tachycardia with AF. Around noon
today, while walking to the bathroom with daughter developed
left sided weakness (face, arm, leg) with right gaze deviation.
Dr. [**Last Name (STitle) 911**] (Neurology resident) promptly saw the patient within
five minutes of symptom onset and noted her to be awake but
somewhat lethargic but oriented to date, locale. She was unaware
of deficits. Within 15-20 minutes she beacme more alert and had
full strength in her left sided extremities but continued to
show some left sided field cut and sensory extinction. She was
taken for an emergent head CT/CTA which showed a possible
in-situ thrombus at R-M1 and R-M2 occlusion. Since her deficits
had largely resolved, the team initially elected not to use iv
tpa beacuse of a probable recent retinal infarction and low
NIHSS (2). The option of IA tPA was discussed with Dr. [**First Name (STitle) **]
from neurosurgery but the stroke team decided against it because
of technical difficulty accessing the R-MCA via an occluded
R-ICA and beacuse of a concern for causing disruption of the
carotid thrombus with distal embolization. At 1:25 her deficits
returned. Her BP~ 130/80s. Her NIHSS was 15. Within the next 15
minutes her deficits improved again (NIHSS 3).After discusiing
the pros and cons of treatment with family it was decided to
proceed with iv tPA. She recieved iv TPA bolus at 1:52 pm
followed by an infusion. She
will be monitored in the neuro-ice for 24 hours. We will aim to
keep her BP~140/80 mm to 180-100 mmHG range. A f/u head CT will
be obtained in the am. On [**10-28**] she had an episode on confusion,
which was attributed to a urinary tract infection, which was
treated with Ciprofloxacin. On [**11-1**] Mrs [**Known lastname **] was
transferred out of ICU to the floor. Cardiology recommended
Cardizem and Metropolol for her atrial fibrillation. In
addition, she was started on Coumadin for her AF and stroke.
She required a couple of doses of Lasix for LVF which was seen
in the CXR. Incidentally, she had an inflammed sebaceous cyst,
which could not be lanced due to the fact that she was on
Coumadin.
Medications on Admission:
1. Plaquenil
2. Atenolol
3. Lisinopril
Discharge Medications:
1. Outpatient Lab Work
INR (please send results to [**First Name5 (NamePattern1) 2951**] [**Last Name (NamePattern1) 30370**]-Myshkin [**Telephone/Fax (1) 79995**])
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Cerebral Infarction
2. Hyperlipidemia
3. Rheumatic heart disease
4. Rheumatoid arthritis
5. HTN
Discharge Condition:
The neurological examination prior to discharge was completely
normal.
Please discuss your sebaceous cyst with your primary care
physician.
Discharge Instructions:
You were admitted to this hospital because you were experiencing
visual changes, and you have multiple risk for stroke this
diagnosis was considered in the first place. While you were in
the hospital you had three events of subtle left side weakness
and neglect.
You need to have your blood drawn for your INR (coumadin level)
on Monday.
Management of Dietary Interactions and Vitamin K: dietary
consistency is the key to maintaining a sustained, stable
response during warfarin therapy. You should be aware of vitamin
K content in common foods, particularly foods high in vitamin K
(green leafy vegetables (broccoli, [**Last Name (un) **] sprouts, turnip
greens, kale, spinach, beet greens), Cauliflower , legumes,
mayonnaise, canola and soybean oils), and should maintain a
consistent amount of these foods in their diet.
The following foods should be avoided or limited, since they
also can effect warfarin therapy: caffeinated beverages (cola,
coffee, tea, hot chocolate, chocolate milk).
Alcohol intake greater than 3 drinks daily can increase the
effect of Coumadin. As long as alcohol intake does not exceed 3
drinks daily, clotting times should not be affected. This amount
of alcohol is present in 12 ounces of table wine or three 12
ounce beers. (Acute binges can raise INR. Chronic alcohol
ingestion may decrease INR. )
Herbal supplements can affect bleeding time. Coenzyme Q10 is an
herbal supplement whose chemical structure is similar to vitamin
K, so it has the potential to affect bleeding time. Herbal
teas: green tea, [**Location (un) 79996**], horsechestnut, tonka, bean, meliot,
and [**Location (un) **]. Other examples include: feverfew, garlic, and
ginseng. Herbal medications should either be avoided or used
consistently while on warfarin therapy.
Followup Instructions:
You need to call Dr. [**Last Name (STitle) 30370**] at [**Telephone/Fax (1) 70871**] on Monday to get set
up in the coumadin clinic and arrange for your blood test.
Neurology:
[**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2117-12-20**]
4:30
Cardiology:
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2117-12-3**]
1:00
The appointment could only be made for 9am or 1pm with Drs.
[**Last Name (STitle) 5858**] and [**Name5 (PTitle) **] - if you would like to make an
appointment for a different time, please call [**Telephone/Fax (1) 62**] and
ask to have an appointment with a different provider.
If you would like a primary care provider within the [**Hospital3 **]
system, you can call [**Telephone/Fax (1) 250**] to arrange it.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 5990, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4353
} | Medical Text: Admission Date: [**2115-12-4**] Discharge Date: [**2115-12-26**]
Date of Birth: [**2070-2-15**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old
morbidly obese woman with hypertension and hypercholesterolemia
who presented with the sudden onset of severe headache with
nausea and vomiting. She was less responsive to her family,
and by the time she arrived in the Emergency Room, she was
proceeded to become unresponsive again. She was emergently
intubated and sent for CT scan which revealed a subarachnoid
hemorrhage with ventricular involvement and hydrocephalus.
PAST MEDICAL HISTORY: Hypertension, obesity,
hypercholesterolemia.
ALLERGIES: TETRACYCLINE.
PHYSICAL EXAMINATION: Vital signs: Blood pressure 220/100.
General: She was intubated and sedated but localizing to
pain. HEENT: Pupils were 3 down to 2 mm and briskly
reactive bilaterally. Motor: She withdrew to pain in all
four extremities.
LABORATORY DATA: White count 9.5, hematocrit 39.8, platelet
count 360; INR 1.1, PT 12.9, PTT 21.2.
CT scan showed subarachnoid hemorrhaging involving cisterns
and ventricles with hydrocephalus.
The patient was admitted to the Neurosurgical Intensive Care
Unit for close monitoring. She also had a ventriculostomy
drain placed at the time of admission.
She was taken to the Angiography Suite and had a cerebral
angiogram which revealed a ruptured dissecting vertebral artery
aneurysm which underwent coil embolization using parent vessel
occlusion. The patient was transferred back to the
Intensive Care Unit. Post angiogram, the patient responded
to verbal stimulation, nodding appropriately, and coughing at
times. She was following commands and moving all
extremities.
Repeat head CT on [**2115-12-5**], showed improving
hydrocephalus with no apparent infarct. The patient was
weaned to extubate, and Nipride was weaned.
On [**2115-12-7**], the patient was extubated, and was awake
and alert. She had weakness of bilateral upper extremities
but was still moving times four. She had a vent drain level
at 5 cm above the tragus. She had TCDs which showed
increased velocity.
On [**2115-12-8**], the patient's vent drain was raised to 10
cm above the tragus. Her intravenous fluids were increased
to 125/hr. The patient's blood pressure was allowed up to
the 200 range. All antihypertensives were discontinued. The
patient was awake, alert, and oriented times three with no
drift and no headache.
On [**12-10**], the patient spiked a temperature to 101.3??????.
She was fully cultured. The patient grew out gram positive
cocci from her line. Her central line was removed. The
patient also had E. coli urinary tract infection. All
cultures came back negative. The patient was continued on
Kefzol for drain prophylaxis. No other antibiotics were
given at this time.
On [**2115-12-12**], the patient spiked a temperature again.
The patient was prophylactically started on Oxacillin and
Zosyn. Cultures were pending. The patient remained awake
and alert, oriented times three. Extraocular movements were
full. Visual fields were full. She was following commands
and moving all extremities.
She was started on triple H therapy which she is to remain on
for two weeks. The patient showed evidence of vasospasm by
TCDs. Vent drain remained in place until [**2115-12-20**],
where it was discontinued, and the patient was transferred to
the regular floor. She remained neurologically stable
throughout her Intensive Care Unit stay. She was seen by
physical therapy and Occupational Therapy on the floor and
found to require acute rehabilitation. Her vitals signs
remained stable. She remained neurologically stable. She
was awake, alert and oriented times three. She was moving
all extremities strongly with no drift.
DISCHARGE MEDICATIONS: Levofloxacin 500 mg p.o. q.24 hours
for 5 days, started on [**12-25**], for E. coli urinary tract
infection, Captopril 37.5 mg p.o. t.i.d., hold for systolic
blood pressure less than 130, Heparin 5000 U subcue q.8
hours, Loperamide 4 mg p.o. q.i.d. p.r.n., Desitin 1
application topically p.r.n., Zantac 150 p.o. b.i.d.,
Albuterol nebs 1 neb q.3-4 hours p.r.n., Tylenol 650 p.o. q.4
hours p.r.n., Atrovent 2 puffs q.i.d., Insulin sliding scale,
Nimodipine 60 mg p.o. q.4 hours, Vioxx 25 mg p.o. q.d. for
osteoarthritis.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: With Dr. [**Last Name (STitle) 1132**] in one month.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2115-12-25**] 14:55
T: [**2115-12-25**] 14:57
JOB#: [**Job Number 102746**]
ICD9 Codes: 4280, 2762, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4354
} | Medical Text: Admission Date: [**2134-3-29**] Discharge Date: [**2134-4-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2356**]
Chief Complaint:
shortness of breath, cough, lower extremity swelling
Major Surgical or Invasive Procedure:
Blood transfusion
History of Present Illness:
87 yo Russian speaking female with hx of dCHF, Aortic and mitral
valve replacements for rheumatic fever, and recent admission for
samonella bactermia, now with worsening dyspnea. Pt was at rehab
and has been haivng increasing fluid retention despite
excalation of lasix and addtion of metolazone. She was sent from
rehab for admission for HF. She has 2 pillow orthopnea. Has been
SOB per daughter and has chronic intermitent angina pains. Also
been having a non-productive cough. Last BM was today, but has
RUQ pain. No urinary sx. Now using oxygen which she does not at
baseline.
.
On arrival VS were 98.8 62 144/62q 22 100. Labs showed proBNP:
3535.
CXR showed increase in pulm edema. EKG showed AV paced,
unchanged at rate of 60. Pt was given lasix 60 IV x 1. ASA
325mg. VS on transfer are 97.7 61 112/66 18 98% 4L.
Past Medical History:
1. Coronary artery disease status post 1 vessel CABG
2. Rheumatic heart disease status post prosthetic aortic and
mitral replacement in [**2122**].
3. Pulmonary hypertension
4. Insulin dependent diabetes mellitus
5. Chronic renal insufficiency (baseline creatinine 1.7-2.0)
6. Atrial fibrillation status post ablation and pacemaker
implantation for tachy brady on coumadin for anticogulation.
7. Cholelithiasis that was previously symptomatic but had
declined surgical intervention.
8. Nephrolithiasis.
9. Spinal stenosis.
10. h/o esophogeal candidiasis
11. HTN
12. HL
13. Anemia (Fe deficiency), requiring tranfusions
14. Recent Hx of falls
Social History:
Has been at rehab recently. Prior to this was living alone. Uses
a walker. Last fall was a few months ago. No etoh, tobacco, or
drugs.
Family History:
Father had DM
Mother had CHF
There is a family history of hypertension, and cardiac disease.
Physical Exam:
Vitals: 96.5 123/53 60 22 100%2l FS 167
General: Alert, oriented, appears in some discomfort
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to above jawline, no LAD
Lungs: crackles at bases, poor airmovement at bases
CV: Regular rate and rhythm, click of heart valve, systolic
murmur throughout chest, [**4-10**]
Abdomen: soft, tender in RUQ, mild distended, bowel sounds
present
Ext: Warm, well perfused, 2+ pulses, no clubbing, 3+ pitting
edema up to sacrum
Neuro: awake, hard of hearing, cooperative, moving all
extremities
Pertinent Results:
CXR [**2134-3-29**]: IMPRESSION: Mild CHF with right fissural fluid and
left pleural effusion, similar to prior study.
[**2134-3-29**] 05:30PM BLOOD WBC-4.4 RBC-2.79* Hgb-8.2* Hct-27.0*
MCV-97 MCH-29.5 MCHC-30.4* RDW-20.5* Plt Ct-194#
[**2134-4-1**] 06:45AM BLOOD WBC-9.5# RBC-2.66* Hgb-7.7* Hct-25.4*
MCV-96 MCH-28.8 MCHC-30.1* RDW-20.4* Plt Ct-200
[**2134-3-29**] 06:17PM BLOOD PT-19.8* PTT-33.2 INR(PT)-1.8*
[**2134-4-1**] 06:45AM BLOOD PT-19.4* PTT-32.7 INR(PT)-1.8*
[**2134-3-29**] 05:30PM BLOOD Glucose-170* UreaN-83* Creat-2.2* Na-134
K-5.9* Cl-95* HCO3-32 AnGap-13
[**2134-4-1**] 06:45AM BLOOD Glucose-136* UreaN-88* Creat-2.2* Na-136
K-3.5 Cl-92* HCO3-33* AnGap-15
[**2134-3-29**] 05:30PM BLOOD ALT-19 AST-78* LD(LDH)-818* CK(CPK)-67
AlkPhos-304* TotBili-0.4
[**2134-4-1**] 06:45AM BLOOD ALT-12 AST-26 LD(LDH)-235 AlkPhos-291*
TotBili-0.5
[**2134-3-29**] 05:30PM BLOOD CK-MB-NotDone proBNP-3535*
[**2134-3-29**] 05:30PM BLOOD cTropnT-0.05*
[**2134-3-31**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2134-3-31**] 12:50PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2134-3-29**] 05:30PM BLOOD ALT-19 AST-78* LD(LDH)-818* CK(CPK)-67
AlkPhos-304* TotBili-0.4
[**2134-3-31**] 06:00AM BLOOD CK(CPK)-33
[**2134-3-31**] 12:50PM BLOOD CK(CPK)-35
[**2134-3-30**] 12:03AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.7*
[**2134-3-31**] 06:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.6
.
Imaging:
CXR [**3-29**]: Mild CHF with right fissural fluid and left pleural
effusion, similar to prior study.
CXR [**4-1**]: 1. New mild pulmonary edema. Stable small pleural
effusions and mild cardiomegaly.
2. No evidence of pneumonia.
CXR [**4-3**]: Mild pulmonary edema is worsened on the right,
improved slightly on the left, moderate right and small left
pleural effusions have substantially increased, particularly the
right. Moderate cardiac enlargement is longstanding. The patient
has prior mitral and aortic valve replacement, congenital right
aortic arch. Transvenous right atrial and right ventricular
pacer leads are unchanged in standard placements. No
pneumothorax.
.
Liver/GB U/S [**4-3**]: 1. Simple cholelithiasis without acute
cholecystitis.
2. Unchanged dilated CBD measure up to 12 mm.
3. Unchanged dilated hepatic veins.
4. Small amount of ascites and bilateral pleural effusions.
.
Pelvic U/S [**4-7**]: 1. 6.5 cm left adnexal cystic lesion only
minimally increased in size compared to [**2130**] with no concerning
features
2. Trace free pelvic fluid.
.
Humerus Xray [**4-10**]: Again noted is a supracondylar fracture with
increased resorption at the fracture site. There is no
radiographic finding to suggest [**Hospital1 **] at this time. There is
approximately 7-mm gap at the medial fracture on the external
rotation view.
.
KUB [**4-10**]: Four total images are submitted. These are somewhat
limited on the basis of technique and patient positioning, but
are the best images are available, given these limitations.
Dual-lead pacemaker and valvular prosthesis again identified.
There is a large amount of stool throughout the colon. No
discrete obstruction is identified. Air-filled small bowel is
also identified, but this does not appear to be pathologically
dilated at this time.
.
EKGs:
[**3-29**]: A-V sequential pacing. Since the previous tracing of
[**2134-3-13**] changes in early precordial QRS voltage is of uncertain
significance. Clinical correlation is suggested.
[**4-2**]: A-V sequentially paced rhythm and intermittent ventricular
pacing. Compared to the previous tracing of [**2134-3-31**] atrial
pacemaker activiy is now recorded.
[**4-6**]:Probably both sinus and atrial pacing with at least one
atrial premature beat. There is ventricular pacing throughout.
Since the previous tracing of [**2134-4-2**] the atrial rate is faster.
Clinical correlation is suggested.
[**4-8**]: Sinus rhythm competing with atrial pacing with ventricular
pacing. Compared to the previous tracing there is no significant
change.
.
.
Labs:
........................WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2134-4-12**] 08:44AM 6.2 2.96* 8.9* 28.7* 97 30.2 31.2 19.6*
214
[**2134-4-11**] 07:50AM 5.8 2.84* 8.5* 26.7* 94 29.9 31.9 19.9*
203
[**2134-4-10**] 07:45AM 6.5 2.94* 9.0* 28.6* 97 30.7 31.6 20.0*
234
[**2134-4-9**] 08:40AM 5.2 2.98* 8.7* 28.0* 94 29.3 31.0 20.1*
221
[**2134-4-8**] 07:46PM 5.2 2.98* 9.0* 28.0* 94 30.3 32.2 19.6*
207
[**2134-4-8**] 08:10AM 5.2 3.18* 9.2* 30.2* 95 28.9 30.5* 19.7*
226
.
.
......................Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2134-4-12**] 08:44AM 108* 56* 1.6* 139 4.9 100 33* 11
[**2134-4-11**] 07:50AM 103* 58* 1.4* 141 3.9 101 31 13
[**2134-4-10**] 07:45AM 237* 64* 1.6* 139 3.8 100 29 14
[**2134-4-9**] 08:40AM 153* 72* 1.7* 140 3.7 100 31 13
[**2134-4-8**] 08:10AM 296* 74* 1.8* 137 3.6 97 31 13
[**2134-4-7**] 07:15AM 206* 78* 2.0* 135 3.9 96 29 14
[**2134-4-6**] 07:50AM 294* 83* 2.1* 134 4.3 97 27 14
.
.
...........................Calcium Phos Mg
[**2134-4-12**] 08:44AM 9.0 3.1 2.0
[**2134-4-11**] 07:50AM 8.8 2.3* 2.0
[**2134-4-10**] 07:45AM 8.9 2.4* 2.4
[**2134-4-9**] 08:40AM 8.5 2.1* 2.1
[**2134-4-8**] 08:10AM 8.8 2.3* 2.3
[**2134-4-7**] 07:15AM 8.7 2.7 2.4
[**2134-4-6**] 07:50AM 8.1* 3.7 2.5
[**2134-4-5**] 05:24AM 8.0* 4.0 2.6
Brief Hospital Course:
87 yo F with hx of dCHF, AVR, MRV, DMII, recent bacteremia, here
with worsening dyspnea and concern for acute on chronic dHF.
# Acute on chronic dCHF: In the setting of recent
hospitalization for bacteremia, during which time the patient
had IVF's and less diuretics. On admission, the patient had
bilateral pitting edema to the sacrum and pulmonary rales. She
was given Aldactone & IV Lasix PRN with good diuresis. Her
electrolytes were carefully monitored and repleted [**Hospital1 **]. She was
maintained on a low salt diet and a 1500ml fluid restriction. On
HD #5, she had a hypotensive event in the morning which was
triggered - she got a fluid bolus and then was maintained on
continuous IVF. Later that day she was found to be unresponsive
with a run of torsades. A code was called, but this event was
self-limited and the patient re-gained pulses. She was sent to
the MICU. EP saw her, discussion below. She had intermittent
chest pain without EKG changes or enzyme leak in the MICU, which
was controlled with nitro/morphine. She was ultimately
transferred out of the MICU after 3 nights. Her fluid status
kept even, and she did have some swelling of her LEs on Lasix.
She was given prn lasix, and her daily diuretic was changed to
Bumex 2 mg [**Hospital1 **]. By day of discharge she had clear lungs on exam
with decreased LE swelling. She continued to have occasional
bouts of intermittent chest pain without EKG changes or
telemetry events, which was controlled with SL nitroglycerine.
She was continued on her CCB, Imdur and her statin.
.
# C. difficile colitis: Patient with leukocytosis & fever to 101
on HD 5. She was started empirically on Flagyl for presumed C.
diff in the context of completing 2 week antibiotic course and
ID was consulted to determine whether she required additional
coverage for Salmonella. They recommended that she remain on
monotherapy with Flagyl, but the patient's condition continued
to deteriorate requiring a ICU transfer (see above). Her C. diff
toxin returned positive in the interim and her coverage was
broadened to Vancomycin/Flagyl. However, given the concern of
medications that might prolong the QT interval, she was switched
to monotherapy PO Vancomycin per ID recommendations. She was
transferred to the floor on this medication. ID requested a
pelvic ultrasound given a finding of adnexal cyst on her CT from
her early [**Month (only) **] admission and low possibility that this could be a
site of infection; this was done and she had small interval
increase in size from previous study in [**2130**] but no change in
morphology or other concerning characteristics. She is to
continue on Vancomycin for two weeks total (day 1 = [**4-2**]). She
continued to have a moderate amount of diarrhea and occasional
blood in her stool, likely related to an elevated INR (see
below). She did have a somewhat distended abdomen on exam but
did not have point tenderness, rebound, guarding, and was not
tympanic. She had occasional complaints of abdominal pain but in
general these were of short duration and responded well to
Maalox/lidocaine. She was started on Sucralfate for suspected
gastritis. A KUB was done on [**4-10**] with a read of "There is a
large amount of stool throughout the colon. No discrete
obstruction is identified. Air-filled small bowel is also
identified, but this does not appear to be pathologically
dilated at this time." A KUB was repeated on [**4-12**] and was read as
stool in the colon without any signs of pneumoperitoneum or
bowel obstruction. The patient will need to continue on a bowel
regimen.
.
# Acute on Chronic renal failure: Creatinine remained stable at
her baseline throughout her stay on the medicine floor despite
receiving Lasix. She did receive several extra doses of lasix
related to fluid overload following her MICU stay. Her diuretic
was changed to Bumex. Spironolactone was continued. Her
electrolytes were followed and repleted as necessary.
# DMII: Patient maintained on a fixed dose & insulin sliding
scale throughout this hospitalization. [**Last Name (un) **] diabetes center
was consulted and made recommendations regarding her insulin
doses.
# h/o Atrial Fibrillation: Patient is AV paced at 60bpm; she
initially remained in NSR during this hospitalization. She was
on her home Amiodarone & Metoprolol. On [**4-2**], she had an episode
of Torsades and a code blue was called, as discussed above. She
returned to a perfusing rhythm. EP saw the patient and
interrogated her pacemaker and confirmed Torsades. She had an
EKG after event without evidence of ischemia. Notably, her
baseline EKG had a long QT. She was evaluated for any
QT-prolonging medications; these included amiodarone and
fluconazole (which had been continued from her previous
admission for concern over [**Female First Name (un) **] esophagitis). Her amiodarone
and metoprolol were held. EP increased her baseline HR to
decrease her QT. Her troponins were cycled and were negative.
She had been started on Flagyl briefly for Salmonella, but this
was discontinued given its possible QT effects. Following
transfer to the floor, she had no further events on telemetry.
Several repeat EKGs were done and these demonstrated gradual
resolution of the prolonged QTc (487 msec to 473 msec). Final
EKG done before discharge was stable.
.
# Hx of Rheumatic Fever s/p AVR/MVR: Goal INR 2.5-3.5, with
history of very poorly maintained INR's. Patient's INR was
subtherapeutic on admission and she was temporarily placed on a
Heparin gtt to Coumadin, but this was stopped at the preference
of her family given prior episodes of bleeding on Heparin. Her
home Coumadin dose was temporarily increased to 5mg daily and
then titrated down to 3mg daily with a therapeutic INR reached
on HD 5. She was also placed on pneumoboots for DVT prophylaxis.
In the MICU, her INR was supratherapeutic and was held. She had
a nosebleed, and received vitamin K. Prior to transfer back to
the floor, she was re-started on her coumadin, and the family
agreed to heparin bridge. This was stopped after her INR came up
to 2.5. She again became supratherapeutic, and her coumadin was
again held. It was restarted on [**4-10**] at 2 mg daily. Her INR was
2.6 on the day of discharge.
.
# Esophagitis: Patient with a diagnosis of esophageal
candidiasis on last admission, treated with 3 weeks of
Fluconazole that was completed on re-admission. She demonstrated
no evidence of persistent infection during this hospitalization,
but she was continued on her home PPI as well Tessilon Perles &
Cepacol lozenges for ongoing cough. The fluconazole was stopped
as above. She did have some throat pain after transfer back from
the MICU and was given Maalox/Lidocaine with generally good
relief.
.
# Elevated LFTs: Patient admitted with elevated Alkaline
phosphatase, AST, & GGT, normal bilirubin. Initially, she c/o
RUQ pain on exam, but refused RUQ ultrasound. Her LFT's were
monitored given her history of Salmonella, but all levels
normalized on HD4 except the patient's Alkaline phosphatase. She
did not have pain that was localized to the RUQ but did have
occasional vague abdominal pain that was improved with maalox,
sucralfate, and tylenol as above. Her KUBs were significant for
possible constipation and her laxatives were re-started.
.
# Hypothyroid: Patient's TSH was 6.3 during this
hospitalization. Prior free T4 obtained within the last 6 months
was within normal limits She was maintained on 37.5mcg daily.
.
# Insomnia: The patient came in on report that she received
trazadone prn for insomnia, but this was tried with negative
effects (daughter reported that patient had hallucinations).
Trazadone was stopped. The patient was given Alprazolam prn for
her anxiety and insomnia.
.
# Code: Patient was FULL CODE on admission, but on [**4-2**], after
Torsades, patient's family decided to change her code status to
DNR/DNI
.
# Emergency Contact: Daughter, [**Name (NI) 8463**] [**Telephone/Fax (1) 103841**]
Medications on Admission:
Maalox Q6H PRN
Amiodarone 200mg qday
Simvastatin 20mg HS
Calcium Acetate 667mg x 2 TID
Sarna lotion Q6H PRN
Ceftriaxone - completed [**3-22**]
Colace 200mg [**Hospital1 **]
Epo 5000units Q5days
Fluconazole 100mg Q48H, still on from last admission
Lasix 80mg [**Hospital1 **]
Metolozone 5mg qday
Insulin lantus 30 units Qday
Isosorbide Mononitrate 90mg qday
Levothryroxine 37.5mcg qday
Lidocaine 2% solution PRN
Metoprolol 25mg [**Hospital1 **]
Nitro 0.4mg SL PRN
Protonix 40mg Qday
Polysaccaride Iron Complex 150 Qday
KCl 40meq per day
Ranitidine 150mg [**Hospital1 **]
Senna 17.2mg [**Hospital1 **] PRN
Spironolactone 25mg qday
SSI
Trazadone prn
Bisacodyl prn
Coumadin 2mg PM
Discharge Medications:
1. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain or fever.
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
5. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
6. Polyethylene Glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO BID (2 times a day) as needed for constipation.
7. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q12H (every 12 hours)
as needed for pain.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
11. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
14. Maalox Advanced 200-200-20 mg/5 mL Suspension Sig: Fifteen
(15) ml PO three times a day as needed for cough, sore throat,
upset stomach.
15. Levothyroxine 25 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
16. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for dysphagia.
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for cough.
20. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
21. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
22. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath, cough, wheezing.
24. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
25. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at breakfast.
26. Humalog 100 unit/mL Solution Sig: 1-20 units Subcutaneous
with meals and at bedtime as needed for per insulin sliding
scale.
27. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
28. Outpatient Lab Work
Please get daily INR and send to Dr.[**Name (NI) 15895**] office
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary: Acute on chronic diastolic heart failure exacerbation,
C. difficile enterocolitis, Torsades de Pointes
Secondary:
Diabetes
Chronic Kidney disease
Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to the hospital for a heart failure
exacerbation. You had shortness of breath and fluid overload.
You were found to have an infection called C. difficile, which
affects your GI tract. We started treatment with multiple
antibiotics, including vancomycin and flagyl (metronidazole).
You were discharged on vancomycin, which you should take for 4
more days to complete the 14-day course.
.
You also had trouble with your heart rhythm while you were here,
and had an episode of very abnormal rhythm called "Torsades de
Pointes". We sent you to the intensive care unit for monitoring.
Several of your medications were stopped or changed. You were
then sent to the inpatient medicine floor.
.
On the inpatient medicine floor you had some abdominal pain, for
which we could not find a clear cause. We also had to modify
your coumadin regimen to get your INR to the right place. You
INR did become very high, and we suspect that this along with
the C. difficile colitis is the reason for you having had some
blood in your stool. You did have some abdominal pain likely
related to bowel movements, but this was generally short-lived
in duration and improved after taking Maalox or Tylenol. This
may also be related to constipation. We also started a lidocaine
patch on your arm for your known elbow fracture. This seemed to
help with the pain there. We did imaging studies of this arm,
and the fracture has still not healed; you should strongly
consider seeing your orthopedist for this as an outpatient. You
should also continue a bowel regimen so that you can clear some
of the stool from your colon.
.
.
Your home medications were changed as follows:
- CONTINUED Maalox Q6H PRN
- STOPPED Amiodarone 200mg qday
- CONTINUED Simvastatin 20mg HS
- CONTINUED Calcium Acetate 667mg x 2 TID
- CONTINUED Sarna lotion Q6H PRN
- STOPPED Ceftriaxone - completed [**3-22**]
- STOPPED Colace 200mg [**Hospital1 **]
- CHANGED Epo 5000units Q5days
- STOPPED Fluconazole 100mg Q48H
- STOPPED Lasix 80mg [**Hospital1 **]
- STOPPED Metolozone 5mg qday
- CONTINUED Insulin lantus 30 units Qday
- CONTINUED Isosorbide Mononitrate 90mg qday
- CONTINUED Levothryroxine 37.5mcg qday
- CONTINUED Lidocaine 2% solution PRN
- STOPPED Metoprolol 25mg [**Hospital1 **]
- CONTINUED Nitro 0.4mg SL PRN
- CHANGED Protonix 40mg Qday to Omeprazole, which is a similar
drug
- STOPPED Polysaccaride Iron Complex 150 Qday
- STOPPED KCl 40meq per day
- STOPPED Ranitidine 150mg [**Hospital1 **]
- CONTINUED Senna 17.2mg [**Hospital1 **] PRN
- CONTINUED Spironolactone 25mg qday
- CONTINUED Humalog sliding scale
- STOPPED Trazadone prn
- CONTINUED Bisacodyl prn
- CONTINUED Coumadin 2mg PM
- STARTED Vancomycin
- STARTED Bumex
- STARTED Lidocaine patches
- STARTED Alprazolam (Xanax)
- STARTED Cepacol lozenges
- STARTED Sucralfate for upset stomach
- STARTED Polyethylene glycol for constipation
Followup Instructions:
Please call for follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 1270**], at [**0-0-**].
.
You should consider making an appointment with your orthopedic
surgeon regarding your fracture.
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]
Completed by:[**2134-4-12**]
ICD9 Codes: 5849, 0389, 4271, 2762, 4280, 5859, 4168, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4355
} | Medical Text: Admission Date: [**2175-6-9**] Discharge Date: [**2175-6-20**]
Date of Birth: [**2105-9-26**] Sex: M
Service: MEDICINE
Allergies:
Gluten
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
altered mental status, fevers
Major Surgical or Invasive Procedure:
1. Lumbar puncture [**2175-6-10**]
2. Intubation [**2175-6-10**]
3. picc-line placement [**2175-6-12**]
History of Present Illness:
69-year-old Haitian speaking male
h/o ESRD s/p kidney transplant in [**2168**], Chronic Hep C, HIV on
HAART (last CD4 220 [**2175-6-7**]), h/o DVTs on coumadin, who was
brought in by ambulance after his cousin found him laying in bed
unresponsive shaking his right arm. Prior to this, his VNA
called him and he was not answering questions appropriately.
She then called his cousin and HCP, to let him know. His cousin
then came to the patient's house and found him as above. He
immediately called 911. Of note, the cousin spoke to the patient
the day prior in the late afternoon and found him to be
answering questions appropriately. In the outpatient, he has
been having difficulty obtaining an appropriate INR as his
seroquel dosing and has had VNA help him with INR checks.
.
In the ED, initial vs were: 100.5 92 152/92 16 95% RA. alert and
oriented x 0. Finger stick 97. T max: 101.3 in ED. CT head
negative for bleed. Labs notable for an INR of 5.6. WBC of 5.2
with a left shift. He was given 1 liter NS, 2 grams CTX, 1 gram
vancomycin. 1 gram of ampicillin was ordered, but not given. EKG
notable for no ischemic changes. Prior to transfer to the floor,
VS: 101.3 96 122/89 16 100 RA.
.
On the floor, patient was immediately noted to be having a
seizure where both eyes deviated to the right with tonic flexion
of right arm. Neuro was consulted immediately. When he was
clear, he reportedly stated he had a bad taste in his mouth. He
was given acyclovir, ampicillin and a total of 3 mg IV ativan,
with brief improvement in his seizures, however seizures
continued to return. He was then transferred to the MICU for
closer monitoring.
.
Upon arrival to the MICU, his IV infiltrated, and no peripheral
access was found. He continued to have seizures with temporary
relief with 1 mg ativan. A femoral line was placed and he was
keppra loaded with 750 mg IV x 1 and given 10 mg IV vitamin K.
.
Review of systems: Unable to obtain due to mental status.
Past Medical History:
1. End-stage renal disease secondary to hypertension, status
post kidney transplant in [**2168**] with deceased donor transplant,
currently on azathioprine and sirolimus.
2. Chronic hepatitis C without history of treatment.
3. Hepatitis B core antibody positive and surface antibody
positive.
4. Celiac sprue.
5. Positive PPD in [**2168-4-11**] and status post INH therapy per
patient, but unclear in [**Name (NI) **].
6. Osteopenia/osteoporosis.
7. Anxiety.
8. Hypertension.
9. Status post left parietooccipital hemorrhagic stroke in
[**2167**],
complicated by seizures.
10. History of DVT x2 with lifelong anticoagulation with
Coumadin.
11. HIV diagnosed while hospitalized for PCP pneumonia in [**Name9 (PRE) 547**]
[**2174**]. He has been on Truvada, renally dosed and raltegravir
since [**2174-7-12**].
Social History:
Patient is originally from [**Country 2045**] and has lived alone recently;
He denies tobacco, alcohol or illicit drug use.
Family History:
Noncontributory.
Physical Exam:
ADMISSION:
Vitals: T:100.1 BP: 188/77 P: 93 R: 17 O2: 93% RA
General: Not oriented, intermittently alert
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, sinus rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE:
Pertinent Results:
ADMISSION LABS:
[**2175-6-9**] 01:00PM PT-52.0* PTT-54.2* INR(PT)-5.6*
[**2175-6-9**] 01:00PM PLT COUNT-308
[**2175-6-9**] 01:00PM NEUTS-78.3* LYMPHS-12.1* MONOS-7.8 EOS-1.7
BASOS-0.1
[**2175-6-9**] 01:00PM WBC-5.2# RBC-3.32* HGB-9.7* HCT-28.4* MCV-86
MCH-29.1 MCHC-34.0 RDW-15.5
[**2175-6-9**] 01:00PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2175-6-9**] 01:00PM cTropnT-<0.01
[**2175-6-9**] 01:00PM LIPASE-71*
[**2175-6-9**] 01:00PM ALT(SGPT)-7 AST(SGOT)-4 CK(CPK)-337* ALK
PHOS-36* TOT BILI-0.0
[**2175-6-9**] 01:00PM GLUCOSE-105* UREA N-21* CREAT-2.3* SODIUM-134
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-25 ANION GAP-12
[**2175-6-9**] 03:35PM rapamycin-12.4
[**2175-6-9**] 09:11PM PT-54.8* PTT-52.9* INR(PT)-5.9*
[**2175-6-9**] 09:11PM WBC-5.8 RBC-3.30* HGB-9.4* HCT-27.8* MCV-84
MCH-28.5 MCHC-33.8 RDW-15.2
.
DISCHARGE LABS:
[**2175-6-20**] WBC 7.5 Hgb 7.8 Hct 22.5 plt 381
[**2175-6-20**] PT: 33.5 PTT: 39.1 INR: 3.3
[**2175-6-20**] Na: 134 K: 3.9 Cl: 103 HCO3: 25 BUN: 22 Cr: 1.8
.
STUDIES:
CT HEAD W/O:
1. No acute intracranial process.
2. Focal encephalomalacia in the left parieto-occipital region,
likely from prior hemorrhage.
3. Stable periventricular hypoattenuation, possible small vessel
ischemic
disease or HIV-related leukoencephalopathy.
.
CXR [**6-9**]: Stable right upper lobe scarring. No acute findings.
.
MRI [**6-10**]:
1. Moderate to severe changes of small vessel disease and brain
atrophy.
2. Chronic blood products in the left parietal lobe likely
indicative of
prior hemorrhage or ischemia.
3. No evidence of acute infarcts, mass effect or hydrocephalus.
.
EEG [**2175-6-11**]:
This is an abnormal video EEG telemetry due to the slow and
disorgnaized background wtih nearly continuous generalized delta
frequency slowing with superimposed mixed alpha and theta
frequency activity and frequent brief periods of generalized
suppression. This pattern is consistent with a moderate diffuse
encephalopathy most commonly seen with medication effect,
metabolic disturbance, or infection. The mixed alpha and beta
frequency activity is suggestive of a medication effect. In
addition, the occasional bifronto-central sharp discharges are
indicative of an underlying cortical irritability. However, no
clear electrographic seizures were seen.
.
EEG [**2175-6-12**]:
This is an abnormal video EEG telemetry due to the slow and
disorganized background with bursts of generalized delta
frequency slowing consistent with a moderate encephalopathy.
There were also periods of prolonged mixed alpha and beta
frequency activity suggestive of a medication effect.
Encephalopathies are most frequently associated with
toxic/metabolic disturbances, infections, and medication
effects. In addition, there were occasional sharp and spike and
slow wave epileptiform discharges seen in the right frontal
region or the frontal regions bilaterally, indicating underlying
cortical irritability and epileptogenic potential. However, no
clear electrographic seizures were seen.
.
EEG [**2175-6-13**]:
This is an abnormal continuous EEG due to the presence of
frequent periods of rhythmic 0.5-1 Hz generalized delta slowing
with embedded frontocentral sharp waves lasting up to 12
seconds. In addition, there were frequent generalized interictal
sharp discharges seen often with a bifronto-central and
occasionally with a right fronto-central predominance. Together,
these patterns are suggestive of a generalized cortical
irritability. In addition, there was one electrographic seizure
seen at 11 a.m. without an associated clinical change, as
described above in the Continuous EEG section. Otherwise, the
background consists of alternating periods of a faster
theta/alpha frequency activity and a slower [**2-12**] Hz delta
activity, as described above, which represents a moderate to
severe diffuse encephalopathy commonly seen with medication
effect, metabolic disturbance, or infection.
.
EEG [**2175-6-14**]: PENDING
EEG [**2175-6-15**]: PENDING
EEG [**2175-6-16**]: PENDING
.
CXR [**2175-6-13**]: Stable right upper lobe nodule.
.
L shoulder x-ray [**2175-6-19**]
Note MRI is more sensitive to evaluate the tendinous and
ligamentous structures. The visualized left lung and ribs are
unchanged and grossly normal. The visualized AC joint is grossly
normal. The humeral head is slightly high riding, which is
suggestive of rotator cuff pathology. Moderate degenerative
changes of the glenohumeral joint with joint space narrowing,
mild glenoid sclerosis, tiny inferior humeral head osteophytes.
No definite fracture. No dislocation.
IMPRESSION:
1. Moderate glenohumeral joint degenerative changes.
2. Mild high riding humeral head, which suggests rotator cuff
pathology.
.
CT head w/o contrast: [**2175-6-19**]
1. No acute intracranial hemorrhage or major vascular
territorial infarct.
2. Chronic microangiopathic ischemic disease.
.
Echo [**2175-6-20**]
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. 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 (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No PFO, ASD, or cardiac source of embolism seen.
Normal global and regional biventricular systolic function.
.
MICRO and OTHER STUDIES:
Serum toxo: IgG positive, IgM negative
Serum and CSF crypt Ag: negative
Serum RPR: negative
Serum CMV viral load: undetectable
C diff: negative
CSF HSV: NEGATIVE
CSF [**Male First Name (un) 2326**] VIRUS: NEGATIVE
CSF HHV6: NEGATIVE
.
Aspergillus negative 0.1
Beta glucan negative <31 pg/mL
.
STOOL CX [**2175-6-12**]: NEGATIVE
C. DIFF [**2175-6-12**]: NEGATIVE
C. DIFF [**2175-6-16**]: NEGATIVE
Brief Hospital Course:
HOSPITAL COURSE:
Pt is a 69 yo M h/o HIV on HAART, ESRD s/p renal transplant, Hep
C, DVTs on coumadin with elevated INR p/w status epilepticus and
fever. Pt was seen by neurology, started on antiepileptics and
admitted to the MICU for closer monitoring. He was intubated for
airway protection and for MRI. Pt was started on
Vanc/CTX/Ampicillin and Acyclovir to cover for meningitis. LP
was initially not able to be done given elevated INR. MRI
without contrast showed old left parietal blood, but no new
infarct. On HOD#1, LP was done and showed few WBCs and slightly
elevated protein, with negative Cryptococcal Ag, Toxo, and HSV;
CSF cultures ultimately did not indicate bacterial or fungal
infection. He was placed on AEDs with Keppra and monitored by
neurology. ID was consulted given concern for meningitis
especially in this gentleman with immune suppression. Several
CSF studies were sent, which were unrevealing.
He was extubated in the MICU, and transferred to the medicine
floors for further care. He was more oriented, with mental
status slowly improving throughout remainder of hospital course.
EEG did show possible seizure focus in right posterior lobe,
but patient remained clinically free of events.
.
ACTIVE ISSUES:
==============
# Status Epilepticus: DDx for onset included meningitis,
encephalitis given fevers, vs. new infarct, hemorrhage. Given
the temporal nature of his seizures with the altered taste,
deviation to right highly concerning for HSV infection though
this came back negative. Opportunistic infections such as
toxoplasmosis or cryptococcus were also considered, but were
negative. CSF studies were not indicative of PML and MRI was not
suggestive of PRES. Patient does have an old left parietal
infarct though this is unlikely to be a seizure focus, contrast
imaging of his head was not performed given renal impairment so
visualization of other intracranial pathology (new small infarct
or enhancing lesions) could not be fully evaluated. LP was done
on HOD 1 and showed slightly elevated WBC to 14 and 5 RBCs and
protein but otherwise unrevealing. Viral encephalitis is most
likely etiology though would not expect seizures solely from
this. Because seizure threshold can also be lowered by
immunomodulators and psychiatric medications; azathioprine/
rapamycin were initially held and seroquel was discontinued.
Patient had several clinical seizures and 1 non-convulsive
seizure seen on EEG, and his Keppra dose was increased to 750mg
q12h. Prior to transfer to the floor, he was not having any
seizure activity and his mental status was improved. On the
medicine floors, he was monitored on EEG, which showed possible
seizure focus in the right posterior lobe.
At time of discharge, patient remained clinically stable and
will follow with neurology as an outpatient for further
management.
# Toxic metabolic encephalopathy: Likely secondary to
encephalitis (most likely viral) as above. [**Month (only) 116**] also be [**Doctor Last Name 688**]
and waxing in setting of delirium and peri- and post-ictal
states. He was treated initially with vancomycin, ceftriaxone
and acyclovir to cover for bacterial meningoencephalitis and HSV
encephalitis though these were subsequently discontinued after
studies came back negative. Patient was also initially intubated
for airway protection and successfully extubated when mental
status improved. He had an NGT placed for tube feeds. Through
the remainder of the hospital course, patient became more alert
and oriented to person/ place; able to follow simple commands
and communicate with healthcare providers through an
interpreter. Of note, patient did have new onset left upper
extremity weakness (see below).
.
# CKD, s/p renal transplant in [**2168**]: Cr remained at baseline of
around 1.8-2.0. Renal transplant team was following patient. His
rapamycin levels were elevated at 14 (goal [**7-19**] one year after
transplant) and rapamycin was held with daily levels checked.
His azathioprine was also briefly held given concern for
myelosupression and then restarted on [**2175-6-17**]. Per renal
transplant, he restarted rapamycin at 1mg daily on [**2175-6-16**].
Rapamycin levels should be checked every 2-3 days and faxed to
renal transplant clinic ([**Telephone/Fax (1) 697**]) where patient will be
followed as an outpatient.
.
# Anemia: Hct 28.4 on admission, which is slightly down from
baseline in the low 30s. Hct trended down to 19.6 on HD 5 and he
received 1U RBCs with appropriate response to 24. He had no
signs of active bleeding, iron studies were not suggestive of
[**Doctor First Name **] and more consisted with ACI. His stools were guaiac
negative. Myelosuppression was also likely contributing given
immunosuppressive agents s/p renal transplant and HIV.
Reticulocyte count was consistent with this. His azathioprine
and rapamycin were initially held to aid in marrow recovery. His
HCT drifted downwards to 22.1 at time of discharge with no signs
of active blood loss or hemolysis.
Labs should be checked as an outpatient with transfusion
parameters to maintain Hct > 21.
.
# DVTs: patient has recent history of DVTs for which he is on
coumadin. He had elevated INR on admission (5.2) which was
attributed to elevated seroquel levels. He was given vitamin K
and coumadin was held, heparin drip was started for bridging.
His coumadin was restarted after his HCT remained stable (as
above) at 2mg daily. INR was again supratherapeutic at 3.3
prior to discharge with subsequent discontinuation of coumadin.
PT/INR should be checked daily with resumption of coumadin to
maintain an INR of [**3-16**].
.
# Left arm weakness: After acute illness, patient was noted to
have isolated left deltoid weakness on exam. Per comprehensive
neurologic exam, there was also a questionable decrease in left
triceps and upper extremity extensiors raising concern for
possible CNS pathology. Stat CT head w/o contrast showed no
acute pathology and echo w/ bubble showed no PFO. As further
imaging would not impact management, repeat MRI head/ neck was
not pursued. Left arm weakness may also be related to rotator
cuff injury from fall prior to admission although patient had no
complaints of discomfort. Shoulder xray showed some elevation
of the humeral head which may be consistent with musculoskeletal
etiology. Further evaluation and management per outpatient
providers.
.
# Femoral line complication: Pt had femoral line placed on left,
but artery was cannulated. Vascular surgery was consulted. Line
was removed once INR <1.8. Pressure was applied, pulses remained
intact, no hematoma and no bruit. He remained stable for the
remainder of the hospitalization.
.
# HIV: Last CD4 count 220. Continued HAART. CSF studies were not
able to be sent for HIV viral load and LP was not repeated given
clinical improvement. He was continued on HAART, and will have
follow-up with ID as an outpatient.
.
# Leukopenia: Most likely [**3-15**] marrow suppression from
immunosuppressants. Has multiple other reasons to be leukopenic
including HIV vs. infection. No clear source of infection.
Sirolimus & Azathioprine was initially held, and restarted on
[**6-16**] and [**6-17**] respectively once leukopenia had resolved.
.
# Respiratory distress: Initially intubated for airway
protection in setting of seizures, s/p extubation on [**2175-6-13**]. On
the medicine floors, he had good O2 sats on room air.
.
# Eosinophilia: Differential checked [**2175-6-14**] with peripheral eos
8.1%. Pt had mild transaminitis earlier in his course that has
since resolved. Only new medication is Keppra. He did not have a
rash, and LFT's were mildly elevated, but downtrended.
Should have follow-up to assess for resolution.
.
# Loose stools: Puting out large amounts from rectal tube in the
MICU and continued on transfer to medicine floors. C. diff x 2
was negative and stool cultures from [**6-12**] were negative. Prior
to discharge, rectal tube removed.
.
# HTN: on clonidine, amlodopine, and metoprolol as outpatient.
Given nicardipine on admission per neuro recs, which was
subsequently discontinued. Patient became increasingly
hypertensive as sedation was weaned and was restarted on
amlodipine and clonidine, and labetolol was added instead of
home metoprolol. His SBP was relatively well controlled at ~140s
at time of transfer to floor. His BP continued to be
well-controlled during this stay on the medicine floors. He was
discharged on Amlodipine, Clonidine per prior home doses, and
started on Labetalol.
.
# Nutrition: Placed on TF's while in the MICU which were
continued after extubation given profound weakness. Speech &
swallow evaluated the pt, and recommended diet of pureed solids
and thin liquids with supplemental tube feeds until PO intake
improved. Patient should have repeat swallow evaluation and
calorie count at LTAC to determine when Dobbhoff can be removed.
# Hep C: Reportedly never been treated
- check viral load
.
# GERD: Protonix held while in ICU, and given Lansoprazole. Once
tolerating po's, pantoprazole was restarted at home dosing.
.
# Anxiety: On seroquel as outpatient, but thought to be
interacting with INR and possible lowering the seizure
threshold. This has been held since admission. Pt should
follow-up with physicians at rehab for further management.
.
TRANSITION OF CARE:
===================
1. CODE: FULL
2. Follow-up:
- Neurology
- Renal transplant
3. Medical management:
- several adjustments to medications made as described
- please monitor rapamycin levels every 2-3 days; fax to
[**Telephone/Fax (1) 697**]
- hold coumadin until PT/INR [**3-16**]
- monitor Hct and transfuse to maintain Hct > 21
4. Outstanding tasks:
- reassess need for nutritional supplementation with calorie
count; repeat speech/ swallow evaluation
5. Barriers to rehospitalization:
- PT/OT to maximize strength and independence in ADL
Medications on Admission:
AMLODIPINE 5 mg Tablet by mouth daily
AZATHIOPRINE - 50 mg Tablet daily
CLONIDINE - 0.2 mg Tablet TID
EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - 1
Tablet(s) by mouth every 48 hours
METOCLOPRAMIDE - 5 mg Tablet by mouth three times daily
METOPROLOL TARTRATE 50 mg Tablet - [**2-12**] Tablet(s) by mouth twice
a day
MIRTAZAPINE - 15 mg Tablet - 1 Tablet(s) by mouth at bedtime For
insomnia, depresion and to stimulate appetite.
PANTOPRAZOLE- 40 mg Tablet, Delayed Release -1 Tablet daily
QUETIAPINE [SEROQUEL] - 50 mg Tablet - 1 Tablet(s) by mouth at
bedtime
RALTEGRAVIR [ISENTRESS] - 400 mg Tablet - 1 Tablet(s) by mouth q
12 hours
SIROLIMUS [RAPAMUNE] - 2 mg daily
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth one time per day to prevent infection
WARFARIN - 2 mg Tablet - take up to 2 Tablet(s) by mouth daily
or
as directed
CALCIUM CARBONATE - (Prescribed by Other Provider) - Dosage
uncertain
CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] - 500 mg (1,250
mg)-400 unit Tablet - 1 Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] - 400 unit Tablet - 1
Tablet(s) by mouth DAILY (Daily)
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - 1,000 mcg Tablet
-
2 Tablet(s) by mouth one time per day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth take up
to 1 tab [**Hospital1 **]
FOOD SUPPLEMENT, LACTOSE-FREE - Liquid - 1 can by mouth 1-2
times daily
MULTIVITAMIN - Capsule - 1 Capsule(s) by mouth once a day
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
5. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. sirolimus 1 mg Tablet Sig: One (1) Tablet PO Q6AM ().
9. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO Q48H (every 48 hours).
12. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
14. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Please hold until INR < 3. Target PT/INR [**3-16**].
15. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. Seizures
2. Fevers
3. Toxic metabolic encephalopathy
4. Anemia
5. Leukopenia
6. CKD s/p renal transplant
Secondary:
1. HIV
2. Hypertension
3. history of DVT's
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 19781**],
It was a pleasure taking care of you during this admission. You
were admitted with seizures and fever. You were intubated during
the seizures to protect your airway and this tube was pulled out
once your medical condition had stabilized. You were able to
breath well on your own and come off oxygen.
You were treated initially with antibiotics given concern for
infection in the brain, but a sampling of the spinal fluid
showed that this was not infected. You were also seen by
neurology and started on an anti-seizure medication. An MRI of
the brain showed no new changes. You had an EEG to monitor for
seizure activity, and this showed an area of focal slowing in
the right poterior brain. You also had an echocardiogram which
showed no abnormalities. By the time of discharge, your mental
status was improving. You did have weakness of your left
shoulder which was likely caused by injury to your arm from a
fall, but may have been caused by a small stroke.
Due to your severe illness, you still required supplemental
nutrition via a dobboff tube which will be removed once you are
eating better.
The following medications were changed during this admission:
- STOP Seroquel 50mg by mouth at night
- STOP Metoprolol tartrate 50mg 0.5 tablet twice daily
- STOP Metoclopramide 5mg three times daily
- HOLD your coumadin 2mg daily: you will need to have your
PT/INR monitored daily until your INR is [**3-16**]
- HOLD your multivitamins while you are still using tube feeds
as supplementation
- DECREASE your sirolimus to 1mg daily: you will need to have
your levels measures every 2-3 days to ensure that you are on
the correct dose
- START keppra 750mg [**Hospital1 **]
- START Labetalol 300mg by mouth three times daily
- START simvastatin 10mg daily
Please continue all other medications you were taking prior to
this admission.
Followup Instructions:
Please follow-up with the following appointments:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2175-7-12**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15675**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: [**Hospital Ward Name **] [**2175-7-7**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 31415**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: TUESDAY [**2175-8-1**] at 9:00 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Fax: [**Telephone/Fax (1) 697**]
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
ICD9 Codes: 2930, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4356
} | Medical Text: Admission Date: [**2132-2-6**] Discharge Date: [**2132-2-18**]
Date of Birth: [**2085-9-4**] Sex: M
Service:
CHIEF COMPLAINT: Endstage renal disease seconary to diabetes
mellitus.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
male with end-stage renal disease secondary to diabetes
mellitus who was scheduled for a kidney transplant from his
sister on [**2132-2-6**]. The patient is currently maintained on
hemodialysis using a left arteriovenous fistula. His right
IJ Perm-a-Cath in place.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. End-stage renal disease.
3. Hypertension.
4. Hemodialysis dependent.
5. Neuropathy
6. Hypothyroidism.
7. Gastroesophageal reflux disease.
8. Depression.
PREVIOUS SURGERIES:
1. Left arm fistula.
2. Incision and drainage of left leg wound.
MEDICATIONS:
1. Zoloft 10 mg p.o. q day.
2. Amitryptiline 20 mg p.o. q day.
3. Atenolol 50 mg p.o. q day.
4. Norvasc 10 mg p.o. q day.
5. Prilosec 20 mg p.o. q day.
6. Levoxyl 500 mcg p.o. q day.
7. Vitamin B12 500 mg q day.
8. TUMS four tabs with meals.
ALLERGIES: No known drug allergies.
INITIAL PHYSICAL EXAMINATION: Vital signs: Blood pressure
158/77, pulse 57. General: No acute distress. Head, eyes,
ears, nose and throat: Negative lymphadenopathy, negative
carotid bruits. Chest clear to auscultation bilaterally.
Cardiac: Regular rate and rhythm. No murmurs. Abdomen:
Scar midline, soft, nontender, negative splenomegaly,
negative bruits. Extremities: Negative edema.
HOSPITAL COURSE: The patient was admitted on [**2132-2-6**] and was
brought to the operating room with a primary diagnosis of
end-stage renal disease. The patient had a living related
renal transplant from his sister. The patient tolerated the
procedure well and was transported to the Post Anesthesia
Care Unit in stable condition.
In the Post Anesthesia Care Unit the patient's initial urine
output totaled 25 cc's. The Foley was irrigated multiple
times without signs of blockage. The patient also had subtle
changes in his electrocardiogram postoperatively with flip
T-waves in the lateral leads. Cardiology was consulted at
that time. Cardiology recommendation included checking
serial enzymes, starting Lopressor and aspirin and continuing
to check electrocardiograms.
At the postop check roughly 9:30 PM the patient's T-wave
changes and ST depressions had resolved. The patient's
urinary output continued to totalling only 50 cc's. The
patient was admitted to the SICU following surgery and was
continued to be followed by Cardiology, the SICU team and
transplant service.
On the third the patient had a Swann-Ganz catheter placed to
better monitor cardiac output.
On the 5th the patient had hemodialysis in which 5 kg was
removed from the patient. It was estimated by the
hemodialysis team that the patient was roughly 30 kg
overweight. On the 7th the patient had a second hemodialysis
in which two liters of fluid was removed.
On the 8th the patient was transferred to the floor and had
roughly 177 cc's of urine out in the previous day. On day 9
the patient's urinary output continued to be in the low side
measuring roughly 116 cc's. The postop cross match which
came back on the 9th was negative. On the [**6-14**]
the patient's urinary output started to increase and had a
total of 300 cc's out from the day before hand. During the
second week of the patient's hospitalization stay his urine
output continued to increase but his hemoglobin slowly
decreased. On the 13th the patient was transfused two units
of packed red blood cells.
On the 14th the patient's urinary output totaled 800 cc's for
the previous day. The patient's hemoglobin was 29.2 on the
14th.
On the 14th the patient is doing well, his urine output was
improving and the patient was stable enough to be discharged
to rehabilitation services.
DISCHARGE PHYSICAL EXAMINATION: T-max 96, heart rate 106,
blood pressure 180/100. Respiratory rate 20, O2 99 on room
air. pO 1860, IV 735, urinary output 800. General: He is
alert and oriented no acute distress. Cardiovascular is
regular rate and rhythm. Respiratory was clear to
auscultation bilaterally. Abdomen was soft, nontender,
nondistended with positive bowel sounds. Incision was clean,
dry and intact. Extremities: Showed no peripheral edema but
mild swelling. Incision was clean, dry and intact with
ecchymosis around the right aspect. White cell count 4.7,
hematocrit 21.6, platelets 193. Chem 7: 129/4.2. 95/23,
68/7.3 and a glucose of 110. Calcium 8.2, phos 6.1, mag of
1.5.
DISCHARGE DIAGNOSIS:
1. Status post living related kidney transplant with
delayed graft function.
2. Insulin dependent diabetes mellitus.
3. Postop atrial fibrillation, A-flutter.
SECONDARY DIAGNOSIS:
1. Hypertension.
2. Peripheral vascular disease.
3. Neuropathy.
4. End-stage renal disease.
5. Hemodialysis dependent prior to transplantation.
DISCHARGE MEDICATIONS:
1. Bactrim one tab p.o. q day.
2. Nystatin swish and swallow 5 cc's q 6 hours.
3. Amiodarone 200 mg p.o. q day.
4. Amphojel 30 cc's p.o. t.i.d.
5. Colace 100 mg p.o. b.i.d.
6. FK 506 3 mg p.o. b.i.d.
7. Prednisone 20 mg p.o. q day.
8. CellCept 1 gram p.o. b.i.d.
9. Levoxyl 50 mEq p.o. q day.
10. Regular insulin sliding scale 200 to 250 - 2 units
Subcutaneously. 251 to 300 - 4 units subcutaneously,
301 to 350 - 6 units subcutaneously. 351 to 400 8
units subcutaneously. Greater than 400 10 units
Subcutaneously and call primary care physician.
11. Zoloft 50 mg p.o. q day.
12. Amitryptiline 20 mg p.o. q day.
13. Protonics 40 mg p.o. q day.
14. Epogen 5000 units with hemodialysis three times a
week.
15. Mag oxide 400 mg p.o. times one on [**2131-2-18**] PM.
16. Percocet 5 one or two tabs p.o. q 4 to 6 hours.
The patient will require care with medications. The patient
will also require blood sugar monitoring, strict I's and O's
and FK506 level checks per the transplant packet. The
patient will also require physical therapy which will include
general therapy and also occupational therapy.
FOLLOW-UP: Patient follow-up with Dr. [**Last Name (STitle) **] per the packet.
The patient will already have an appointment scheduled for
him. The patient will also follow-up with Cardiology,
[**Telephone/Fax (1) 10316**] with Dr. [**Last Name (STitle) **] on [**2-26**] at 10 AM in the
[**Hospital Unit Name **] 4B.
DISCHARGE STATUS: Stable and good. To rehabilitation
services.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], M.D. [**MD Number(1) 15476**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2132-2-18**] 14:46
T: [**2132-2-18**] 15:15
JOB#: [**Job Number 34137**]
ICD9 Codes: 9971, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4357
} | Medical Text: Admission Date: [**2126-12-21**] Discharge Date: [**2127-1-5**]
Date of Birth: [**2066-10-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 60-year-old man with cirrhosis due to hepatitis C (VL
in [**10-4**] was > 1 million) and alcohol, ESLD on transplant list,
h/o GI bleed, esophageal varices, recent HCC s/p radiofrequency
ablation, presented to OSH ED with weakness and poor PO intake.
He was found to have anemia to hct of 22, requiring 3 units of
pRBCs. He also c/o dyspnea, but no cough, and was found to have
a LLL infiltrate. He was treated for CAP with ceftriaxone,
azithromycin and duonebs. Cardiac markers were negative x3, but
note made of prolonged QT on EKG. Overnight on [**12-20**] to [**12-21**],
pt appeared fluid overloaded with dyspnea, so furosemide was
started. He was also started on methylprednisone for possible
wheezing and concern for developing shock and ?adrenal
insufficiency (BP 84/51). They broadened to Vanc/Levo for 1 dose
for HCAP.
Per patient report, he initially presented to the hospital
because of weakness in all his muscles and hips, which had been
gradually worsening since [**2126-7-25**]. He said he had a cough
yesterday, producing brown, non-bloody sputum, but this was the
first time it was productive. And in fact, had not had a cough
at home. He has had progressive SOB for several months since
[**Month (only) 205**], but denies CP or pleuritic CP. He says he's afraid to take
deep breaths since his RFA, and had CP then that felt like "a
rib was broken," but currently denies any CP or pleuritic CP. He
denies any fever, chills or night sweats, but says at the
hospital yesterday he was told he had a low-grade fever.
Recorded temp of 100.5 per OSH records. He also endorses 20lb wt
loss over the past 4 mos, due to anorexia, and "everything
tastes like cardboard." He denies leg swelling, abdominal
swelling or abdominal pain. He has had watery BM's with the
lactulose, and had a black stool yesterday, but denies BRBPR. He
denies any sick contacts at home.
.
On transfer, initial vs were: T 98.8 P 84 BP 121/65 R 21 O2 sat
92% on 100% non-rebreather. Currently, the patient states he
feels anxious about everything that's going on, and feels
slightly short of breath, but otherwise denies complains. He
currently denies any pain anywhere.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
constipation, abdominal pain. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias.
Past Medical History:
Hepatitis C
End-stage liver disease (on transplant list) as of [**11/2126**]
Hepatocellular carcinoma s/p radiofrequency ablation [**2126-11-6**]
GI bleed in [**2126-7-25**]: EGD with "watermelon stomach," grade [**1-26**]
esophageal varices and portal hypertensive gastropathy
Gastroesophageal reflux disease
COPD/emphysema due to a long history of smoking (never been
intubated or required steroids)
Depression
Anxiety
Seasonal allergies
Left cataract surgery
h/o alcohol use, last used 35yrs ago
Social History:
Notable for significant tobacco use, which he reports he quit
approximately 15 years ago, previous smoking history 2
ppdx20yrs, 40py. He has been sober from alcohol and drugs since
[**2091**]. He is married and lives with his wife. [**Name (NI) **] has three
children from a previous marriage, age 40, age 36, and age 30,
all in good
health. He is a retired software engineer. He used injection
drugs (barbituates) last in the [**2086**]'s and had multiple tattoos
with shared needles.
Family History:
Notable for lung cancer in both of his parents, both deceased.
Brother with multiple medical problems, but unsure as they are
estranged. His mother also suffered from diabetes.
Physical Exam:
ADMISSION PHYSICAL:
Vitals: T: 98.8 BP: 121/65 P: 84 R: 21 O2: 92% on 100%
non-rebreather
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, poor oral hygiene with drying
secretions on lips and teeth
Neck: supple, JVP not elevated though difficult to evaluate
given thick neck, no LAD
Lungs: no use of accessory mm of breathing, speaking in full
sentences, fine crackles in LLL, no rhonchi or wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, non-tender, non-distended, no rebound
tenderness or guarding, liver edge not palpated, no fluid wave
GU: foley placed, yellow urine in foley catheter
Skin: erythema in lower abdomenal skin folds, several petechiae
on bilateral lower extremities
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE PHYSICAL:
Pertinent Results:
ADMISSION LABS:
.
DISCHARGE LABS:
.
MICRO:
BCX [**12-21**] - pending
Legionella Ag [**12-21**] - pending
.
IMAGING:
CXR [**12-21**]:
New extensive parenchymal opacities have been demonstrated
throughout the
lungs with significant worsening of the left lower lobe
consolidation and new right upper lung consolidation as well as
diffuse opacities. Differential diagnosis is wide and may
include pulmonary edema, widespread infectious process such as
viral, mycoplasma, PCP or even bacterial. Hemorrhage would be
another possibility. Please correlate with clinical findings.
There is no appreciable pneumothorax. Some degree of underlying
pulmonary edema definitely cannot be excluded.
Brief Hospital Course:
This is a 60 year old male with hep C cirhosis, HCC s/p
radiofreqency ablation, recently added to the transplant list,
who presented with pneumonia at OSH, transferred here for
further management.
#. Hypoxia, dyspnea: The pt had c/o dyspnea, but no cough. His
dyspnea was thought to be due to to PNA as evidenced by new
purulent cough and infiltrates on exam, also suggested by CXR
with worsening consolidation in LLL and new consolidation in
RUL. No evidence of pulmonary HTN on echo, not fluid overloaded
with normal EF, and no evidence of PE on CTA. Pt initially
required 100% non-rebreather, and was placed on CPAP overnight.
Started on Vancomycin, Cefepime for HCAP, and Levofloxacin to
cover atypicals. In terms of the workup for the resp failure,
Sputum Cx, Blood Cx, legionella Ag were sent, which showed AFB
on smear. OSH CT chest was reviewed, showing diffuse GGOs. OSH
microdata showed no growth. Patient's sputum showing AFB on
smear was sent to state lab for PCR probe, which was
indeterminate for MTB. A second sputum smear was sent and was
negative for AFB, but given earlier indeterminate result a PCR
probe was nonetheless sent to the state lab. Initial and repeat
BAL failed to grow bacterial organisms, and were negative for
PJP via immunofluorescence, as well as legionella, fungal, and
viral cultures. The BAL also failed to show eosinophilia,
ruling out Eo PNA. Serum studies showed negative beta-glucan
and histo Ag. A quantiferon gold was sent given concern for MTB
and was negative.
The patient was maintained on the vent during his ICU course,
and early on met criteria for ARDS and so was placed on ARDSnet
vent settings. He tolerated these setting well, but showed
little signs of improvement, thus precluding attempts to wean
the ventilator. Later in his ICU course, intermittent
agitation, especially at night, became a limiting factor of
effective ventilation.
Wide coverage for typical and atypical bacterial sources was
maintained in the ICU, though MTB treatment was not initiated
d/t equivocal testing and patient's baseline liver disease. MTB
PCR came back negative and patient was taken off TB precautions.
He also received a trial of steroids, but continued to pull
extremely high tidal volumes (though some minimal improvement on
the vent). The wife expressed that her husband did not want to
be intubated to begin with and in light of him not improving,
she wanted to take him to hospice. After a few days of careful
consideration, he was made CMO on [**1-4**] and was extubated. The
wife was at the bedside and the patient continued to breath on
his own. He was made comfortable with Morphine and Ativan before
passing away.
#. Cirrhosis, HCC: Pt deactivated from list by transplant team
during ICU stay.
.
# pancytopenia: Patient initially presented to OSH with Hct of
22, with guaiac positive stools, but not frank bleeding. On
initial presentation, Hct 27.7, from 22 at OSH per report, s/p 3
units PRBC's. Hct was checked q6hr and was stable. Guaiac here
was positive, but with brown stool. His omeprazole was increased
from 40mg daily to [**Hospital1 **] given recent Hct drop, guaiac positive
stools. Placed on folic acid (600mcg at home) 1mg here, and
continued on Ferrous sulfate. Thrombocytopenia was thought to
be related to his liver disease initially. However, patient's
platelets and particularly his leukocytes slowly dropped during
his ICU course. Hemolysis and DIC were ruled out, and HIT was
thought to be unlikely. BM team was consulted, with concern of
possible infiltrative process. A peripheral smear indicated
probable adequate marrow function and a B.M. Bx was taken which
showed no growth and No clonal cytogenetic aberrations were
identified. Abx coverage was changed to eliminate cefepime with
meropenem substituted, with a slow recovery of WBCs over ensuing
days. On [**1-2**] all antibiotics of Vanc, meropenem and Levaquin
were d/c'd given likely non-infectious etiology, negative
cultures and Infectious Disease recommendations.
.
#Cellulitis vs. DVT: Patients R arm overlying PICC became
swollen, ecchymotic and erythematous and he spiked fevers around
the same time. An UE U/S showed no DVT, and given cellulitic
appearance and pain, the picc was pulled. There was not
immediate resolution of symptoms, and some spreading of the
ecchymosis and pain led to concern for bleeding into the arm.
Q4 neurovascular checks were initiated to monitor for
compartment syndrome. There was no progression of the swelling
and compartment syndrome was ruled out.
Medications on Admission:
- buspirone 30mg daily
- Folic acid 600mcg daily
- Wellbutrin 75mg daily (not XL per wife)
- clotrimazole 10 mg Troche dissovle one troche in mouth five
times a day Do not eat or drink within 15 minutes after taking
- ergocalciferol (vitamin D2) 50,000 unit Capsule 1 Capsule(s)
by mouth once a week x 3months (on Saturday, received [**12-21**])
- fluoxetine 40 mg Capsule 2 Capsule(s) by mouth daily
- lactulose 10 gram/15 mL Solution 15 ml by mouth three times
daily titrate to [**3-28**] bowel movements daily
- modafinil [Provigil] 100 mg Tablet 1 Tablet(s) by mouth twice
daily (confirmed with wife)
- nadolol 20 mg Tablet 1 Tablet(s) by mouth daily
- omeprazole 40mg daily
- rifaximin [Xifaxan] 550 mg Tablet 1 Tablet(s) by mouth twice a
day
- cetirizine 10 mg Tablet 1 Tablet(s) by mouth daily
- Ferrous sulfate 325mg daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 486, 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4358
} | Medical Text: Admission Date: [**2109-4-9**] Discharge Date: [**2109-4-10**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o F mild dementia, HTN who presented to [**Hospital1 18**] [**Location (un) 620**] for
right-sided abdominal pain. At [**Location (un) 620**] found to have a
perforated, emphysematous gallbladder and consequently
transferred to [**Hospital1 18**] [**Location (un) 86**]. On arrival to our ED T 98.1 BP
114/73 HR 128 RR 24 O2Sat 99% 3 L NC. Patient with BP decreased
to 78/48-85/60. Patient given morphine 2 mg IV, zofran 4mg IV
and Vancomycin IV. Patient given Zosyn and 1.5 L NS prior to
transfer. Surgery evaluated patient and deemed not a surgical
candidate.
.
On arrival to MICU patient is alert. She reports progressive
right-sided abdominal pain of 1 week duration. She reports
associated nausea and vomiting. Otherwise history is limited due
to patient's pain.
Past Medical History:
1. Hypertension.
2. Mitral valve prolapse.
3. Parathyroid adenoma.
S/P R distal radius fx, closed reduction and perc pinning ([**2101**])
R hip fx ORIF DHS ([**2101**])
Social History:
She lives alone and uses a walker for assistance. Denies any
tobacco, alcohol or drug use.
Family History:
n/c
Physical Exam:
On Admission:
GEN: elderly frail female in pain. Alert, oriented to name and
person (not place or date). Able to have conversation but
limited due to pain.
HEENT: PERRL, EOMI, anicteric, dryMM
RESP: Anterior breath sounds clear
CV: RR, S1 and S2 wnl, no m/r/g
ABD: firm, + rebound, + gaurding, tender to palpation in all
quadrants, limited bowel sounds
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
Pertinent Results:
Admission:
[**2109-4-8**] 11:47PM BLOOD WBC-2.3*# RBC-4.26 Hgb-12.2# Hct-36.8#
MCV-87 MCH-28.7 MCHC-33.2 RDW-14.1 Plt Ct-233
[**2109-4-8**] 11:47PM BLOOD Neuts-37* Bands-50* Lymphs-7* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 Other-0
[**2109-4-8**] 11:34PM BLOOD PT-13.1 PTT-26.8 INR(PT)-1.1
[**2109-4-8**] 11:47PM BLOOD Glucose-166* UreaN-27* Creat-0.8 Na-145
K-4.0 Cl-108 HCO3-25 AnGap-16
[**2109-4-8**] 11:47PM BLOOD ALT-13 AST-19 AlkPhos-56 TotBili-0.6
[**2109-4-8**] 11:47PM BLOOD Albumin-3.5 Calcium-8.0*
[**2109-4-8**] 11:25PM BLOOD Lactate-2.5*
.
CT A/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 620**] images reviewed - free fluid and free air
tracking from emphysematous gallbladder wall, free fluid
spillage throughout abdomen.
Brief Hospital Course:
[**Age over 90 **] y/o F HTN, dementia who presents with acute abdominal pain
and found to have ganrenous gallbladder with perforation
complicated by peritonitis and sepsis. Condition associated with
high mortality with surgery or without surgery. Patient
evaluated by surgery and deemed not a surgical candidate.
Discussed by phone with her HCP who later came in. HCP and
family were very clear that Ms. [**Known lastname 105623**], in this circumstance,
would prefer to focus on comfort and quality of life (and
avoidance of pain) rather than on attempts to extend life. She
was transitioned to comfort-focused care and passed away with
family by the bed-side.
Medications on Admission:
Vitamin B
Miralax
Multivitamin
Omeprazole
Vitamin E
Niferex GOLD Oral 750 mg
Calcium Carbonate 750 mg
Temazepam 15 mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
passed away
Discharge Condition:
passed away
Discharge Instructions:
passed away
Followup Instructions:
passed away
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
Completed by:[**2109-4-10**]
ICD9 Codes: 0389, 4019, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4359
} | Medical Text: Admission Date: [**2115-3-13**] Discharge Date: [**2115-3-20**]
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
woman with left circumflex stent in [**2113-7-30**] after a
non Q-wave myocardial infarction with recent return of angina
at rest x2 weeks, referred to [**Hospital6 2018**] for a diagnostic catheterization from [**Hospital3 28116**]. On catheterization prior to her stenting in [**2113-7-30**], the patient had an LAD with a total occlusion, a
proximal circumflex of 90% at the OM1 and an RCA of 50%. Her
ejection fraction at that time was 45%. She has done well
since then with no recurrence of symptoms. Two weeks ago,
she had an acute onset of nocturnal angina, took two
sublingual nitroglycerin with relief. She saw her primary
care provider and was started on nitroglycerin paste and is
now referred back for catheterization.
PAST MEDICAL HISTORY:
1. Severe low back pain which is chronic.
2. Hypothyroid.
3. Status post appendectomy.
4. Status post bladder suspension.
5. Status post hemorrhoidectomy.
6. Status post ovarian cyst removal.
7. Abdominal aortic aneurysm, which has been stable for the
past three to four years followed by CT scan q 3 to 4 months.
8. Hypertension.
Cardiac risk factors include positive for hypertension,
positive for high cholesterol, negative for diabetes
mellitus, negative for smoking, positive for family history.
SOCIAL HISTORY: Significant for tobacco use. She has
stopped x1 year. Prior to that she smoked one pack per day
for 60 years.
TRANSFER MEDICATIONS:
1. Captopril 37.5 mg tid.
2. Synthroid 0.15 mg qd.
3. Lopressor 25 mg [**Hospital1 **].
4. Hydrochlorothiazide 25 mg qd.
5. Lipitor 10 mg qd.
6. Potassium chloride 20 milliequivalents qd.
7. .............. 20 mg qd.
8. Miacalcin nasal spray 2200 international units qd.
9. Aspirin 325 mg qd.
10. Nitroglycerin 0.4 sl prn.
SOCIAL HISTORY: The patient lives in [**Location 28117**] with
[**Last Name (LF) 15560**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28118**].
LABORATORY DATA: INR is 1.0. White blood cell count is 8.5,
hematocrit 37.7, platelets 442. Sodium is 140, potassium
4.6, chloride 101, CO2 31, BUN 18, creatinine 0.8, glucose
87.
ADMISSION PHYSICAL EXAM:
GENERAL: The patient feels well with no complaints of
shortness of breath or chest pain.
LUNGS: Clear to auscultation.
HEART: Heart sounds are regular rate and rhythm, S1, S2 with
no murmurs, rubs or gallops.
EXTREMITIES: She has bilateral femoral pulses with a soft
bruit, trace dorsalis pedis and posterior tibial pulses.
ABDOMEN: Soft, nontender with no bruits. She has been NPO
for cardiac catheterization.
The patient underwent cardiac catheterization. Please see
catheterization report for full details. In summary, the
catheterization showed apical dyskinesis, inferior
hypokinesis with an ejection fraction of 35%, LAD 100%
lesion, circumflex 60% mid lesion, RCA 75% mid lesion with
diffuse disease throughout. The cardiothoracic surgical team
was consulted. The patient was seen by cardiothoracic
surgery and the option of surgical intervention was discussed
with the patient. She was accepted by cardiothoracic surgery
for coronary artery bypass grafting and on [**3-15**] she was
brought to the Operating Room where she underwent coronary
artery bypass grafting x3. Please see the Operating Room
report for full details. In summary, the patient had a
coronary artery bypass graft x3 with a left internal mammary
artery to the LAD, a saphenous vein graft to the PDA and a
saphenous vein graft to OM1. The patient tolerated the
procedure well and was transferred from the Operating Room to
the Cardiothoracic Intensive Care Unit. She did well
immediately postoperatively and was extubated on the day of
her surgery. She remained hemodynamically stable overnight
on a small dose of Neo-Synephrine which was weaned off on the
morning of postoperative day #1. She remained
hemodynamically stable off the Neo-Synephrine and was
transferred to the floor for continuing postoperative care
and cardiac rehabilitation. Her chest tubes were
discontinued on postoperative day #1.
Over the next several days, the patient did well. Her
activity level was increased. Her only complaint throughout
the next several days was nausea felt to be related to the
Percocet which she was receiving for pain. Percocet was
discontinued and nausea resolved. On postoperative day #3,
the patient's Foley catheter was removed and on postoperative
day #5, the patient's temporary pacemaker wire was removed.
At that time, it was felt that the patient was
hemodynamically stable and her activity level was adequate
that she could be discharged to home and arrangements were
made for the patient to be discharged to home with a [**Month (only) **]
nurse [**First Name (Titles) **] [**Last Name (Titles) **] physical therapy follow up at her home.
At the time of discharge, the patient's condition is stable.
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: Temperature 98.7??????, heart rate 67 sinus rhythm,
blood pressure 119/65, respiratory rate 20, O2 saturation 94%
on room air. Her preoperative weight is 70.8 kg. Her
discharge weight is 72.6 kg.
GENERAL: Alert and oriented x3, moves all extremities,
follows commands.
RESPIRATORY: Breath sounds decreased at the left base,
otherwise clear to auscultation. Heart sounds regular rate
and rhythm, S1, S2, no murmurs, rubs or gallops. Sternum is
stable. Incision with Steri-Strips open to air, clean and
dry.
ABDOMEN: Soft, nontender, nondistended with normoactive
bowel sounds.
EXTREMITIES: Warm and well perfused with 1+ edema of the
left lower extremity. Left lower extremity incisions are
with Steri-Strips, open to air, clean and dry.
DISCHARGE LAB DATA: Hematocrit 24.9, sodium 138, potassium
4.3, chloride 102, CO2 28, BUN 30, creatinine 0.9, glucose
108.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg qd.
2. Colace 100 mg [**Hospital1 **].
3. Lasix 20 mg qd x7 days.
4. Potassium chloride 20 milliequivalents qd x7 days.
5. Metoprolol 25 mg [**Hospital1 **].
6. Captopril 37.5 mg q8h.
7. Synthroid 0.15 mg qd.
8. Lipitor 10 mg qd.
9. Miacalcin nasal spray 2200 international units qd.
10. Tylenol 650 mg q4h prn.
The patient is to be discharged home with VNA. She is to
have follow up with Dr. [**Last Name (STitle) 1537**] in one month, follow up wound
check in two weeks, also to have follow up with Dr. [**Last Name (STitle) 28119**]
within a month and with her primary care provider also within
[**Name Initial (PRE) **] month.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft x3 with left internal mammary artery to LAD and
saphenous vein graft to PDA and saphenous vein graft to OM.
2. Hypothyroid.
3. Status post appendectomy.
4. Status post bladder suspension.
5. Ovarian cyst removal.
6. Abdominal aortic aneurysm.
7. Hypertension.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2115-3-20**] 12:14
T: [**2115-3-20**] 12:25
JOB#: [**Job Number 28120**]
ICD9 Codes: 4111, 4019, 2720, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4360
} | Medical Text: Admission Date: [**2167-4-7**] Discharge Date: [**2167-4-14**]
Date of Birth: [**2088-11-13**] Sex: M
Service: MEDICINE
Allergies:
Celebrex / Glucotrol Xl
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
TKR
History of Present Illness:
The patient is a 78 y.o. male with dm, htn, dyslipidemia,
djd, atrial fibrillation who was admitted for total knee
replacement surgery which he underwent on [**2167-4-7**]. His post op
course was c/b hypotension for which he was placed on
neosynepherine gtt. He was weaned off with fluid boluses and
was transfused 1 U prbcs. He then developed atrial fibrillation
with RVR with rates =150. He was asymptomatic. He was given 150
mg IV amiodarone along with 100 mg po amidarone- his home dose.
His atrial fibrillation remained poorly controlled and thus he
was transferred to medicine for further management.
Past Medical History:
1. Atrial Fibrillation
2. Diabetes type 2
3. coronary artery disease
4. HTN
5. Dyslipidemia
6. Degenerative joint disease
7. Chronic renal insufficiency
Social History:
Positive tobacco history, no significant alcohol use.
US Veteran
Family History:
noncontributory
Physical Exam:
VS Tm=100.9, Tc = 99.7, BP = 100-120s/40s, P 69-140s RR 18
O2Sat 93% on 3L I/O = 3660/1402 and 5425/1465 thus approx 5L
positive
GENERAL: Elderly male laying in bed. NAD He has a productive
cough
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Bibasiar crackles with soft wheezes diffusely
Cardiac: tachy irreg, irreg, nl. S1S2,
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Neurologic:
-mental status: Alert, oriented x 1. [**2117-5-18**], Nixon president.
Obeys commands
Pertinent Results:
Studies/Imaging:
ECG: Afib at 140
.
CXR: [**4-9**] Small left pleural effusion and adjacent atelectasis
developed yesterday, are stable. Upper lungs are clear. Mild
cardiomegaly is unchanged. Pleural thickening extending from
the right costal pleural surface into the minor fissure has been
present without change since [**2163**], of no active clinical
significance. Tip of the right central venous line projects
over the SVC. No pneumothorax, mediastinal widening or right
pleural effusion.
.
[**9-22**] stress:
6 mins on modified [**Doctor First Name **]- test stopped due to fatigue. No
anginal sx
LVEF = 59% and no ischemia identified.
.
Echo:
[**3-/2164**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60%). Right ventricular chamber size and free wall motion
are normal. The aortic Valve leaflets (3) are mildly thickened
but not stenotic. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
.
PFTs [**2-23**]: Mild restrictive defect
.
Brief Hospital Course:
78 y.o. M with DM, HTN, Atrial fibrillation/atrial flutter s/p L
TKR whose post op course was complicated by hypotension requring
neo, low grade fevers, cough and atrial fibrillation with rapid
response.
.
1. CV:
A. Rhythm: The pt has known Atrial Fibrillation and developed
rapid ventricular response post op. The etiology of the rapid
ventricular response was initinally unclear, however the ddx
included CHF, COPD flare, PNA, PE, or stress secondary to post
op. LENIs were negative for DVT, and the CXR was more
consistent with Pulm edema rather than PNA. He was therefore
treated symptomatically for his Atrial fibrillation and was also
diursed aggressively with lasix to remove the source of
stimulation. He was loaded on Amiodarone IV but also required
additional nodal agents including beta blockers and a diltiazem
drip for adequate control of his rate. He was subsequently
weaned off diltiazem and the amiodarone was decreased to a
maintenance dose and he converted to NSR. In addition, he was
also started on coumadin anticoagulation as well for dual
benefit of Atrial fibrillation and TKR ppx. At time of
discharge, his medication regimen for Atrial fibrillation
consisted of Amiodarone 200mg once daily as well as metoprolol
25mg [**Hospital1 **] and coumadin 3mg QHS. The pt should follow up with his
private cardiologist Dr. [**Last Name (STitle) 108411**] in re: to his atrial
fibrillation. Of note, he was admitted on plendil, HCTZ, BB,
ACEI and amiodraone however the plendil, BB and HCTZ was
discontinued in favor of other antihypertensives with nodal
action as above. ACEI was continued but at a reduced dose for
additional CAD benefit.
.
B. Ischemia: Although unlikely, ischemia could not be ruled out
as a cause of rapid ventricular response. He was therefore
ruled out with enzymes x3. In addition, ECGs were without acute
ST or T wave changes. He was continued on ASA, the lisinopril
dose was decreased as above (from 40 to 2.5mg) to allow for more
room for rate control. Please try to wean down the nitro paste
to off and continue to titrate up the ACEI dose as tolerated as
an outpt once his amiodarone dose is stabilized. The statin
dose was increased based on lipid panel obtained during the
admission. The pt was discharged on simvastatin 40mg QHS.
.
C. Pump: The pt was clinically in overt CHF with pulm edema
visible on CXR as well as physical exam and LE edema with
elevated JVP. The pt was rate controlled as above and also was
started on afterload reduction with ACEI and he was diuresed
with lasix IV. He was given 40mg IV lasix with good response.
As an outpt, he should be continued on 80mg PO lasix (the PO
equivalent to IV lasix) with close monitoring of his kidney
function. He should have daily weight and strict ins and outs
measured to verify appropriate diuresis (with goal of neg
500cc/day) without compromise of kidney function as verified by
routine labs (chem7) drawn atleast twice a week.
.
2. TKR: The pt underwent a TKR by Dr. [**Last Name (STitle) **] on [**2167-4-7**]. He
should be on weightbearing as tolerated on the left leg.
Continue to use the CPM (Continuous Passive Motion) Machine to
improve the range of your knee - 0 to 90 degrees. He should
continue the keflex for two weeks post discharge, this should
subsequently be followed up by Dr. [**Last Name (STitle) **] as an outpt after the
appointment. In re: to wound care, please keep incision clean
and dry. Apply a dry sterile dressing to the wound each day
while it is draining. Once draning has stopped, you can leave
the wound open to the air. You may begin showering with a
waterproof dressing over the wound after being discharged from
the hospital. You can shower normally (no bandage) starting one
week after surgery (as long as there is no drainage from the
wound. If the wound is draining, wait 24 hours after it has
stopped before showering) - pat the incision dry with a towel,
do not rub the incision. Do not take a bath, swim or otherwise
submerge your incision in water. Monitor the wound daily for
signs of infection including redness around the incision that is
warm to the touch, pus-like drainage from the wounds,
fever/chills, temp>101.5, or any other symptoms that concern
you. Notify Dr. [**Last Name (STitle) **] if you have any concern for possible
infection.
.
3. ID: The pt also complained of a productive cough, with low
grade temps and wheezing which was concerning for PNA/bronchitis
vs. COPD exacerbation (given known h/o tobacco use). Another
consideration was also CHF from massive fluid resuscitation
during TICU stay post op. The pt was monitored closely for
other signs of infection (chills, rigors, WBC count,
bacteremia). Blood cultures were NGTD, sputum cultures were
NGTD and UA was also unrevealed. He was therefore treated
empirically for COPD exacerbation and CHF. The CHF was treated
as above, while his COPD was managed with the addition of
flovent and standing nebulizer treatments of atrovent and
albuterol. The pt continued to have some wheezing throughout
the remainder of the hospital course but his respiratory status
remained stable and he was without any evidence of infection.
He was only maintained on post op Cephlexin as per orthopaedic
service.
.
4. DM: The pt was admitted on oral hypoglycemics, however given
the multitude of complications, the pt was taken off his oral
hypoglycemics and started on lantus 10units QHS. Pioglitazone
was added back to his regimen later for additional CAD ppx.
However given the decompensated CHF, the pt was not started back
on sulfonylureas for risk of hypoglycemia. The pt may be able
to be started back on glyburide 1.25mg daily once his CHF is
compensated as an outpt.
.
5. Mental Status: The pt was delerious post op. This was
thought to be due to narcotics and post op pain. Infection was
ruled out as above. This has resolved by the time of transfer
to medicine.
.
6. Pain: The pt was continued on oxycodone and acetominophen
rtc as per ortho for pain.
.
7. Prophylaxis: The pt was initially given IV heparin but was
transitioned to coumadin as above, PPI was contineud for GI ppx
and he was continued on a bowel regimen.
.
8. FEN: diabetic p.o. diet as tolerated
.
9. Code: Full.
.
The discharge summary was completed by Dr. [**Last Name (STitle) **] on the day
of discharge.
Medications on Admission:
ADMISSION MEDICATIONS:
Actos 45 mg daily
amiodarone 100 mg
Aspirin 81 mg daily
Plendil 10 mg daily
Glyburide1.25 mg daily
Hydrochlorothiazide 12.5 mg qd,
Lisinopril 40 mg qd
metoprolol 50 mg [**Hospital1 **],
Zocor 40 mg daily
sulfasalazine 500 mg [**Hospital1 **].
.
MEDICATIONS ON TRANSFER:
1. 1000 ml NS Bolus 1000 ml
2. Heparin 5000 UNIT SC TID Order date: [**4-8**] @ 1403
3. Hydrochlorothiazide 25 mg PO DAILY
4. Insulin SC (per Insulin Flowsheet)
5. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
6. Acetaminophen 1000 mg PO TID
7. Lisinopril 40 mg PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
9. Amiodarone HCl 200 mg PO DAILY
10. Metoprolol 50 mg PO BID
11. Amiodarone HCl 150 mg IV ONCE
12. Milk of Magnesia 30 ml PO Q6H:PRN constipation
13. Aspirin 81 mg PO DAILY Start:
14. Oxycodone 5 mg PO Q4-6H:PRN
15. Calcium Carbonate 500 mg PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Calcium Gluconate 2 gm / 100 ml D5W IV PRN ca<115
18. Docusate Sodium 100 mg PO TID
19. Felodipine 10 mg PO PM
20. Simvastatin 40 mg PO DAILY Order date: [**4-7**] @ 1139
21. Flunisolide Inhaler *NF* 250 mcg/Actuation Inhalation QD
1 spray each nostril QD * Patient Taking Own Meds *
22. SulfaSALAzine 500 mg PO DAILY Order date: [**4-9**] @ 0555
23. Furosemide 40 mg IV ONCE Duration: 1 Doses
24. Zolpidem Tartrate 5 mg PO HS:PRN Order date: [**4-8**] @ 2137
25. GlyBURIDE 2.5 mg PO DAILY Order date: [**4-9**] @ 1314
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
6. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg Intravenous
Q8H (every 8 hours) as needed.
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: Two (2) Inhalation
Q6H (every 6 hours).
12. Albuterol Sulfate 0.083 % Solution Sig: Two (2) Inhalation
Q4H (every 4 hours) as needed.
13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
14. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
17. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
19. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
20. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*20 ml* Refills:*2*
22. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours) for 14 days.
24. Nitroglycerin 2 % Ointment Sig: 0.5 Transdermal Q6H (every
6 hours): Please titrate down as tolerated.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. TKR
2. Atrial fibrillation with rapid ventricular response
3. Pulmonary Edema
4. Diabetes
Discharge Condition:
Good
Discharge Instructions:
Please follow up with your doctors.
Please take all of your medications as instructed. Several
changes in your medications have been made after discussion with
your other doctors.
Please weigh yourself daily. If you notice an increase in body
weight of more than 3lbs, please call your PCP as this may
indicate a need to change your lasix (furosemide) dosage.
Please have the Rehab facility check routine labs (Chem7) to
evaluate your kidney function.
Please also have the Rehab facility check your INR to adjust
your coumadin dose as necessary.
Activity: Weightbearing as tolerated on the left leg. Continue
to use the CPM (Continuous Passive Motion) Machine to improve
the range of your knee - 0 to 90 degrees.
Wound care: Please keep incision clean and dry. Apply a dry
sterile dressing to the wound each day while it is draining.
Once draning has stopped, you can leave the wound open to the
air. You may begin showering with a waterproof dressing over
the wound after being discharged from the hospital. You can
shower normally (no bandage) starting one week after surgery (as
long as there is no drainage from the wound. If the wound is
draining, wait 24 hours after it has stopped before showering) -
pat the incision dry with a towel, do not rub the incision. Do
not take a bath, swim or otherwise submerge your incision in
water. Monitor the wound daily for signs of infection including
redness around the incision that is warm to the touch, pus-like
drainage from the wounds, fever/chills, temp>101.5, or any other
symptoms that concern you. Notify Dr. [**Last Name (STitle) **] if you have any
concern for possible infection.
Followup Instructions:
Please follow up with your PCP within two weeks of discharge.
Although you already have an appointment with Dr. [**Last Name (STitle) 1683**] in the
end of [**Month (only) 547**], please schedule an earlier appointment to verify
satisfactory progress as well. You can reach her office at
[**Telephone/Fax (1) 1144**].
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 10657**] Date/Time:[**2167-4-20**]
9:30
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 9612**] MEDICINE (PRIVATE)
Date/Time:[**2167-5-14**] 9:00
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2167-6-18**] 10:00
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5849, 4280, 496, 5119, 5180, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4361
} | Medical Text: Admission Date: [**2178-12-2**] Discharge Date: [**2179-1-3**]
Date of Birth: [**2123-8-27**] Sex: F
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 32137**]
Chief Complaint:
wheezing, malaise
Major Surgical or Invasive Procedure:
mechanical ventilation
bronchoscopy
thoracentesis
History of Present Illness:
55 YOF c/o SOB and cough for one week. It is accompanied by
myalgias and chest pain on right side as well as some back pain.
Had URI symptoms first, with nasal congestion, headache. Cough
is non-productive, but feels chest congestion. Husband has been
sick for 1 month with cough. She denies fevers, chills, nausea,
vomiting, abdominal pain. She felt light headed when standing
and SOB with ambulation. No dysuria, leg swelling or pain. No
h/o CHF or clots. Recently traveled to [**State 108**]. No exotic pets
or [**Location (un) **] exposures.
In ED T 97.5 104 90/51 16 99 RA then dropped toBP 70/40 RR 30
with 92 on RA. She was given 2 L NS and BP came up to 90/50.
Her CXR showed a RLL, and her wheezing improved with neb
treatment. She was administered levofloxacin and ceftriaxone.
Past Medical History:
Depression
Acne
Social History:
Non smoking, occasional EtOH, no ilicit drug use. Married.
Employed as a work book editor. Swims long distance at
baseline.
Family History:
Father AAA
Physical Exam:
Vitals 97.8 109 89/47 38 97 % NRB
General Pleasant middle aged woman tachypneic in mild
respiratory distress
HEENT sclera white conjunctiva pink mmm
neck no jvd
cv regular s1 s2 no m/r/g
pulm lungs with coarse bs right base +egophony +dull
abd soft nontender +bowel sounds
extrem warm no edema +palpable distal pulses
neuro alert and awake
derm mild facial flushing
Pertinent Results:
Admission labs:
[**2178-12-2**] 02:35PM PT-13.3 PTT-26.6 INR(PT)-1.1
[**2178-12-2**] 02:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
BURR-1+ TEARDROP-1+
[**2178-12-2**] 02:35PM NEUTS-53 BANDS-24* LYMPHS-9* MONOS-7 EOS-1
BASOS-0 ATYPS-1* METAS-4* MYELOS-1*
[**2178-12-2**] 02:35PM WBC-2.1*# RBC-3.61* HGB-10.8* HCT-29.9*
MCV-83 MCH-29.9 MCHC-36.1* RDW-13.9
[**2178-12-2**] 02:35PM TOT PROT-5.3* ALBUMIN-2.6* GLOBULIN-2.7
[**2178-12-2**] 02:35PM CK-MB-NotDone
[**2178-12-2**] 02:35PM cTropnT-<0.01
[**2178-12-2**] 02:35PM LIPASE-12
[**2178-12-2**] 02:35PM ALT(SGPT)-21 AST(SGOT)-11 CK(CPK)-10* ALK
PHOS-111 TOT BILI-0.5
[**2178-12-2**] 02:35PM GLUCOSE-144* UREA N-27* CREAT-0.9 SODIUM-134
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-14
[**2178-12-2**] 02:38PM LACTATE-3.1*
[**2178-12-2**] 03:09PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2178-12-2**] 03:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2178-12-2**] 04:42PM TYPE-ART TEMP-36.7 PO2-83* PCO2-38 PH-7.36
TOTAL CO2-22 BASE XS--3 INTUBATED-NOT INTUBA
[**2178-12-2**] 07:06PM TYPE-ART TEMP-36.6 O2-100 PO2-99 PCO2-35
PH-7.39 TOTAL CO2-22 BASE XS--2 AADO2-592 REQ O2-95
INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
.
Other labs:
[**2178-12-8**] 03:17PM BLOOD Ret Aut-1.9
[**2178-12-10**] 03:52AM BLOOD Fibrino-520*
[**2178-12-8**] 03:17PM BLOOD Hapto-411*
[**2178-12-5**] 04:08AM BLOOD calTIBC-142* VitB12-GREATER TH Folate-5.3
Ferritn-301* TRF-109*
[**2178-12-5**] 04:08AM BLOOD PEP-NO SPECIFI IgG-974 IgA-149 IgM-99
[**2178-12-18**] 06:50AM BLOOD HIV Ab-NEGATIVE
IGG SUBCLASSES 1,2,3,4
Test Result Reference
Range/Units
IGG 1 [**Telephone/Fax (3) 32138**] MG/DL
IGG 2 143 L 241-700 MG/DL
IGG 3 23 22-178 MG/DL
IGG 4 11 4-86 MG/DL
IGG 1[**Telephone/Fax (1) 32139**] MG/DL
.
Micro:
[**2178-12-2**] 2:15 pm BLOOD CULTURE 1ST SET VENIPUNCTURE.
**FINAL REPORT [**2178-12-15**]**
Blood Culture, Routine (Final [**2178-12-15**]):
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
ADDITIONAL SENSITIVITIES REQUESTED PER DR. [**Last Name (STitle) **]
#[**Numeric Identifier 32140**]
[**2178-12-9**]. TYPE F: Identified by State Laboratory.
RESULT REC'D BY PHONE-SAMPLE WILL BE FINALIZED UPON
RECEIPT OF
WRITTEN REPORT.
SENSITIVITIES PERFORMED BY FOCUS DIAGNOSTICS INC..
CEFUROXIME = SENSITIVE ( <= 0.5 MCG/ML ).
CHLORAMPHENICOL = SENSITIVE ( <= 0.5 MCG/ML ).
CLARITHROMYCIM = SENSITIVE ( 2 MCG/ML ).
Levofloxacin = SENSITIVE ( <= 0.03 MCG/ML ).
MEROPENEM = SENSITIVE ( <=0.06 MCG/ML ).
SULFA X TRIMETH = SENSITIVE ( <= 0.06 MCG/ML ).
IMIPENEM = SENSITIVE ( <= 0.5 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
HAEMOPHILUS INFLUENZAE,
BETA-LACTAMASE NEGATIVE
|
AMPICILLIN------------<=0.12 S
AMPICILLIN/SULBACTAM-- <=1 S
CEFTRIAXONE-----------<=0.03 S
CEFUROXIME------------ S
LEVOFLOXACIN---------- S
MEROPENEM------------- S
TETRACYCLINE----------<=0.25 S
TRIMETHOPRIM/SULFA---- S
Aerobic Bottle Gram Stain (Final [**2178-12-5**]):
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name 5647**] [**2178-12-5**] 1000.
PLEOMORPHIC GRAM NEGATIVE ROD(S).
.
Imaging:
[**12-2**] CXR: There are bibasal effusions with infiltrates at both
lung bases, more marked
on the right. The cardiomediastinal silhouette is unremarkable.
CONCLUSION:
Infiltrates at lung bases, highly suggestive of consolidation.
Please ensure
followup to clearance.
.
US liver: Sludge-filled gallbladder with tiny gallstones. No
evidence of acute
cholecystitis.
.
[**12-5**] CT chest: Diffuse bilateral airspace consolidation
predominantly involving
the lower lobes, but also involving the upper lobes more
focally. Diffuse
ground-glass attenuation of the aerated portions of the lungs,
with relative
sparing of the lung apices.
,
[**12-5**] CT sinuses: Pansinusitis. No evidence of erosive bone
changes.
,
Echo: Suboptimal image quality. Mild mitral regurgitation
without discrete vegetation. Mild aortic valve sclerosis. Normal
biventricular cavity sizes with excellent global and normal
regional biventricular systolic function.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
.
[**12-13**] CT chest: 1. Increased bilateral nonhemorrhagic layering
pleural effusion, now
moderate-to-large and increased multifocal consolidation and
ground-glass
opacity, more widespread and more dense, could be worsening of
multifocal
pneumonia, alveolar hemorrhage, or developing ARDS, should be
correlated with
labs.
2. Signs of anemia.
3. Gallstone.
[**12-21**] LENIs:
IMPRESSION:
No evidence of DVT.
[**12-21**] RUQ U/S:
IMPRESSION:
1. Sludge and stone-filled gallbladder with no definite evidence
of acute
cholecystitis, though the gallbladder does appear moderately
distended. If
clinical concern for cholecystitis persists, recommend further
evaluation with
a HIDA scan.
2. Unchanged echogenic nodule at hepatic dome.
[**12-23**] CTA CHEST/CT ABD/CT PELVIS:
IMPRESSIONS:
1. Diffuse pulmonary consolidations and ground-glass opacities
are increased in density and extent compared to [**2178-12-13**].
2. Anasarca. Moderate right greater than left pleural effusions
are also
slightly increased.
3. No evidence of pulmonary embolism.
4. Mildly prominent mediastinal lymph nodes, non-specific and
unchanged.
5. Cholelithiasis, without CT evidence for acute cholecystitis.
No acute
intra- abdominal pathology seen to account for the patient's
symptoms.
[**12-23**] CT SINUS:
Marked improvement in chronic sinus disease. No evidence of
abnormal
enhancing lesions or osseous destruction.
[**12-25**] Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
[**12-25**] ECHO:
The left atrium and right atrium are normal in cavity size. The
right atrial pressure is indeterminate. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Mild tricuspid regurgitation with normal valve
morphology. Moderate pulmonary artery systolic hypertension.
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Compared with the
prior study (images reviewed) of [**2178-12-8**], the estimated
pulmonary artery systolic pressure is higher. The other findings
are similar.
[**2178-12-28**] Bronchial washings:
NEGATIVE FOR MALIGNANT CELLS.
Brief Hospital Course:
55 YOF otherwise healthy c/o malaise and cough for 1 week which
likely represents pneumonia.
# Bilateral Pneumonia/ARDS: Likely pathogen H flu, as bacterial
suprainfection following viral infection, as grown from blood
cultures on the day of admission. Initially, the patient was
started on vancomycin, ceftaz and azithromycin. The antibiotic
regimen was changed on [**2178-12-5**] when blood cultures positive, to
ceftaz and azithro only. The same day the patient was becoming
more tired with increased tachypnea and was intubated. The
patient continued to have fevers through ceftaz treatment, so an
Echo was done on [**2178-12-7**] to rule out endocarditis, no evidence
of vegetations noted. At that time, the CXRs showed more volume
overload, so the patient was diuresed with IV lasix of 40mg [**Hospital1 **]
with good volume removal. As the patient was unable to be
weaned off the mechanical ventilator, CT scan was done which
showed large pleural effusions. A thoracentesis was performed
on [**2178-12-13**] which showed a transudative effusion, likely
secondary to volume overload. As she continued to spike fevers
with ceftaz treatment, the regimen was changed to meropenem and
vancomycin on [**2178-12-13**], vancomycin stopped on [**2178-12-15**], per ID
meropenem should continue for a total of 3 weeks. The patient
was successfully extubated on [**2178-12-14**]. She was able to maintain
reasonable O2 sats on nasal cannula for the next two days and
was sent to the floor.
.
Mrs [**Last Name (un) 32141**] was transfered to the medical floor on [**12-16**]
sating 94% on 5L NC. Over the next 4 days she became
increasingly tachypnic with progressive oxygen requirement. Her
leukocystosis rose to 21 despite no additonal culture data and
continuation of meropenem. On [**12-19**] she was transfered back to
the MICU for tachypnea and desaturations to the 70s.
.
Although the patient's profound sickness and long recovery is
typical for H flu pneumonia her young age and lack of
immunocompromise were atypical for getting this infection.
Investigation for immunocompromise was undertaken. HIV was
negative, SPEP and UPEP for normal. IGG subtyping showed
isolated deficiency of IGG 2 of unclear significance. She had no
evidence of diabetes and no reason to be functionally asplenic.
.
There was a possibility raised by the ICU team that she may have
underlying lung disease prior to her pneumonia. It is possible
that she may have pulmonary venoocclusive disease, pulm HTN, or
small distal PEs not seen on CTA. This will need to be addressed
in the future by her pulmonologist.
.
Patient has documented dead space of 84%. Patient had completed
a course of treatment for known H. flu bacteremia with
azithromycin, 7 day empiric course of meropenem. After worsening
around [**12-20**], patient was started on vanc/zosyn. On [**12-24**] and [**12-25**]
[**Female First Name (un) 576**] was done bilaterally for concern of empyema but did not
reveal a source of infection. Patient was trached on [**12-25**].
Patient continued to be tachypneic in the 30-40s with an element
of anxiety. Multiple bronchs have been done and there does not
appear to be a current PNA. Concern for inflammatory causes less
in the setting of no bronchial fluid or peripheral
eosinophillia. Differential includes infectious cause vs. BOOP.
There has been a poor response to antbiotics and no secretions
on bronch argues against PNA. Patient's peribronchovascular
pattern could be consistent with BOOP over typical ARDS picture.
BOOP would require treatment with steroids and until clear
diagnosis is made difficult to justify steroids in the setting
of possible infectious cause. Differentiation of the etiologies
of the ARDS would require tissue bx. This would require VATS but
the patient does not have enough lung reserve to take down one
lung for the procedure. The patient??????s clinical resp pattern is
consistent with pulmonary fibrosis vs. rind. IP did not feel
thoracentesis would be beneficial. Patient got PMV valve placed
on [**12-30**], resp status improving. Over the next couple of days pt
progressively tolerated longer trials of CPAP/PSV, PMV trials
and eventually trach mask. Pt was seen by S&S and recommended a
formal exam when the pt was able to tolerate the trach mask/PMV
for a more consistent period of time.
.
# Fever/Leukocytosis: After being readmitted to the MICU for
hypoxia the pt had a persistent leukocytosis and fever. Finally
defervesced [**2178-12-29**]. Pt had extensive w/u for source of
infection including negative BALs, LENIs, bilateral
thoracentesis, CT Sinuses/Chest/Abdomen/Pelvis, blood cxs, urine
cxs, stool cxs and ECHO. Pt grew VRE from urine cx from [**2178-12-22**]
but ID did not feel that this was causing her infection,
however, given her persistent fever and leukocytosis Linezolid
was given [**Date range (1) 19594**]. Pt seen by Dermatology for rash on back
which was cutaneous candidiasis and treated with Fluconazole
[**Date range (1) 28307**]. No other sources of infection were identified. Pt
remained with resolving ARDS.
# Hypotension: The patient became more hypotensive on the day
after intubation, likely secondary to sedating medications and
infection. Fluid resuscitated and required levophed at that
time. Central and arterial lines placed. The patient was
taking spironolactone at home for unknown reasons, was held in
the setting of low blood pressures. Pt continued to have MAPs
55-65 throughout the admission but maintained adequate urine
output and normal mental status.
.
# Anemia: Previous baseline HCT in [**2176**] of 35, since admission
she has been less than HCT 30. The HCT was as low as 21
requiring transfusion of 2 units of blood. Iron studies were
consistent with anemia of chronic disease. No evidence of DIC,
B12 and folate normal. Management should continue as an
outpatient.
.
# Depression: Her home oral medications, geodon and prozac,
were initially held while the patient was sedated and restarted
after 1st extubation. Ritalin held during hospitalization. Pt
then restarted on prozac 80mg Qdaily and ziprasidone 40mg [**Hospital1 **].
Pt was seen by outpatient psychiatrist and recommended
continuing with current therapies.
.
FEN: vegetarian diet, Replete lytes
Prophy: Heparin SQ
Access: 2 PIV
Code: full
Communication: with patient
Medications on Admission:
Meds
Prozac 40 QD
Ritalin
Geodon
Spironolactone
.
Allergies
clindamycin-face swelling
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
6. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
7. Ziprasidone HCl 40 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
10. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
11. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
14. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Lidocaine HCl 40 mg/mL (4 %) Solution Sig: One (1)
Injection tid () as needed for prn cough.
17. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day).
18. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed.
19. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q6H (every
6 hours) as needed for air hunger.
20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
21. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Haemophilus influenzae pneumonia
Acute respiratory distress syndrome
Anemia
.
Secondary diagnosis:
Depression
Anxiety
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital for shortness of breath. You
were found to have a severe pneumonia, requiring admission to
the intensive care unit and intubation as well as tracheostomy.
You were treated with antibiotics with slow improvement of your
symptoms and resolution of the infection. You still have
underlying inflammation in your lungs that may take months to
resolve completely.
.
Please follow up with your doctors as detailed below.
.
If you become short of breath, have fevers or chills, cough up
blood, have chest pain, abdominal pain or diarrhea, difficulty
urinating, or any other worrisome symptoms please call your
doctor and go to the emergency room.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 2205**]
Completed by:[**2179-1-3**]
ICD9 Codes: 5119, 7907, 4589, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4362
} | Medical Text: Admission Date: [**2110-1-3**] Discharge Date: [**2110-1-8**]
Date of Birth: [**2078-1-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p fall, ear bleed, L shoulder pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
31 yo male who awoke with stabbing left shoulder pain and
incidentally found that his left ear was bleeding. Reports came
home from work and drank 7 beers, went to sleep and awoke with
the pain described. Works in construction and reports frequent
head trauma's, today at work sustained minor hit to vertex of
his head, there was no LOC; reports headache X 1 wk. Multiple
falls, cable to back the week prior. He went to an area hospital
where CT scan performed revealed right SDH, pneumocephalus above
right petrous bone; xrays revealed left scapula fracture.
Past Medical History:
None
Social History:
Works in construction.
20 pack/year tobacco
Drinks ETOH in binges
Family History:
Noncontributory
Physical Exam:
PE on admission:
T 99.8 HR 114 BP 123/80 RR 18 room air Sats 99%
Gen-thin male, boarded and collared, calm
Skin-no ecchymoses, no visible skin breaks
HEENT-NCAT, 4 mm bilat pupils, PERRL, EOMI, MMM, left ear canal
with dried blood,midline trachea
Cor-ST, no m/r/g
Chest- CTA bilat
Abd- Soft ,NT, ND
Extr-2+ pulses, no edema
Musculosk-FROM x4
Neuro-A & ) x3, appropriate speech and affect; CN II-XII intact
[**Last Name (un) **]- intact to light touch
Motor-[**4-25**] str x4
Pertinent Results:
[**2110-1-3**] 07:53PM GLUCOSE-99 UREA N-6 CREAT-0.7 SODIUM-139
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-28 ANION GAP-11
[**2110-1-3**] 07:53PM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-1.9
[**2110-1-3**] 07:53PM WBC-11.1* RBC-4.42* HGB-14.7 HCT-41.2 MCV-93
MCH-33.4* MCHC-35.8* RDW-12.1
[**2110-1-3**] 07:53PM PLT COUNT-197
[**2110-1-3**] 06:07AM PHENYTOIN-14.9
MR THORACIC SPINE [**2110-1-4**] 7:15 PM
MR CERVICAL SPINE; MR THORACIC SPINE
Reason: ? ligamentus injury
[**Hospital 93**] MEDICAL CONDITION:
31 year old man with T12 compression fracture
REASON FOR THIS EXAMINATION:
? ligamentus injury
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI cervical and thoracic spine.
CLINICAL INFORMATION: Patient with T12 compression fracture,
rule out ligamentous injury.
TECHNIQUE: T1 and T2 sagittal and inversion recovery sagittal
images of the cervical spine were obtained. T1 sagittal images
of the thoracic spine were obtained. The patient was unable to
continue and therefore exam was not completed.
FINDINGS: In the cervical region no evidence of fracture or
marrow edema is seen. There is no evidence of ligamentous
disruption seen. The alignment is normal. The spinal cord
demonstrates normal signal. There is disk bulging at C6-7 level.
In the visualized upper thoracic region marrow edema is seen at
the superior endplate of T3 which could be due to mild
compression.
Limited evaluation of the thoracic spine on the scout images of
the thoracic spine demonstrates compression of T10 vertebra as
seen on the CT of [**2110-1-4**]. There is no abnormal widening of the
intrapinous distances seen. However, evaluation is limited for
ligamentous injury.
IMPRESSION: Mild compression of the superior endplate of T3 and
compression of T10 vertebral bodies. Thoracic spine could not be
evaluated as patient was unable to continue. No evidence of
epidural hematoma or spinal cord compression in the cervical
region.
CT T-SPINE W/O CONTRAST [**2110-1-4**] 3:47 PM
CT T-SPINE W/O CONTRAST
Reason: S/P MVC ASSESS FOR FX,BACK PAIN
[**Hospital 93**] MEDICAL CONDITION:
31 year old man s/p mvc
REASON FOR THIS EXAMINATION:
assess for fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: History of MVC, evaluate for fracture.
COMPARISON: None.
TECHNIQUE: Contiguous axial images of the thoracic spine were
obtained with coronal and sagittal reconstructions.
CT T-SPINE: There is a fracture of the superior anterior
endplate of T10, with slight wedging. There is no evidence of
retropulsion of fragments. Additionally, there are associated
fractures of several left ribs adjacent to their articulation
with thoracic vertebral bodies, at the T2, T4-7, and T10-12
levels. No right-sided rib fracture is seen. There is no
evidence of spondylolisthesis. MR provides better evaluation of
intrathecal contents; however, the contour of the thecal sac
appears to be within normal limits. There is a left pleural
effusion with associated atelectasis. There is a small right
pleural effusion. On the limited portions of the lungs, no
definite pneumothorax is seen.
IMPRESSION: There is a fracture of the anterior portion of the
superior endplate of T10. Additionally, there are fractures of
the left ribs posteriorly at the T2, T4-7, and T10-12 levels.
There are bilateral pleural effusions, greater on the left.
These results were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3035**] at 4:30 p.m.
on [**2110-1-4**].
MR L SPINE SCAN [**2110-1-5**] 2:13 AM
MR L SPINE SCAN
Reason: ? ligamentus injury
[**Hospital 93**] MEDICAL CONDITION:
31 year old man with T12 compression fracture
REASON FOR THIS EXAMINATION:
? ligamentus injury
MR LUMBAR SPINE, [**2110-1-5**]
HISTORY: T12 compression fracture. Is there evidence of
ligamentous injury?
Sagittal and axial imaging was performed with long TR, long TE
fast spin echo and short TR, short TE spin echo technique. No
contrast was administered. No prior lumbar spine imaging studies
are available for comparison.
FINDINGS: This is a preliminary report. Although all of the
images appear to have been acquired, the exam is still marked in
"arrived" status, indicating that there are further images or
processing to be done. Based on the available information, there
is no evidence of encroachment on the spinal canal, injury to
the conus medullaris, or vertebral body fractures from T11 to
the sacrum. There is loss of signal at the L4-5 intervertebral
disc with a focal tear in the posterior anulus. These are
manifestations of degenerative disc disease.
There is a markedly enlarged bladder.
CONCLUSION: Preliminary study still in "arrived" status. There
are degenerative changes at L4-5 without evidence of fracture,
subluxation, or encroachment upon the spinal canal.
Brief Hospital Course:
Patient admitted to the trauma service. Neurosurgery consulted
and recommended Dilantin and serial head CT scans. Orthopedics
consulted because of scapular fracture; non operative management
with Physical therapy and CT imaging. Neurosurgery Spine
consulted for his T10 fracture and have recommended TLSO brace
to be worn while OOB. He was fitted for the brace on [**2110-1-4**].
ENT evaluated left ear canal, no fractures of the bones
identified. Patient will need to follow up with ENT after
discharge. Physical therapy consulted and have recommended
outpatient PT after discharge.
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*1*
2. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Fall
Subdural hematoma
Pneumocephalus
Left scapula fracture
T10 fracture
Discharge Condition:
Stable
Discharge Instructions:
You must wear your TLSO brace while out of bed.
Follow up with Neurosurgery in [**5-29**] weeks.
Follow up with Orthopedics in 2 weeks.
Followup Instructions:
Call [**Telephone/Fax (1) 9986**] for an appointment with Dr. [**Last Name (STitle) **] in [**5-29**]
weeks. Inform his office that you will need a repeat head CT
scan for this appointment.
Call [**Telephone/Fax (1) 1228**] for an appointment in [**Hospital **] Clinic in 2
weeks.
Call [**Telephone/Fax (1) 64521**] to schedule an appointment with Dr. [**First Name (STitle) **],
Otolaryngology, for your left ear.
Completed by:[**2110-1-8**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4363
} | Medical Text: Admission Date: [**2152-6-3**] Discharge Date: [**2152-6-6**]
Date of Birth: [**2080-4-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sudafed / Tequin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
intubation/extubation
History of Present Illness:
72 yo female with pmhx sig for breast cancer, aortic aneurysm,
gastritis, and hypertension who was brought to [**Hospital1 18**] ED by
ambulance after being found down by neighbors for an
undetermined amount of time. The patient had large hematoma to
left forehead, but head CT did not show any evidence of bleed.
CT c-spine negative. Patient limited historian, responsive to
pain, not able to answer questions.
.
In the [**Name (NI) **], pt was intubated for airway protection. Infectious
workup started w/ blood, urine cultures and CXR. Lactate wnl.
Given dose of Levo/Flagyl for possible aspiration pneumonia.
Transferred to MICU for further care.
.
Patient unable to give further history or ROS. Daughter
[**Name (NI) 653**], states that pt called her aunt early today and
complained of feeling "disoriented", said that she hit her head
and needed to go to the hospital. She then pressed her lifeline
and the ambulance and neighbor came, at which time they found
her conscious but disoriented; with a large hematoma on her
right forehead. The daughter states that she has otherwise been
in her usual state of health, but has been on pain medications
for chronic pancreatitis and most recently for shoulder pain. In
addition, she has a history of falls and LOC in the past from
"dehydration", most recent episode about one month earlier, did
not require medical attention
Past Medical History:
autoimmune pancreatitis: during recent hospitalization for
abdominal pain, cystic mass in the head of the pancreas was
noted and also "fullness" in the area of the SMA, which could
represent mesenteric vasculitis
-L lumpectomy for stage I breast ca s/p lumpectomy and XRT in
[**2151-2-10**]. BRCA (-).
- Spiculated LUL mass, stable from [**11-14**] to [**1-16**] - outpt
pulmonary f/u with Dr. [**Last Name (STitle) **] at [**Hospital1 18**]
- 3cm descending thoracic, and 3cm AAA and RCI aneurysmal
ectasia seen on CTA and abdominal [**Hospital1 4338**]/A, supposed to f/u with
vascular surgery (Pompaselli) [**5-15**].
-Gastritis
-Chronic esophagitis with Barrett's esophagous
-Hypertension
-Anemia (baseline Hct 35, has EPO injections every two
weeks)--recent bone marrow biopsy suggestive, but not
diagnostic, of myelodysplastic syndrome
-Spinal stenosis
-Depression
Social History:
Lives alone, with help from son and daughter who live in the
area. Retired nurse. [**First Name (Titles) **] [**Last Name (Titles) **]. Long smoking history (100+ pack
year), quit 15 years ago.
Family History:
Mother with [**Name2 (NI) 499**] cancer. Two sisters with breast cancer.
Physical Exam:
GEN: intubated, lethargic but [**Last Name (LF) 18248**], [**First Name3 (LF) **] follow commands
HEENT: R hematoma on R superior forehead. Pupils constricted but
equal and reactive, EOMI
CV: 2/6 systolic murmur, LUSB, non-radiating. RRR. Large
ecchymoses on R breast
LUNGS: bronchial BS B/L, no focal crackles or wheeze
ABD: soft, nt, nd, nabs
EXT: warm, dry. Ecchymoses and edema around L wrist.
NEURO: responds to voice, follows commands, moves all
extremities spontaneously, reflexes intact B/L
Pertinent Results:
[**2152-6-2**] 10:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
[**2152-6-2**] 10:10PM GLUCOSE-132* UREA N-39* CREAT-1.8*
SODIUM-130* POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-25 ANION GAP-13
[**2152-6-2**] 10:10PM ALT(SGPT)-26 AST(SGOT)-42* LD(LDH)-277*
CK(CPK)-653* ALK PHOS-96 AMYLASE-35 TOT BILI-0.4
[**2152-6-2**] 10:10PM CK-MB-22* MB INDX-3.4 cTropnT-<0.01
[**2152-6-3**] 02:57AM WBC-3.4* RBC-2.90* HGB-9.2* HCT-27.1* MCV-94
MCH-31.6 MCHC-33.7 RDW-15.4
Brief Hospital Course:
72 yo female with ho breast cancer, aortic aneurysm
(conservative managment, gastritis, and hypertension, autoimmune
pancreatitis who was brought to [**Hospital1 18**] ED by ambulance after
being found down after unintentional opiod overdose.
1 Loss of consciousness- diff includes opiate OD, syncope from
hypovolemia, arrythmia, stroke, infectious process, seizure;
improved with time and pt able to give a more detailed history
of what happened and most likely secondary to narcotics and
benzos
2 pain control for autoimmune pancreatitis
- given her intentional Opiod overdose, will continue morphine
SR 30mg [**Hospital1 **], and stop dilaudid 4mg [**Hospital1 **] to avoid confusion.
- morphine 15mg IR q4-6 h prn for break through pain
- continue creon
- f/u w/ GI Dr. [**Last Name (STitle) 174**] regarding further managment of autoimmune
pancreatitis
3 Hypertension- continue atenolol (titrated up to 37.5 mg from
25 mg daily) and dilt (120mg daily home dose)
4 pancytopenia - stable. Normal EGD in [**2152**], no c-scope on
record. Iron studies in [**Month (only) **] w/ low iron, elevated ferritin. Bone
marrow in past suggestive of MDS. Also w/ chronic gastritis;
continue H2B.
5 Respiratory Failure- patient intubated for airway protection
secondary to altered mental status (narcs). Extubated morning
after admission. On cxr has R lower lobe infiltrate, likely
aspriation. Briefly on azithromycin, and CXR improved, and abx
stopped.
6 ARF- baseline creatinine .8. Likely pre-renal given elevated
BUN. ATN also possibility if patient hypotensive in field for
unknown time; improved with fluid
7 Elevated CK- likely secondary to fall. Could consider rhabdo
given renal failure. No blood on UA. improved w/ IVFs
8 Breast cancer- s/p lumpectomy and radiation in left breast one
year ago, apparently no injections or blood draws from left arm
per daughter; held femara
9 Aortic aneurysm- followed by Vascular [**Doctor First Name **], plan for repeat US
in 6 months
HCP is [**Name (NI) **] [**Telephone/Fax (3) 105383**]
Medications on Admission:
1. Creon 30 mg daily
2. Lipitor 40 mg qhs
3. Morphine ER 30 mg [**Hospital1 **]
4. Lidocaine patch
5. Miralex
6. Diltiazem 120 mg qd
7. Ambien CR 6.25 mg qd
8. NTG SL prn
9. Trevatan eye gtt
10. Trazadone 225 mg qhs
11. Doxepin 150 mg qhs
12. PPI 40 mg [**Hospital1 **]
13. Folic acid 1 mg qd
14. Atenolol 25 mg qd
15. Klonopin 0.5 mg [**Hospital1 **]
16. Dilaudid 4 mg prn
17. ?Prednisone (was on taper, unclear if still on prednisone;
if so, would be on 5mg daily at this point)
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
6. Atenolol 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
7. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical once a day as needed for pain.
9. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
10. Miralax 17 g (100%) Powder in Packet Sig: One (1) PO once a
day as needed for constipation.
11. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain: do not take within 4 hours of
your long acting morphine.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Accidental opiate overdose
chronic autoimmune pancreatitis
pancytopenia, likely myledysplastic syndrome
Discharge Condition:
good
Discharge Instructions:
Do not take your short acting pain medication within 4 fours of
the long acting medication. Please test your lifeline when you
get home since it's not clear that it worked for you. Call your
doctor if you get fevers, chills, cough, or any other concerning
symptom. You always need to walk with a walker to stay safe.
Please note, we increased your atenolol. Please also note, we
did not restart the dilaudid but instead, you are on morphine
extended release and instant release for breakthrough pain.
Followup Instructions:
Provider: [**Name10 (NameIs) 13368**] [**Last Name (NamePattern4) 13369**], MD Phone:[**Telephone/Fax (1) 1091**]
Date/Time:[**2152-6-9**] 11:00
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2152-7-5**] 10:45
Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2152-7-18**] 9:20
ICD9 Codes: 5849, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4364
} | Medical Text: Admission Date: [**2137-3-25**] Discharge Date: [**2137-4-3**]
Date of Birth: [**2061-6-10**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Keflex
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
"edema"
Major Surgical or Invasive Procedure:
Right heart catherization
CVVHD (hemodialysis)
History of Present Illness:
75 year old female with CAD, CHF EF 60%, DMII, COPD presenting
from Dr.[**Name (NI) 3536**] office with decompensated heart failure and
episodes of chest pain. Patient was recently admitted from
[**Date range (1) 62457**] and during admission had chest pain radiating to her
jaw w/ associated shortness of breath. She underwent pMIBI
which showed reversivle lateral wall defects. Given concurrent
GI work-up it was felt that further cardiac work-up could be
done as outpatient and consideration of cardiac catheterization.
Patient is somewhat difficult to get a history from, but does
state she has had a couple of episodes of chest pain since her
last discharge, is unable to tell me how long the episodes
lasted or associated symptoms. She does feel like she continues
to gain weight and feels that she has gained "80 lbs of fluid
since last [**Month (only) 205**]." She has baseline leg swelling but this feels
worse than usual and is uncomfortable.
.
Patient is also complaining of bilateral knee pain since fall 3
days prior to admission. She was walking from her walker to bed
and may have tripped. She thinks she fell on her knees and may
have hit her head (although she is not sure). She has been
ambulating since and does have quite a bit of pain at baseline
for which she takes ultram. Her baseline pain seems to be in
bilateral knees and lower back at sight of prior back surgery.
.
ROS: No fevers, chills, (+) nausea (?baseline), no vomiting,
baseline abdominal pain, knee pain. Orthopnea at baseline (2
pillow), no PND. Chest pain episodes as above. Breathing feels
somewhat worse than normal, no coughing.
Past Medical History:
R-sided heart failure with pulmonary HTN. R heart cath in [**2134**]
demonstrated elevated R filling pressures (RVEDP 26 and PCWP 25)
with prominent V-waves, and mod pulm hypertension. [**2134**] TTE
demonstrates normal LVEF (60%), with mildly dilated RV and
normal RV function
CAD: ?NSTEMI '[**23**]
COPD
asthma
DM2
Hypertension
Depression
Anxiety
Restless leg syndrome
H/o anasarca: in [**8-28**], thought [**1-25**] R heart failure + hepatic
dysfunction/low albumin
h/o distal CBD stricture s/p ERCP and sphincterotomy
h/o runs of atrial tachycardia during [**2-27**] admission
GERD
s/p TAH
s/p open cholecystectomy
Social History:
lives at [**Hospital1 11851**] NH, moved last year from [**State 8842**], has son in
the area; +tob- 1ppd x 50y, denies EtOH and drugs
Family History:
father died of CVA, mother died of colon cancer at unknown age
Physical Exam:
VS - 98.2F HR 76 BP 124/64 18 93RA
134.8kg
Gen: awake, alert although poor historian, NAD, lying w/ HOB
elevated
HEENT: PERRL, EOMI, anicteric sclera, OP clear, MM sl dry
Neck: supple, obese, difficult to assess JVP
CV: distant S1, S2, no appreciated murmurs
Pulm: clear to auscultation, limited air movement, no crackles,
wheeze appreciated
Abd: Normoactive bowel sounds, soft, obese, mild, diffuse TTP
all quadrants, negative [**Doctor Last Name 515**] sign, no rebound or guarding
Ext: warm, chronic venous stasis changes, 2+ LE edema b/l to
knees. Knees without effusion. Small bruise on medial aspect
of R knee. L knee with TTP below and above patella. Full ROM
on knees and hips b/l. Hips non-tender to palpation.
Back: well-healed surgical scar around L3-5 with TTP (pt states
baseline)
skin: no rash
Neuro: CN II-XII intact, 5/5 strength in R prox and distal upper
and lower extremity and L lower extremity. 4/5 strength in L
hand grip and biceps ([**1-25**] carpal tunnel per pt and baseline) [**4-27**]
deltoid on L.
.
Pulses:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Pertinent Results:
[**2137-3-25**] 03:58PM BLOOD WBC-13.8* RBC-4.52 Hgb-11.3* Hct-34.4*
MCV-76* MCH-25.0* MCHC-32.9 RDW-16.1* Plt Ct-207
[**2137-3-27**] 09:15AM BLOOD WBC-14.5* RBC-4.89 Hgb-11.8* Hct-36.8
MCV-75* MCH-24.2* MCHC-32.1 RDW-16.3* Plt Ct-228
[**2137-3-25**] 03:58PM BLOOD Glucose-137* UreaN-68* Creat-2.9*# Na-133
K-5.8* Cl-91* HCO3-33* AnGap-15
[**2137-3-26**] 06:00AM BLOOD Glucose-117* UreaN-73* Creat-3.9* Na-129*
K-5.9* Cl-87* HCO3-31 AnGap-17
[**2137-3-27**] 09:15AM BLOOD Glucose-135* UreaN-83* Creat-4.1* Na-130*
K-6.2* Cl-86* HCO3-35* AnGap-15
[**2137-3-25**] 03:58PM BLOOD ALT-12 AST-16 CK(CPK)-105 AlkPhos-108
TotBili-0.4
[**2137-3-25**] 03:58PM BLOOD CK-MB-4 cTropnT-0.11*
[**2137-3-25**] 11:40PM BLOOD CK(CPK)-84
[**2137-3-26**] 06:00AM BLOOD CK(CPK)-73
[**2137-3-26**] 06:56AM BLOOD cTropnT-0.18*
[**2137-3-27**] 09:15AM BLOOD Calcium-8.3* Phos-6.3* Mg-3.0*
.
Brief Hospital Course:
# Acute renal failure - baseline 1.0 (2.0 at nursing home on
[**3-24**], now rising 2.9->4.8). ACE inhibitor and metformin held
given acute renal failure. FeUrea 17 (c/w pre-renal). Renal
team was consulted. Patient initiated on CVVH due to concern
for uremia, given tremors and BUN of 99. However, urine output
was preserved and patient received a trial off of CVVH. Renal
function continued to improve and patient began to autodiurese.
She is now at baseline renal function. She should have her
renal function checked on Monday and the results faxed to Dr. [**Name (NI) 10875**] office at [**Telephone/Fax (1) 9825**] (fax), phone [**Telephone/Fax (1) 3512**]. If
her creatinine is increased by 30% from baseline of .[**7-24**], then
the lisinopril and metformin should be stopped and restarted
after renal function improves at a lower dose.
.
#. Congestive heart failure - Patient admitted initially with
chest pain and shortness of breath. Could not undergo
left-heart catheterizaion due to renal insufficiency. However,
right-heart catheterization demonstrated elevated filling
pressures as above, likely due to diastolic dysfunction. Patient
was not actively diuresed, and oxygen saturation, daily weights,
and fluid balance were monitored. CVP approx 10 when line was
pulled. Therefore was not recommended for further diurese
especially given recent renal failure.
.
#. Coronary artery disease - Patient ruled out for active
ischemia and did not have any new ECG changes. She was
maintained on her aspirin and beta-blocker. ACE inhibitor was
held due to acute renal failure. During a previous admission,
stress MIBI showed reversible lateral wall defect.
Catheterization deferred on that admission as she was undergoing
work-up for CBD papillary mass (path neg for malignancy). On
this admission, cardiac catheterization was deferred until renal
function improved and will be readdressed as an outpatient.
.
# DMII - Held oral hypoglycemics (metformin, glipizide) while
inpatient initially when in renal failure. Once patient was
with noramal renal function, she was transitioned back to home
meds with better glucose control. Continue humulin sliding
scale.
.
# Diarrhea - Postive for C. difficile and started on
metronidazole on [**2137-3-31**]. Should complete a 2 week course of
metronidazole (finishes [**2137-4-14**])
.
# History of fall - Patient was unable to provide details. No
apparent loss of consciousness. She may have hit her head. Head
CT neg for bleed.
.
# COPD - Continued outpatient regimen of tiotropium,
fluticasone-salmeterol, and albuterol prn.
.
#. PPx: SC heparin, PPI, bowel regimen (pt constipated), contact
precautions for h/o MRSA, VRE, and C. difficile.
.
#. Code: FULL discussed with pt and son by [**Name (NI) 121**] 6 team. Neither
would want prolonged intubation
Son, [**Name (NI) **], is HCP:
home: [**Telephone/Fax (1) 62458**], work: [**Telephone/Fax (1) 62459**], cell: [**Telephone/Fax (1) 62460**]
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17143**] wants to remain involved
Medications on Admission:
potassium 10mEq po qday
HCTZ 50mg po qday
lisinopril 20mg po qday
dulcolax prn
MOM prn
trazodone 125mg po qhs prn
metoprolol 100mg po bid
ASA 81 qday ultram prn
tiotropium 18mcg qday
advair 250/50 inh [**Hospital1 **]
fluticasone nasal spray
albuterol inh prn
lasix 80mg po bid
protonix 40mg po qday
montelukast 10mcg po qday
calcium carbonate po tid
cholecalciferol qday
colace [**Hospital1 **]
neurontin 400mg po tid
glyburide 2.5mg qday
MVI
metformin 750mg [**Hospital1 **]
lipitor 40mg po qday
spironolactone 100mg po qday
senna [**Hospital1 **]
Humulin sliding scale
tramadol 50mg po q4-6 hrs prn
oxycodone/tylenol 1-2 tabs po q4-6hrs prn
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Gabapentin 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheeze.
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO once a day.
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
10. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Nasal once a day as needed for allergy symptoms.
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Calcium 500 with Vitamin D 500-200 mg-unit Tablet Sig: One
(1) Tablet PO three times a day.
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
14. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding
scale Subcutaneous ASDIR (AS DIRECTED).
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for pain.
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
18. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Metformin 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
20. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
21. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
22. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
24. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Congestive heart failure, exacerbation
Acute renal failure
.
Diastolic heart failure
Diabetes
Discharge Condition:
Afebrile, stable vital signs, tolerating POs, ambulating with
assistance.
Discharge Instructions:
You were admitted with worsening of your heart failure and then
also had worsening kidney function. You were briefly on
dialysis and it improved.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to a 2 gm sodium diet
Fluid Restriction: 1500 L daily
.
Please return to the ED if you have any shortness of breath,
worsening of your edema, chest pain, vomiting, abdominal pain,
fever, chills, passing out or other concerning symptoms.
An antibiotic Flagyl (metronidazole) was added for your
intestinal infection - please complete the course as instructed.
Please abstain from all alcohol while on this medication as it
will cause strong side effects.
Followup Instructions:
You should follow up with your cardiologist as well as your PCP.
Your appointment is on [**2140-4-16**]:45 AM. You MUST call
[**Telephone/Fax (1) 19196**] if you cannot make this appointment.
.
You should also follow up with Dr. [**First Name (STitle) 437**] Wednesday at 1PM [**4-10**]
ICD9 Codes: 5849, 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4365
} | Medical Text: Admission Date: [**2164-7-20**] Discharge Date: [**2164-8-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Transfer from [**Hospital6 **] for cardiac cath
Major Surgical or Invasive Procedure:
Cardiac cath with stenting
Endotracheal intubation
Cardioversion
Central Line placement
History of Present Illness:
[**Age over 90 **] year old woman with h/o anemia [**2-25**] angiodysplagia-related GI
bleed, h/o colon cancer, CAD s/p anterior MI [**2164-6-19**], resulting
in depressed EF (35%) who was transferred from [**Hospital1 **] Hosp for cardiac catherization.
.
Recent relevant history:
Pt had an anterior MI on [**2164-6-19**] and was treated medically at
NEBH. She did not undergo cardiac catherization at that time.
TTE showed LVEF=35% with severe hypokinesis of the apex
infero-apically to antero-apically. There was akinesis of the
distal septum, about halfway to the apex, including the apex.
There was no AR, 2+ MR, 2+ TR, with PA pressures between 70 and
75mmHg.
.
Pt was d/c'd to a cardiac rehab where she had persistant chest
discomfort, SOB, palpitations with nausea, and was re-admitted
to [**Hospital1 **] for evaluation on [**2164-6-28**]. There, MI was ruled out
by cardiac enzymes and pt's symptoms were determined to be
likely related to mild CHF along with anxiety. Pt was diuresed,
then sent back to rehab with medication adjustments.
Back at the rehab, patient continued to have vomitting, chest
tightness, and LUQ pain, and pt was admitted to [**Hospital3 7872**] on [**2164-7-3**]. Again, she was ruled out for MI by EKG and
cardiac enzymes. Persantine stress test, which did not reproduce
her pain, showed mostly fixed anterior infarct with mild lateral
peri-infarct edema, no ischemia. She was D/C'd to rehab with a
diagnosis of non-cardiac chest pain likely d/t GERD.
.
About one week later, on [**7-19**], she experienced similar symptoms,
partially relieved by SL Nitro. She went to her scheduled follow
up appointments with Dr. [**Last Name (STitle) 11679**] and Dr. [**Last Name (STitle) **] (GI), and during
it she was found to have a her hct=26, and troponin=0.62 with
equivocal EKG changes. She was admitted to [**Hospital3 **] for
transfusion, but after 1 unit of pRBCs, she developed acute
congestive heart failure. She was diuresed with Lasix 80 IV,
given Nitro paste, and, after these treatments, became
hypotensive to 79/33. Dopamine was started. Cardiac enzymes
revealed trop 2.96 and CK 170 (MB not done). Decision was made
to transfer patient to [**Hospital1 18**] for further management/
catherization. Of note, her WBC also increased to 15.2, and
started on empiric Levaquin.
.
On arrival to [**Hospital1 18**], pt admitted to CCU team. [**Name (NI) 47025**], pt was
without complaints. She was taken to cath lab, where a near
total occlusion of proximal/ostial LAD was found along with a
Lcx 90% lesion (Lcx dominant vessel). The LCx lesion was
approached first. While intervening on the LCx lesion, the
patient became hypotensive--likely from occluding the dominant
LCx, causing decreased flow to LAD. WIth the hypotension, she
also became nauseous and vomitted (?aspirated). She then became
asystolic. CPR was initiated as the procedure continued. The LAD
lesion was stented with good resultant flow and the LCx lesion
was angioplastied (with resultant dissection). During this, the
patient was intubated and started on levophed and dopamine. She
went into a wide complex tachycardia--VT vs. SVT/sinus tach w/
incomplete RBBB. She was started on lidocaine gtt and given
300mg Amio bolus. At the time of transfer to the CCU, the
patient's ABG was 7.04/36/436 and lactate 6.
.
On arrival to the CCU, the patient was still vented. Her blood
pressure dropped into the 50s shortly after her arrival. After
getting 2amps of bicarb, BP improved to SBP 90-100s. A-line
placement was attempted unsuccessfully (with doppler in b/l
radial vessels). A right femoral venous catheter was placed. Of
note, pt had bloody NGT drainage.
.
*** Cardiac review of systems is notable for current absence of
dyspnea on exertion, ankle edema, syncope or presyncope. (Prior
to cath)
Past Medical History:
HTN, Hyperlipidemia
GERD
CAD - NSTEMI [**5-/2164**]; P-MIBI w/ fixed anterior defect
CHF
mild aymptomatic, noncritical carotid stenosis
mild aortic stenosis
h/o colon cancer, s/p colon resection
iron deficiency anemia
chronic low-grade GI bleed secondary to angiodysplasia of small
bowel
? COPD
s/p cholecystectomy, appendectomy
Social History:
Patient had been living independently and doing her own ADLs
until her MI in [**2164-5-24**]. Since her MI, she has been in rehab.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Day of Discharge
VS: T 97, BP 119-152/39-55, HR 57-81, RR 18-20, 98 O2 % 1L
Gen: thin, in NAD, resp or otherwise. Oriented x3. Mood, affect
appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no appreciable JVD.
CV: RRR normal s1/s2, III/VI SEM heard best at LUSB, no rubs or
gallops
Chest: Kyphosis, barrel chest. Resp were unlabored, no accessory
muscle use. No crackles, wheeze, rhonchi.
Abd: Soft, + bruising, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
[**2164-7-20**] 07:38PM BLOOD WBC-13.6*# RBC-2.80* Hgb-8.4* Hct-27.1*#
MCV-97# MCH-30.0 MCHC-31.0 RDW-16.3* Plt Ct-453*
[**2164-7-20**] 06:30PM BLOOD Glucose-589* UreaN-28* Creat-1.2* Na-125*
K-3.2* Cl-100 HCO3-8* AnGap-20
[**2164-7-20**] 07:38PM BLOOD Calcium-7.7* Phos-4.8* Mg-1.4*
[**2164-7-20**] 07:38PM BLOOD PT-18.3* PTT-150* INR(PT)-1.7*
[**2164-8-3**] 07:20AM BLOOD WBC-14.9* RBC-3.69* Hgb-11.1* Hct-34.4*
MCV-93 MCH-30.0 MCHC-32.2 RDW-18.8* Plt Ct-486*
[**2164-8-3**] 07:20AM BLOOD Glucose-106* UreaN-26* Creat-1.2* Na-142
K-3.8 Cl-102 HCO3-29 AnGap-15
[**2164-8-2**] 07:45AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7
.
[**2164-7-20**] 07:38PM BLOOD CK(CPK)-153*
[**2164-7-21**] 03:48AM BLOOD CK(CPK)-353*
[**2164-7-22**] 04:51AM BLOOD CK(CPK)-219*
[**2164-7-20**] 07:38PM BLOOD CK-MB-14* MB Indx-9.2*
[**2164-7-21**] 03:48AM BLOOD CK-MB-28* MB Indx-7.9* cTropnT-2.31*
[**2164-7-22**] 04:51AM BLOOD CK-MB-8 cTropnT-1.88*
.
[**2164-8-1**] 06:55AM BLOOD proBNP-[**Numeric Identifier 47026**]*
.
[**2164-7-21**] 03:48AM BLOOD ALT-390* AST-407* LD(LDH)-509*
CK(CPK)-353* AlkPhos-122* Amylase-208* TotBili-0.3
[**2164-7-31**] 06:45AM BLOOD ALT-38 AST-24 AlkPhos-85 TotBili-0.3
.
ECHOCARDIOGRAM [**2164-7-23**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
hypokinesis of the mid inferolateral wall and distal inferio
wall. The remaining segments contract normally (LVEF = 55 %).
The estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are moderately
thickened. There is mild-moderate aortic valve stenosis (area
1.2cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen.
There is at least mild pulmonary artery systolic hypertension.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction suggestive of CAD. Mild-moderate
aortic valve stenosis. At least mild pulmonary artery systolic
hypertension.
Brief Hospital Course:
[**Age over 90 **] year old woman with h/o CAD, s/p anterior MI [**2164-6-19**],
resulting in depressed EF (35%) and anemia [**2-25**]
angiodysplagia-related GI bleed who was transferred from [**Hospital1 15204**] Hosp for cardiac catherization and is s/p LCx
stent with dissection leading to cardiac arrest requiring
resuscitation and intubation. Clinical status gradually
improved but course complicated by multiple episodes of acute on
chronic congestive heart failure (although present EF wnl),
stable at discharge on diuretics.
.
1.) CAD/Ischemia: S/p cardiac cath, which showed dominant Lcx
with 90% lesion & ostial LAD lesion. The LAD lesion was stented
and the Lcx lesion was angioplastied. This was complicated by
dissection of LCx, with subsequent cardiac arrest in cath lab
that resolved with CPR and pressors. The patient was medically
managed with ASA, plavix, statin, and metoprolol. She would
benefit from starting an ACE I once her creatinine has
stabilized.
.
2.) Dysrrhythmia: Pt went into wide-complex tacycardia (VT vs.
SVT/sinus tach with partial RBBB) after her cardiac arrest,
converting to NSR on lidocaine drip & amiodarone. Pt
subsequently developed A fib with RVR in the 130s, which
resulted in a hypotensive episode requiring cardioversion x 7
before stabilizing. Throughout the rest of her hospital course,
patient remained in normal sinus rhythm. The amiodarone and
digoxin was discontinued prior to discharge as the Afib only
occurred in the setting of recent MI/cardiac arrest.
.
3.) Acute on chronic systolic heart failure: Prior echo showed
an EF of 35%, improved to 55% on [**2164-7-23**] echo. During her
hospital course, pt had multiple episodes of acute respiratory
distress secondary to the development of pulmonary edema in the
setting of hypertension, likely due to a stiff LV. She was
acutely managed with Lasix, morphine, nitropaste and nebs prn
with good response. She received afterload reduction with
hydralazine. She also received a short course of prednisone in
light of her COPD. CXR on [**7-31**] showed improvement in mild
pulmonary edema with bilateral pleural effusions present which
partially layer and occupy the fissure. Pt stable on discharge
dose of Lasix 40 mg po daily, to be sent to rehab with O2 for
dyspnea on exertion.
.
4.) R/o infection: Differential dx of acute respiratory distress
included pneumonia. CXR [**7-26**] with poor inspiratory effort and
thus was difficult to interpret. Endotracheal tube culture was
MRSA +, and vancomycin was started empirically in the setting of
acute respiratory distress although pt was afebrile with nl wbc.
However, CXR [**7-28**] was consistent with mod pulm edema with no
opacities suggestive of PNA, so vancomycin was discontinued.
Since then, patient has been afebrile, although WBC increased to
peak of 17.3 but trending down at 14.3 on discharge in context
of recent prednisone course. Low suspicion for active infection
as pt continued to be afebrile without cough/sputum, UA neg, Ucx
with normal flora, C. diff neg.
.
5.) Delirium: Pt experience several episodes of delirium
(sundowning) in the setting of complicated hospital course in
intensive care unit. She responded well to Haldol. Since her
transfer to the floor, her mental status is much improved
without further incidences.
.
6.) Acute renal failure: Pt with baseline Cr of 1.2. On
discharge, creatinine is stabilizing at 1.2, down from a
creatinine max of 1.7. We suspected this was due to contrast
nephropathy, shock, or possibly prerenal volume depletion.
.
7.) Anemia: Pt has h/o anemia due to chronic GI bleeding related
to angiodysplasia of small bowel, s/p 1 unit pRBC transfusion at
OSH on [**2164-7-19**]. She had bloody NGT drainage post-cath. On
[**2164-7-27**] she had clear bloody fluid per rectum. She had a guiac +
black stool on [**2164-7-31**] and subsequently. However, she had a
normal colonoscopy within the past year. In addition, Hct was
stable (ranging from 31 to 35) and in light of her complicated
hospital course, it was determined by the attending and with
family that further intervention with endoscopy would not offer
any therapeutic benefit. She will continue enteric-coated ASA
81mg PO daily and Plavix 75 mg PO daily for her stent. She is
on Lansoprazole 30 daily.
.
8.) Elevated LFTs were noted post-hypotension. We suspected this
was secondary to shock liver as they normalized when re-checked
on [**2164-7-31**].
.
9.) FEN/GI: Speech and Swallow evaluated the patient several
times post-extubation and in her most recent eval they did not
find clinical evidence of aspiration and she was advanced to
liquids and soft solids. Clinical nutrition saw the patient on
[**2164-8-1**] and recommended that she be on a low salt diet with
supplemental high calorie, high protein shakes. She should have
regular calorie intake monitoring to ensure adequate nutrional
support.
Medications on Admission:
Advair Diskus 150 mcg 1 puff b.i.d.
Spiriva 1 capsule inhaled daily
Aldactone 25 mg p.o. daily
Avapro 75 mg p.o. daily
Crestor 10 mg p.o. daily
Desyrel 50 p.o. at bedtime
iron sulfate 325 mg a day
Lasix 20 mg Monday, Wednesday, and Friday
Plavix 75 mg a day
Pletal 50 mg a day
Protonix 40 mg b.i.d.
Tenormin 25 mg
Zetia 10 mg a day
Carafate 1 g liquid four times daily.
Discharge Medications:
1. Clopidogrel 75 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
2. Rosuvastatin 5 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY
(Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Date Range **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
6. Hydralazine 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6
hours).
7. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
8. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as
needed.
10. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One
(1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
13. Colace 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day.
14. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**1-25**] Sprays Nasal
QID (4 times a day) as needed.
15. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Month/Day (2) **]: One (1)
Tablet PO once a day.
17. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Coronary Artery Disease s/p stenting
Ventricular Fibrillation s/p cardioversion
Aspiration Pneumonia
COPD exacerbation
.
Secondary:
Hypertension
Mental Status Changes
Chronic Kidney Failure
Discharge Condition:
Stable. ambulating with minimal supplemental oxygen with 1
person assist for transfers.
Discharge Instructions:
You were admitted for cardiac cath and underwent stenting of
your coronary arteries. However, the procedure was complicated
by a ventricular arrhythmia that required cardioversion. You
were intubated emergently and transferred to the cardiac
intensive care unit. Your heart muscle appears to have
preserved function and you will follow up with your cardiologist
for a follow up ECHO in [**4-29**] weeks.
.
We have made some changes to your medications as seen below:
We have discontinued your Aldactone, Avapro, Pletal, Protonix,
Zetia, Carafate, Atenolol.
We have changed your Lasix to 40mg by mouth daily and Trazodone
to 25mg PO qHS.
We have added the following medications:
Hydralazine 10mg, two tabs by mouth every 6 hours.
Metoprolol 50mg by mouth twice a day.
ASA 81mg PO daily
Lansoprazole 30mg PO daily.
.
If you develop any new chest pain, shortness of breath or any
other general worsening of condition, please call your PCP or
come directly to the ED.
Followup Instructions:
Dr. [**Last Name (STitle) 11679**] follow up appointment on Tuesday [**8-7**] at 2pm
Dr. [**Last Name (STitle) **] follow up appointment Wednesday [**8-15**] at 10am
Completed by:[**2164-8-3**]
ICD9 Codes: 4275, 4254, 9971, 5849, 2930, 5070, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4366
} | Medical Text: Admission Date: [**2187-11-20**] Discharge Date: [**2187-12-13**]
Date of Birth: [**2124-10-19**] Sex: F
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
fevers, cough
Major Surgical or Invasive Procedure:
[**11-20**] central venous line placement
[**11-21**] endotracheal intubation
History of Present Illness:
Ms. [**Known lastname **] is a 63 year-old female with DM2 who presented to OSH ED
with flu like symptoms, fever, and SOB. Her symptoms began
Friday [**11-16**] with body aches and a cough. She also reports an
H1N1 outbreak in her area. She then developed fever to 102 and
chills last night, and today developed wheezing. Cough was dry,
non-productive, thinkns there might have been some blood in it
today. Symptoms associated with generalized fatigue and weakness
and lightheadedness especially on standing. She had nausea but
no vomiting, and did have diarrhea x 3 today. She presented to
an OSH ED, where she was noted to be hypoxic to 85% ra, and
hypotensive to 80s. CXR showed bilat infiltrates. CBC with
49%bands and wbc 5.2. Received 2l ivf, CTX, azithro, and
transferred to [**Hospital1 18**].
In the emergency department, triage VS were: t=unable, 117
90/50, 38, 95%. Pressure dropped to 70s. Was mentating fine,
satting well on NRB. A RIJ was placed and levophed was started.
Vancomycin, zosyn, and tamiflu were added to previously given
abx regimen. Lactate returned at 4.4. 1.5 liters of IVF were
given with lactate improved to 3.2. CXR revealed retrocardiac
consolidation which may represent pneumonia or atelectasis.
Intubation was considered but pt appeared well enough on NRB
that this was not performed. Most recent VS: 101/59 101 27 97%
NRB. Levophed at 0.04.
Of note, en route to the [**Last Name (LF) 153**], [**First Name3 (LF) 8125**] Hospital called with report
that patient flu swab returned positive for H1N1- however,
reports were never confirmed and when [**Hospital 8125**] hospital sent
records, there was no documentation of flu swab.
Past Medical History:
DM2 on orals
s/p CCY
s/p hysterectomy
HL
GERD
depression
Social History:
Lives in [**Location 13360**] with daughter and son-in-law and
[**Name2 (NI) 7337**]. denies tobacco, alcohol, drug use. No recent
hospitaliztions but daughter is [**Name8 (MD) **] RN
Family History:
non-contributory
Physical Exam:
T= 96.5 BP= 113/48 HR=101 RR=15 O2=92%
GENERAL: Pleasant, obese female, mod resp distress
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI.
Neck: RIJ in place. JVP difficult to assess [**2-19**] habitus.
CARDIAC: tachycardia with no m/r/g
LUNGS: shallow repsirations with poor air movement, diffuse
rhonchi and expiratory wheezing, and focal crackles RML area.
ABDOMEN: obese, hypoactive BS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ DP/PT pulses.
SKIN: No rashes/lesions, ecchymoses.
Pertinent Results:
Lactic Acid:3.2 mmol/L
CXR [**2187-12-11**]: FINDINGS: The right lateral chest is not included
on the study. In comparison with the previous chest radiograph,
the diffuse multifocal airspace opacities are unchanged with
mild superimposed pulmonary edema. No pneumothorax,
cardiomediastinal silhouette is unchanged with mild
cardiomegaly.
CHEST CTA [**2187-11-28**]
IMPRESSION:
1. Diffuse multifocal airspace consolidations in both lungs, not
significantly changed. Mediastinal lymph nodes are likely
reactive.
2. Diffuse fatty infiltration of the liver.
3. Right distal renal artery rim-calcified aneurysmal dilatation
measuring
1.2 cm.
4. Perirectal fat stranding with small amount of fluid within
the presacral space. Clinical correlation is recommended.
IMPRESSION: Retrocardiac consolidation which may represent
pneumonia or atelectasis.
LIVER ULTRASOUND [**2187-12-3**]:
IMPRESSION:
1. Diffusely echogenic liver compatible with fatty infiltration.
Other forms
of liver disease and more advanced liver disease cannot be
excluded.
2. No abnormality at the gallbladder fossa.
3. No intrahepatic biliary duct dilatation. CBD measures up to 8
mm in a
post-cholecystectomy patient.
ECG: EKG:
sinus tachy at 116, NA/NI, no ST changes.
CT ABD [**2187-11-28**]
1. Diffuse multifocal airspace consolidations in both lungs, not
significantly changed. Mediastinal lymph nodes are likely
reactive.
2. Diffuse fatty infiltration of the liver.
3. Right distal renal artery rim-calcified aneurysmal dilatation
measuring
1.2 cm.
4. Perirectal fat stranding with small amount of fluid within
the presacral
space. Clinical correlation is recommended
Brief Hospital Course:
Ms. [**Known lastname **] is a 63 year old lady with diabetes who was admitted to
the ICU on [**2187-11-20**] with fevers and respiratory distress.
#. Sepsis/Pneumonia: Due to concern for influenza and possible
superimposed bacterial pneumonia, she was started on tamiflu and
empiric antibiotics including
vancomycin/ceftriaxone/levofloxacin on admission. She had
worsening respiratory distress and was intubated on [**11-21**], with
multifocal infiltrates on CXR. Gram stain of sputum
demonstrated gram positive cocci and gram negative rods but
cultures were ultimately negative, including a negative
influenza DFA. She developed ARDS and was managed with the
ARDSnet protocol, eventually having an esophogeal balloon
placed. Antibiotics were broadened to include cefipime, which
was later changed to meropenem. Her respiratory status
gradually improved and she was extubated on [**2187-12-10**]. By the
time of transfer, she was satting comfortably on nasal cannula
and able to converse in a soft voice with some understanding of
our conversations. She is slightly confused, likely due to heavy
amount of sedative medications and prolonged intubation.
#. Acute Renal failure: She developed acute renal in the
setting of sepsis and likely acute tubular necrosis. Her renal
function normalized with continued treatment of her sepsis.
#. DM2: She was treated with an insulin sliding scale. She can
restart metformin as an outpatient.
#. Hyperlipidemia: She can be restarted on lipitor. During her
hospitalization, she did develop transaminitis (which was the
reason lipitor was held), but this was thought to be secondary
due to an antibiotic sided effect, as liver enzymes trended
downward upon discontinuation of the offending [**Doctor Last Name 360**].
# Depression: She can be restarted on prozac and amitryptiline.
Medications on Admission:
amitryptyline
lipitor 80mg qHS
prozac 30mg daily
omeprazole 20 mg
metformin 1000mg [**Hospital1 **]
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ml
Injection TID (3 times a day).
2. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for rash in groin.
3. Acetaminophen 100 mg/mL Drops [**Hospital1 **]: 325-650 mg PO Q6H (every 6
hours) as needed for pain/fever.
4. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
5. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: See sliding scale
Subcutaneous ASDIR (AS DIRECTED).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours).
7. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Fluoxetine 10 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO DAILY
(Daily).
10. Senna 8.6 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO BID (2 times a day)
as needed for consti.
11. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
12. Prozac 20 mg Capsule [**Last Name (STitle) **]: Thirty (30) mg PO once a day.
13. Atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Sepsis
Pneumonia
Acute respiratory distress syndomre
Acute renal failure
Secondary:
Obesity
Diabetes type 2
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital because of shortness of
breath. We treated you for pneumonia and had to mechanically
ventilate you, but you were eventually able to breathe on your
own.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
Return to the ED if you have fevers, chills, chest pain,
shortness of breath, or any other concerning symptoms.
Followup Instructions:
Schedule an appointment with your PCP in one to two weeks.
ICD9 Codes: 0389, 5845, 2762, 2767, 2724, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4367
} | Medical Text: Admission Date: [**2118-2-27**] Discharge Date: [**2118-3-15**]
Date of Birth: [**2042-2-7**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Latex
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Right subdural hematoma
Major Surgical or Invasive Procedure:
AV fistula graft partial resection
Left IJ line placement
History of Present Illness:
Patient is a 76 year old female with end stage renal disease
who was at [**Hospital3 **] following a mechanical fall at home
where
she reportedly struck her head on the right side. She was
admitted on [**2118-2-22**] and had been undergoing dialysis. On [**2-27**]
while undergoing dialysis she had an episode where she was
observed to begin twitching on the left side of her face and was
transiently unresponsive. The entire seizure lasted
approximately
2 minutes and she was not aware of the episode. She states she
has never had an episode like this or has ever been told that
she
has had one that she was unaware of. Following the episode she
underwent a noncontrast CT scan of the head which showed a right
sided subdural hematoma measuring 10mm at it;s thickest and
producing no measurable midline shift. Neurologically she
returned to her baseline following a post-ictal period. After
reviewing the CT scan it was determined that she would be
transferred to [**Hospital1 18**] for further evaluation. Prior to transfer
she received 2 units of FFP, platelets, and vitamin K. Of note,
she was found to have MSSA bacteremia while at [**Hospital3 **] with
a presumed fistula cellulitis. She had been using a right arm
fistula and a left IJ dialysis line was placed as well.
Subsequently she had the left IJ line discontinued and a femoral
catheter was placed. Upon arrival she has no complaints and
verbalizes well her reasoning for transfer. She denies
headaches,
nausea, vomiting, dizziness, weakness, numbness, tingling,
changes in vision, hearing, or speech, or changes in bowel
habits.
MEDICINE ACCEPT NOTE:
Ms. [**Known lastname 33522**] is a 76yo F with history of ESRD on HD, DVT with IVC
filter and OA s/p R knee replacement who presented to [**Hospital3 10960**] after a mechanical fall, had seizure like activity
during HD on [**2-27**] and was found to have small subdural hematoma
on CT, erythema around her AV graft and blood cultures on [**2-22**]
+for MSSA.
Ms. [**Known lastname 33522**] was admited to OSH following a mechanical fall at
home where she reportedly struck her head on the right side. She
was admitted on [**2118-2-22**] and had been undergoing dialysis. On [**2-27**]
while undergoing dialysis she had an episode where she was
observed to begin twitching on the left side of her face and was
transiently unresponsive. The entire seizure lasted
approximately
2 minutes and she was not aware of the episode. She states she
has never had an episode like this or has ever been told that
she has had one that she was unaware of. Following the episode
she underwent a noncontrast CT scan of the head which showed a
right sided subdural hematoma measuring 10mm at its thickest and
producing no measurable midline shift. Neurologically she
returned to her baseline following a post-ictal period. After
reviewing the CT scan it was determined that she would be
transferred to [**Hospital1 18**] for further evaluation. She has had 2
subsequent CT scans that showed that the bleed is stable and
does not require intervention. Patient is followed by Neurology
who did bedside EEG monitoring and saw no seizures. Though she
was initially on anti-seizure meds (Keppra/Dilantin), they were
dc'd 2/13 days ago and pt still remains seizure free.
While at OSH, she was found to have a DVT in the R brachial
vein, and [**4-20**] blood cultures on [**2-22**] grew MSSA. She received
vancomycin for this until narrowing to cefazolin on [**2-25**] after
cx data returned. Given her presumed infected AV graft, she had
a L IJ HD line placed on [**2-25**] but this stopped functioning, and
R femoral HD line was placed on [**2-26**]. On [**2-28**], her R femoral HD
line was removed and L IJ HD line was placed. The patient had a
TTE on [**2-26**] at OSH which did not show any vegetations but was
remarkable for mild to moderate MR [**First Name (Titles) **] [**Last Name (Titles) **]. ID is following.
She was transitioned to Vancomycin per HD protocol. TEE was
obtained [**3-2**] and ruled out endocarditis.
Currently, patient feels "much better." She denies any pain at
fistula site. No sob, no chest pain, no abdominal pain, no
cough, no headache, no dysuria. Does report constipation, last
BM 4 days ago.
Past Medical History:
ESRD on HD tuesday/thursday/saturday
afib
GI bleeds
gastric bypass
DVT with IVC filter
sarcoidosis
Social History:
lives at home with husband, no ETOH or tobacco
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
VS - Tc 99.8 Tm 100.2 BP 118-158/33-57 HR 82-99 RR 19 O2-sat
%95RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, irregularly irregular, no MRG, nl
S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs); left hand with splint and swelling s/p fall at home; R AV
fistula non erythematous, non tender, +bruit
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly, muscle strength 5/5
throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM:
VS: Temp 97.4, BP 178/78, HR 99, RR 20, O2 96% on RA
GEN: A&OX3, NAD
HEENT: PERRL, MMM, OP clear
NECK: supple, no LAD, JVD not visulized
LUNG: CTA bilaterally, no r/rh/w
HEART: RRR, no m/r/g
EXT: non pitting edema in LUE
SKIN: bruise over L knee with dressings, incision over R
forearm, 1 cm skin tear over L forearm
Pertinent Results:
ADMISSION LABS
[**2118-2-28**] 12:14AM BLOOD WBC-8.7 RBC-2.08*# Hgb-6.7*# Hct-20.9*#
MCV-100* MCH-32.2* MCHC-32.1 RDW-15.0 Plt Ct-394
[**2118-2-28**] 12:14AM BLOOD PT-11.1 PTT-22.1* INR(PT)-1.0
[**2118-2-28**] 12:14AM BLOOD Glucose-104* UreaN-82* Creat-6.7*# Na-133
K-4.3 Cl-88* HCO3-28 AnGap-21*
[**2118-2-28**] 12:14AM BLOOD ALT-6 AST-34 LD(LDH)-386* AlkPhos-79
Amylase-98 TotBili-0.4
[**2118-2-28**] 12:14AM BLOOD Albumin-3.3* Calcium-7.2* Phos-4.7*
Mg-2.2
[**2118-2-28**] 08:00PM BLOOD calTIBC-198* VitB12-1367* Folate-GREATER
TH Ferritn-1584* TRF-152*
[**2118-2-28**] 12:14AM BLOOD Phenyto-<0.6*
DISCHARGE LABS
[**2118-3-15**] 07:00AM BLOOD WBC-10.4 RBC-2.66* Hgb-8.3* Hct-26.3*
MCV-99* MCH-31.4 MCHC-31.6 RDW-17.5* Plt Ct-516*
[**2118-3-15**] 07:00AM BLOOD PT-25.2* INR(PT)-2.4*
[**2118-3-15**] 07:00AM BLOOD Glucose-64* UreaN-38* Creat-4.3* Na-139
K-3.9 Cl-98 HCO3-29 AnGap-16
[**2118-3-15**] 07:00AM BLOOD Calcium-9.1 Phos-1.2* Mg-2.3
PERTINENT LABS
[**2118-3-6**] 06:16AM BLOOD ESR-50*
[**2118-3-1**] 02:34PM BLOOD Ret Aut-1.9
[**2118-3-9**] 10:50AM BLOOD Albumin-3.0* Mg-2.1
[**2118-3-1**] 02:34PM BLOOD calTIBC-200* Ferritn-1643* TRF-154*
[**2118-3-1**] 02:34PM BLOOD PTH-198*
[**2118-3-6**] 06:16AM BLOOD CRP-195.9*
[**2118-3-14**] 07:40AM BLOOD Phenyto-7.3*
[**2118-3-11**] 11:00AM BLOOD Phenyto-8.0*
[**2118-3-9**] 12:35PM BLOOD Phenyto-8.8*
MICROBIOLOGY
Blood culture [**2-28**] X2, [**3-1**] X2, [**3-2**] X2, 2/17X1, 2/19X1 - no
growth
AV graft - MSSA
Catheter tips [**2-28**] and [**3-2**] - no growth
Radiology Report
CT HEAD W/O CONTRAST Study Date of [**2118-2-28**] 3:16 AM
IMPRESSION: Right-sided subdural hematoma measuring up to 11 mm
in maximal
thickness. Prior images are not available for comparison at the
time of
report. No significant shift of midline structures.
WRIST(3 + VIEWS) LEFT Study Date of [**2118-2-28**] 3:44 PM FINDINGS:
Three views show no evidence of fracture or dislocation. There
is some soft tissue swelling dorsally at the wrist level. There
is calcification in vascular structures about the wrist.
Degenerative change is seen in the first CMC and triscaphe
joints.
CHEST PORT. LINE PLACEMENT Study Date of [**2118-2-28**] 11:07 AM
IMPRESSION: AP chest compared to most recent prior chest
radiographs
currently available, from [**2108-7-10**]:
Left supraclavicular dual-channel central venous line ends in
the left
brachiocephalic vein close to its junction with the right
brachiocephalic
vein. There is no mediastinal widening, pleural effusion, or
pneumothorax. Heart size is top normal, but pulmonary
vasculature is engorged. Band-like areas of opacity in both
lungs are mostly atelectasis. Although there is no mediastinal
vascular engorgement, the other findings suggest patient is on
the verge of cardiac decompensation.
.
[**2-28**] EEG: IMPRESSION: This is an abnormal continuous ICU
monitoring study because of asymmetric background with further
slowing over the right hemisphere.
This finding is indicative of diffuse cortical and subcortical
dysfunction in the right hemisphere. Background is also slightly
slow
over the left hemisphere indicative of a mild diffuse
encephalopathy.
In addition, there are frequent right central and temporal sharp
waves
consistent with a potential epileptogenic focus in this region.
There
is one verbal event report and two pushbutton activations in
this file,
all due to activity discontinuation, eye closure, or low
amplitude
shaking of the left arm with no electrographic seizures on EEG.
The
latter episode is suspicious for focal motor seizures which may
not
have an electrographic correlate. Note is made of irregular
heart rate
with occasional wide complex premature beats.
[**3-1**] EEG: IMPRESSION: This is an abnormal continuous ICU
monitoring study because of diffuse background slowing
consistent with a mild to moderate
encephalopathy with non-specific etiology. A few brief clinical
events
are detected throughout the recording showing mainly myoclonic
jerking
of the left arm and rarely of the right arm with no correlating
electrographic seizure. These episodes most likely represent
focal
motor seizures. Compared to the prior day's recording, there is
an
increase in the number of clinical events; however, EEG is not
changed.
[**3-1**] Right Upper extremity doppler ultrasound:
IMPRESSION: Patent right upper extremity AV graft with elevated
velocities at the venous anastomosis suggesting significant
stenosis.
[**3-1**] CT head noncontrast:
IMPRESSION:
1. Stable subdural hematoma layering over the right cerebral
convexity,
measuring up to 11 mm in maximal thickness, with no change in
degree of mass effect.
2. No new foci of hemorrhage or shift of normally-midline
structures.
[**3-2**] TEE: IMPRESSION: No evidence of valvular vegetations or
abscess seen. The ascending aorta is moderately dilated. Mild
to moderate aortic regurgitation is seen. Mild anterioir leaflet
MVP with mild MR.
[**3-2**] CTA w/ & w/o contrast
1. No definite evidence of mass, infarct or septic embolus,
though this
examination would be expected to have low sensitivity to the
last of these. If clinical concern persists, this could be
further evaluated with an MRI (if feasible), as suggested
previously.
2. Unchanged appearance of right frontal convexity subdural
hematoma, without significant mass effect.
3. Normal cerebral vasculature without steno-occlusive disease,
dissection, or aneurysm larger than 3 mm.
[**3-7**] CT head w/o contrast
IMPRESSION: Unchanged right frontoparietal subdural hematoma
without increase in mass effect or new hemorrhage.
[**3-10**] US guided HD line placement
IMPRESSION:
1. Uncomplicated placement of a 19-cm tip-to-cuff tunneled
dialysis line with the distal tip at the right atrium. The line
is ready to use.
2. Occlusive new thrombus in the left internal jugular.
3. Chronic [**Last Name (un) **]-occlusive disease of the right internal jugular.
[**3-12**] CT head w/o contrast:
1. Interval evolution of subacute on chronic subdural hematoma
overlying the right cerebral hemisphere, not significantly
changed in size compared to CT from [**2118-3-7**].
2. Persistent mild leftward shift of normally midline
structures, not
significantly changed. No central herniation.
3. No acute large vascular territorial infarction.
[**3-14**] CT head w/o contrast
1. No change in subacute on chronic subdural hematoma overlying
the right
cerebral hemisphere.
2. No new hemorrhage.
Brief Hospital Course:
Ms. [**Known lastname 33522**] is a 76yo F with history of ESRD on HD, DVT with IVC
filter and OA s/p R knee replacement who presented to [**Hospital3 10960**] after a mechanical fall, had seizure like activity
during HD on [**2-27**] and was found to have small subdural hematoma
on CT, as well as erythema around her AV graft and blood
cultures on [**2-22**] positive for MSSA, presumably from graft
infection. Her hospital course was c/b several nonocclusive
thrombi (see below) and occasional witnessed seizure activity.
ACTIVE ISSUES:
# Subdural hematoma: Patient had a 10mm subdural hematoma s/p
mechanical fall c/b seizure activity at OSH. Her SDH was
considered to be stable on repeat CTs during admission; while a
small herniation and increase in size of the SDH was observed on
one CT head, this was considered to be due to different slices
being taken. Her neurological exam remained unchanged throughout
admission other than during and after her seizure episodes (see
below). Neurology and neurosurgery both stated that heparin
would be OK from their standpoint for her b/l arm and Right IJ
clots at a goal PTT 40-60 (see below). The patient was guaiac
negative [**3-11**]. The heparin was started on [**3-11**], and a head CT
once her goal PTT was reached was stable. Coumadin was started
on [**3-12**] and we recommend to continue to three months. Her goal
INR should be 2.0-2.5 given the history of complications. Her
INR on discharge day was 2.4.
# Seizures: Her seizures were likely [**2-17**] her SDH; while an EEG
did not show seizure activity, on [**3-9**] she had a witnessed
seizure with L face and arm involvement (some R arm movement)
lasting about 3.5 min, broke on its own before ativan 2mg given.
She had postictal confusion, a slight L facial droop and
slightly slurred speech. The seizures were unlikely to be uremic
or electrolyte-related in etiology, and pt has no seizure Hx.
She was dilantin loaded on 2/22am and maintained on dilantin
thereafter. She was maintained on fall, aspiration, and seizure
precautions. Neurology recs regarding her seizures were as
follows: if seizes for >5 min, give Ativan 1mg. However, if
self-resolved, give another 300mg IV Dilantin and holding off on
using Ativan.
# nonocclusive thrombi: she was found to have nonocclusive
thrombi in her b/l brachial veins and R IJ, which were
visualized on US from [**3-6**]. After her condition stabilized and
she did not have active seizures, anticoagulation with heparin
bridge to coumadin was commenced as described above. Her goal
INR should be 2.0-2.5 given the history of complications. Her
INR on discharge day was 2.4.
# MSSA bacteremia: Patient had 4/4 bottles +MSSA at OSH on [**2-22**].
Source presumed to most likely be infection of AV graft that was
removed on [**3-3**]. TEE on [**3-2**] ruled out endocarditis. CT head
did not show e/o septic emboli. We continued cefazolin at HD
sessions per ID recs, for a 6-week course (d1 = [**2-22**]). The pt had
low-grade fevers on [**2025-3-3**], and a leukocytosis of 19 on [**3-6**];
at that time, her CXR was unremarkable, but a US of graft site
saw fluid collection and nonocclussive clots. She defervesced
and remained stable for the remainder of admission. F/u blood
cultures did not show any growth.
# ESRD on HD s/p RUE AV fistula: Gets dialysis T,Th,Sat. Pt
likely had infection of AV graft, and transplant surgery
resected a portion of her graft. She received a temporary line
on 2/17am, then had a tunneled IJ line placed on [**3-10**]. She
continued to receive dialysis. Her last session was on the day
of discharge.
# Anemia: Pt's Hct on [**3-9**] was 21.8, down from 24.2 on [**3-8**]. Pt
required 2U RBC's for Hct 19.3 upon admission. Renal transfused
1U RBC's at HD on [**3-10**] and gave one dose of Epo. Her post
transfusion Hct was satisfactory and appropriately bumpted at
27. Renal service recommended Epo to be given at HD sessions.
CHRONIC ISSUES:
# HTN: continued metoprolol
# HLD: continued home atorvastatin
TRANSITIONS OF CARE:
-Pt need cefazolin for AV-fistula related bacteremia.
Recommended dosing regimen: 2 g Cefazolin iv during dialysis on
Monday and Wednesday, 3 g Cefazolin iv during dialysis on
Friday. The last dose should be on [**4-6**].
-Pt need anticoagulation for three months. Goal INR should be
2.0-2.5 given the subdural hematoma and prior history of RP
bleed on coumadin
-Due to seizures, patient can NOT drive for at least six months
(earliest she could drive would be approximately [**2118-9-17**].
-Per neurology recommendations: if pt has seizures: if seizure
lasts 5 min, give Ativan 1mg. However, if self-resolved, give
300mg IV Dilantin and hold off on using Ativan.
Medications on Admission:
Aspirin 325mg PO qd
Atorvastatin 40 mg PO qd
Calcitriol
Colace
Lorazepam p.r.n.
Metoprolol 50mg PO qd
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
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 for constipation.
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
6. warfarin 2 mg Tablet Sig: One (1) Tablet PO [**Last Name (LF) **],[**First Name3 (LF) **],Sat for 3
months.
7. warfarin 1 mg Tablet Sig: One (1) Tablet PO Mon,Wed,[**Last Name (LF) **],[**First Name3 (LF) **]
for 3 months.
8. Outpatient Lab Work
INR, every other day until INR stable at range 2-2.5
9. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
10. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
14. cefazolin 1 gram Recon Soln Sig: Two (2) gram Intravenous
[**Last Name (LF) 33523**], [**First Name3 (LF) **] for 3 weeks: Please give during dialysis on Monday and
Tuesday.
15. cefazolin 1 gram Recon Soln Sig: Three (3) gram Intravenous
qFri for 3 weeks: Please give during dialysis on Friday.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Subdural Hematoma
Seizures
MSSA bacteremia
Renal Failure
Hypocalcemia
Acute anemia
Venous thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 33522**],
It was a privilege to provide care for you here at the [**Hospital1 1535**]. You were transferred here after
you had a seizure and a new brain bleed as well as bacteria in
your blood.
You were evaluated by the neurosurgeons who felt that you did
not need surgery. You did have seizures while you were admitted,
and you were evaluated by the neurologists as well. On
discharge, you should follow up with Dr. [**Last Name (STitle) **] and have a CAT
scan before the appointment as scheduled below.
The blood in your bacteria was thought to be from an infection
of your AV fistula graft. You went to the operating room and
part of the graft was removed. (You will follow up with
transplant surgery in [**3-20**] weeks to decide when you can have a
new one placed). We treated the infection with IV antibiotics
which you will continue on discharge to complete a 6 week
course. In the mean time, you will have dialysis through the
tunneled line.
In addition, we also found that you have a venous thrombosis in
your neck veins. We started you on anticoagulation and you
tolerated coumadin well in the hospital. You will continue the
treatment and have your coumadin level checked periodically.
We have made the following changes to your medications:
NEW:
-Cefazolin (for infection)
-Phenytoin (to prevent seizures)
-Senna (for constipation)
-Warfarin (for venous thrombosis)
CHANGED: None
STOPPED:
-Aspirin
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 33524**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 26774**]
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge.**
Department: TRANSPLANT CENTER
When: MONDAY [**2118-3-21**] at 8:30 AM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2118-3-22**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2118-4-12**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], 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: RADIOLOGY
When: TUESDAY [**2118-4-26**] at 10:00 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2118-4-26**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5856, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4368
} | Medical Text: Admission Date: [**2136-7-4**] Discharge Date: [**2136-7-16**]
Service: MEDICINE
Allergies:
Pronestyl / Quinidine / Clonidine / A.C.E Inhibitors /
Spironolactone / Flagyl / Levaquin / Compazine / Keflex
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
vomiting, diarrhea
Major Surgical or Invasive Procedure:
left IJ central venous catheter; PICC
History of Present Illness:
HPI: 86 y/o F h/o CAD, CHF, DM, AFib on coumadin, and chronic c.
diff colitis on PO vanco a/w vomiting and diarrhea x 2 days. She
began having more frequent formed BM's approx. 1 week PTA, at
which time the patient's daughter increased vancomycin from 250
mg daily to QID. However it is unclear whether this was given as
there was a new home health aide caring for the patient. 2 days
PTA she developed anorexia and nausea associated with poor oral
intake, had a few episodes of non-bloody vomiting and [**9-30**]
non-bloody episodes of diarrhea. Notably, she has not vomited
during past bouts of C. diff. She has not had fever, chills, URI
symptoms, abdominal pain, sick contacts, recent antibiotics
(other than PO vanco) or recent travel.
.
Over the past two weeks, she had had a [**12-21**] lb. weight gain and
has felt more lethargic, reportedly similar to how she has
during past episodes of fluid retention. Per the home health
aide, the patient has had more labored breathing and O2sats in
the low 90s on room air, requiring oxygen in the daytime, a rare
occurence for her. The daughter reports increasing her dose of
lasix to as much as 160 mg daily in an attempt to remove some
fluid. The patient has stable chronic 5-pillow orthopnea and
uses 2 L oxygen at night. She has not had dizziness,
lightheadedness, CP, palpitations, cough, SOB, or DOE. She was
seen in cardiology clinic the day prior to admission, at which
time routine labs revealed BUN 38/Cr 2.1/K 5.9. She was
instructed by her cardioligst's office to stop taking the [**Last Name (un) **],
potassium, and diuretics and to come to the ED.
.
In the ED, initially afebrile HR 83 BP 100/48 RR 20 O2sat 96% RA
100% 4LNC. She was reportedly guaiac negative. K+ peaked at 6.9
(D50 & insulin given) f/b 5.2. WBC 11.3 with 83% PMNs, no bands.
Lactate 5.5 f/b 4.1. INR 3.4. A left IJ was placed. She was
given just 1 L NS in light of severe systolic dysfunction. SBP
never dropped below 100, MAP ranged 55-78, with HR 50's-70's.
CVP ranged 6-11 cmH20, ScvO2 65-78. She had minimal urine
output. She was treated with IV flagyl for presumed C. diff
colitis, and IV ampicillin and cefepime for +U/A. CXR revealed
bilat effusions R>L and cephalization c/w CHF. Abd/pelvis CT w/o
contrast preliminarily showed intraperitoneal free fluid and
colonic wall thickening predominantly on the right c/w
third-spacing or infectious colitis. She was transferred to the
ICU for observation and further management of CHF and ARF.
.
In the ICU, patient had a TTE which showed worsening of her EF
to 15%, pulmonary hypertension, and severe aortic stenosis. On
[**7-8**], patient was started on hydralazine to decrease afterload.
On [**7-9**], lasix and albumin were added, and patient's UOP
increased to 40 cc/h. Patient's progress notes were reviewed.
Past Medical History:
1. CAD - s/p PCI with BMS [**8-20**]
2. CHF (LVEF 25% 10/06)
3. Rheumatic, multivalvular disease (mod AS, mod-severe AR)
4. Afib
5. CHB s/p pacemaker placement
6. IDDM
7. Hyperlipidemia
8. Dementia
9. HTN
10. h/o GI bleed
11. Hypothyroidism
12. Temporal arteritis
13. s/p R CEA
14. chronic c. diff colitis
15. CKD - b/l Cr. ~1.6
Social History:
Lives at home in [**Location (un) 745**], MA with 24[**Hospital 8018**] home health aid.
Daughter is very involved in her care as well. Retired
secretary/homemaker. Husband died in [**2131**]. She does not smoke
or drink ETOH.
Family History:
unknown.
Physical Exam:
V/S - T 95.9 HR 79 BP 143/39 RR 28 96% 2L CVP 7
GEN - Somnolent, but arousable; appears comfortable lying in bed
HEENT - PERRL; poor dentition; OP clear with dry MM
NECK - JVP to angle of jaw; L IJ with blood-stained dressing
CV - RRR nl S1S2 +S3 IV/VI syst ejec murmur @ base
PULM - decr. BS @ bases, no w/r/r
ABD - soft NTND +BS no rebound, guarding
EXT - warm, dry +distal pulses trace LE edema
NEURO - oriented to person, birthdate, hospital; not oriented to
month, year, president, [**Location 27224**]
Pertinent Results:
CXR - There is multichamber cardiomegaly with bibasilar
effusions and some upper lobe venous diversion. The findings are
suggestive of congestive heart failure. A left-sided unipolar
cardiac pacemaker is seen with the tip projected over the right
ventricle. There are degenerative changes noted in the thoracic
spine.
.
CT ABD/PELVIS w/o contrast (prelim) - large right pleural
effusion and small left effusion with right lower lobe opacity
could reflect atelectasis or pneumonia; intraperitoneal free
fluid and colonic wall thickening predominantly on the right,
could reflect third spacing other differential includes
infectious colitis, including C diff. Study not equipped for
evaluation of bowel ischemia due to lack of IV contrast which
remains in the differential
.
TTE [**7-5**] - The left atrial volume is markedly increased
(>32ml/m2). The right atrium is markedly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is severe regional left ventricular systolic dysfunction
with akinesis of the inferior wall, mild hypokinesis of the
basal inferolateral, lateral and anterolateral segments and
severe hypokinesis of the other segments. There are three aortic
valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The mitral valve shows
characteristic rheumatic deformity. Mild to moderate ([**12-21**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] Moderate to severe [3+] tricuspid regurgitation
is seen. There is severe pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is a small
posterior pericardial effusion. There are no echocardiographic
signs of tamponade. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
Compared with the prior study (images reviewed) of [**2134-9-21**],
overall LV systolic function may be slightly worse. The
esitmated pulmonary artery systolic pressures are now higher.
The degrees of valvular abnormalities are similar. There is a
small pericardial effusion seen on the current study that was
present on the prior but not mentioned in the report.
Brief Hospital Course:
A/P: 86 y/o F h/o CAD, CHF, DM, AFib hypertherapeutic on
coumadin, and chronic c. diff colitis on recently elevated dose
of PO vanco a/w vomiting and diarrhea with evidence of colitis,
and acute on chronic renal failure in the setting of escalating
diuresis.
.
#Acute on chronic renal failure - Patient presented with acute
on chronic renal failure. Her Cr has been steadily improving,
and yesterday, her Cr was 1.4 (baseline). Patient's UOP has been
increasing, and she put out 700 cc yesterday.
- Goal UOP >20-30 cc/h
- Holding K
- Continue Lasix 40 mg PO BID
- Begin Metolazone 2.5 mg daily
.
#Acute on chronic systolic heart failure - TTE revealed worsened
valve and LV function c/w exam [**9-24**]; substantial pleural
effusions but no respiratory compromise. CEs negative, ECG
unchanged, no new findings on TTE so unlikely recent ischemic
event precipiated this decompensation.
- Continue BB and [**Last Name (un) **], Lasix, and Metolazone
- Titrate O2 to maintain sat >92%.
- Continue digoxin
.
# possible Burisitis- patient with reproducible pain with
lifting left leg, but not with bending left knee localized to
top of femur, likely musculoskeletal, ordered x-rays soft
tissue/ bone to reassure daughter (no like pain in right leg)
- femur xr showed degenerative changes, f/u as outpt
.
#. UTI: Patient had a U/A yesterday which showed moderate
leukocytes, small blood, few bacteria, and <1 epi. Patient had
foley removed.
- unclear i/o's since pt is incontinent, but foley was removed
earlier due to possible UTI
- cipro given d [**2-20**]
.
# Bilat pleural effusion/RLL opacity - likely transudative
effusions in the setting of decompensated CHF, cannot exclude
underlying PNA but low suspicion since no fever or leukocytosis;
stable resp. status on minimal O2 requirement
-no indictation for ABX for now (esp. in light of h/o c. diff)
-blood Cx still pending
.
#N/V/D - suspect viral etiology as has not had vomiting with
prior episodes of c. diff; no c/o pain, benign abdominal exam,
and supratherapeutic INR makes ischemia/thrombosis less likely;
lactate trending down. [**Month/Day (4) **] negative x3.
- Continue PO vanco qday.
.
#Anemia - Hct 32, b/l ~38; no s/sx bleeding but GI tract most
likely source; has polyps on prior colonoscopies; on Fe
replacement for chronic anemia, likely element of ACD as well.
Hct today was 27.1.
- Transfuse for Hct <21%
- Monitor daily Hct
- Guiac stools \, on d.c, guiac negative, h/h has significant
lab variation, no clincal problems
.
#AFib - V-paced
-holding coumadin with supratherapeutic INR
.
#DM -
-[**12-21**] basal insulin + RISS while NPO, f/b full dose NPH when
eating
.
#CAD - no ischemic changes on EKG and negative troponins x3
-cont. ASA, B-blocker
.
#HTN -
- Cont. carvedilol and restart [**Last Name (un) **] for HTN, afterload reduction
.
#Hypothyroidism
- Cont. thyroxine
- TSH, free T4 WNL
.
# SW issues/ elder abuse - Her daughter would like for her to
live with her again and will be hiring two caretakers to watch
over the patient. There will be a family meeting on Monday
morning with the Social Worker and team to reinforce the fact
that the patient's meds should not be changed arbitrarily.
- However, her daughter thought this was a [**Name (NI) **] flair, and
increased her Flagyl to TID instead of qday (without medical
authorization). She had also increased the patient's furosemide
without medical consent (to ~80 [**Hospital1 **]).
.
#F/E/N-slightly better PO intake
- Cardiac diet, with supplements
- Monitor lytes [**Hospital1 **]
- Encourage PO entake. [**Month (only) 116**] require tube feeds if caloric intake
does not increase
.
#PPx - PPI, INR ok, supratheraputic heparin, D/c'ed , no need
for bowel regimen
.
#Access - 2 PIV, PICC (d/c'ed PICC on 7.28)
.
#Contact - Daughter [**First Name8 (NamePattern2) **] [**Known lastname 100724**] [**Telephone/Fax (1) 100725**]
.
#CODE STATUS - FULL
.
# Disposition: To Rehab. Patient is unable to pivot while
working with PT and will require more than 2 caretakers.
- outpatient f/u, PCP [**Name9 (PRE) **],[**First Name3 (LF) 251**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 100755**], appt for
tues, [**7-24**] 11:20am
- [**Doctor Last Name **] cardiology f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 696**] [**10-18**] 11:40 [**Telephone/Fax (1) 62**]
Medications on Admission:
ASA 81 mg daily
CALCIUM-CHOLECALCIFEROL 500 mg (1,250 mg)-400 unit- [**Unit Number **] daily
CALCITONIN 200 U 1 spray once a day
CARVEDILOL 6.25 mg [**Hospital1 **]
COUMADIN 5 mg daily
DIGOXIN .0625 mg daily
DONEPEZIL 10 mg daily
FERROUS SULFATE 325 mg daily
FUROSEMIDE 60 mg daily
INSULIN NPH - 12 units once a day
INSULIN LISPRO [HUMALOG] daily before breakfast per SS
LATANOPROST [XALATAN] - 0.005 % - 1 drop both eyes at bedtime
LEVOTHYROXINE 112 mcg daily
LIPITOR 10 mg daily
LOSARTAN 25 mg daily
METOLAZONE 2.5 mg daily
POTASSIUM CHLORIDE 70 mEq
PROTONIX 40 mg daily
SACCHAROMYCES BOULARDII - 500 mg [**Hospital1 **]
SERTRALINE [ZOLOFT] 75 mg qHS
VANCOMYCIN 250 mg daily (was increased to 250 mg QID)
Discharge Medications:
1. Outpatient Physical Therapy
Please evaluate and treat as needed.
2. Mattress [**Last Name (un) 100756**]
Please provide mattress [**Last Name (un) **] that fits home hospital bed to
help alleviate and avoid skin breakdown
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Primary: Acute renal failure, chronic renal disease,
1. CAD - s/p PCI with BMS [**8-20**]
2. CHF (LVEF 25% 10/06)
3. Rheumatic, multivalvular disease (mod AS, mod-severe AR)
4. Afib
5. CHB s/p pacemaker placement
6. IDDM
7. Hyperlipidemia
8. Dementia
9. HTN
10. h/o GI bleed
11. Hypothyroidism
12. Temporal arteritis
13. s/p R CEA
14. chronic c. diff colitis
15. CKD - b/l Cr. ~1.6
Discharge Condition:
stable
Discharge Instructions:
You have been admitted for vomiting, diarrhea and chest pain.
You were also found to be in worsened kidney failure. You were
treated with fluid, medications and antibiotics. Once improved
you are now being discharged home for further recovery. We
discussed that you may benefit from a short stay at rehab, but
you have opted to go home with 24 hour care which is reasonable
as well. You will continue to have VNA and home PT services at
home.
Your medications have been adjusted while inpatient. Take all
medications as prescribed. Most importantly, you should be on
Lasix 40 mg by mouth twice daily and Metolazone 2.5 mg by mouth
daily.
All medication changes must be confirmed by medical specialist.
Do not adjust medications on your own.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L
Please keep all outpatient appointments.
Return to the hospital if you notice fevers,
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2136-7-24**] 11:20
Provider: [**Name10 (NameIs) **] FERN, RNC Date/Time:[**2136-7-31**] 11:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2136-10-10**] 11:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**], MD Date/Time: [**2136-10-18**] at 11:40
Completed by:[**2136-7-16**]
ICD9 Codes: 5849, 5990, 5119, 4280, 2449, 2724, 4168, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4369
} | Medical Text: Admission Date: [**2159-10-15**] Discharge Date: [**2159-10-23**]
Date of Birth: [**2096-4-23**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Nsaids
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
tracheostomy
History of Present Illness:
This is a 63 year-old man who is well known to the Transplant
service. He underwent a liver transplant in [**5-/2158**] for EtOH
and HCV cirrhosis. His post operative course was complicated by
a wound dehiscence and respiratory failure.
At rehabilitation he had his tracheostomy tube removed over the
subsequent 48 hours developed respiratory failure. He
presented to an outside hospital where an endotracheal tube was
place and was transfered to the [**Hospital1 18**] for management. Of note
he had a tracheal stenosis identified at bronchoscopy in [**Month (only) 216**]
of [**2158**] which was due to subglottic grannulation tissue. The
stenosis was determined to have caused a 90% stenosis. The
granulation tissue was resected by the interventional
pulmonoology service at the [**Hospital1 18**].
Past Medical History:
OLT [**2158-5-22**] c/b wound infection
HCV
DM II
Esophageal varices
BPH
Bipolar d/o
Heart Failure
Social History:
Quit ETOH 17yrs ago
Quit tobacco 8yrs ago
No illicit drug use
Divorced, lives alone
Family History:
Noncontributory
Physical Exam:
On admission to the [**Hospital1 18**], the patient was afebrile. He was
intubated and in no apparent distress or discomfort. His chest
was clear to auscultation bilaterally. His abdomen was soft and
non tender. His extremities were warm and well perfused.
Pertinent Results:
[**2159-10-15**] 08:18PM TYPE-ART PO2-97 PCO2-30* PH-7.40 TOTAL
CO2-19* BASE XS--4 INTUBATED-INTUBATED
[**2159-10-15**] 08:18PM TYPE-ART PO2-97 PCO2-30* PH-7.40 TOTAL
CO2-19* BASE XS--4 INTUBATED-INTUBATED
[**2159-10-15**] 06:48PM ALT(SGPT)-20 AST(SGOT)-15 ALK PHOS-148*
AMYLASE-67 TOT BILI-0.3
[**2159-10-15**] 06:48PM WBC-5.1 RBC-3.57* HGB-10.3* HCT-29.8* MCV-83#
MCH-28.9 MCHC-34.6 RDW-14.7
[**2159-10-23**] 05:13AM BLOOD WBC-3.6* RBC-3.27* Hgb-9.1* Hct-27.5*
MCV-84 MCH-28.0 MCHC-33.1 RDW-13.9 Plt Ct-95*
[**2159-10-23**] 05:13AM BLOOD Glucose-180* UreaN-24* Creat-1.3* Na-145
K-4.3 Cl-106 HCO3-32 AnGap-11
[**2159-10-23**] 05:13AM BLOOD ALT-23 AST-15 AlkPhos-352* TotBili-0.2
Brief Hospital Course:
The patient was admitted to the [**Hospital1 18**] surgical ICU on [**2159-10-15**].
During his hospitalization a Thoracic Surgery consult was
obtained. It was likely that the cause of his respiratory
failure was due to mechanical obstruction. A sputum culture
from HD 2 showed Pseudomonas, which was considered to be a
contaminant. On HD 3, a post-pyloric feeding tube was placed
for nutritional support. His goal feeding rate was determined
to be 65 cc/hour of Respolar, which would give him 2371 kcals,
and 117g protein. On HD 4, the patient underwent an open
tracheostomy by the Thoracic surgery service. His tube feeds
were restarted on POD 1. The patient was kept at [**Hospital1 18**] for
increased secretions requiring frequent suction. On POD 4, the
patient was started on Ceftazidime for presumed pneumonia
diagnosed by chest X-ray and clinical presentation (low grade
temperature of 100.1 and no WBC count, but increased
secretions). On POD 5, he was evaluated for a Passy-muir valve
but he did not tolerate the procedure well because of excessive
coughing and difficulty swallowing his secretions. Please see
the recommendations of the speech and swallow team for more
detail. The remainder of his post-operative course was
uneventful and he returned to rehabilitation in stable condition
on POD 5.
Medications on Admission:
rapamune 5', MMF 500'''', prednisone 5', risperidol 1.5 HS,
amlodipine 10', lorazepam 0.5'' PRN
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day).
2. Loperamide 1 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily).
3. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO BID (2
times a day).
4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
5. Risperidone 1 mg/mL Solution Sig: One (1) PO HS (at
bedtime).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Albuterol Sulfate 0.083 % Solution Sig: [**12-10**] Inhalation Q4H
(every 4 hours) as needed.
8. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Sirolimus 1 mg/mL Solution Sig: One (1) PO DAILY (Daily).
12. Prednisone 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Mycophenolate Mofetil 200 mg/mL Suspension for
Reconstitution Sig: One (1) PO QID (4 times a day).
14. Lansoprazole Oral
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
18. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed.
19. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours).
20. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: One
(1) Intravenous Q12H (every 12 hours) for 8 days.
Disp:*16 32g* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
respiratory failure
liver failure; s/p liver transplant
Discharge Condition:
stable
Discharge Instructions:
Tracheostomy tube is to remain in place.
A speaking valve may be used.
Followup Instructions:
Please call Dr/ [**Doctor Last Name **] office as needed with any questions
Completed by:[**2159-10-23**]
ICD9 Codes: 486, 4280, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4370
} | Medical Text: Admission Date: [**2168-8-16**] Discharge Date: [**2168-9-3**]
Date of Birth: [**2104-9-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
63 y/o male s/p CABG on [**2168-7-26**], d/c'd to rehab on [**8-3**].
Re-admitted on [**8-16**] with sternal wound drainage.
Major Surgical or Invasive Procedure:
bedside excisional debridement of sternal wound
History of Present Illness:
s/p cabg, discharged to rehab, began to have sternal wound
drainage, managed w/antibiotics, did not improve. re-admitted
for IV antibiotics and wound debridement
Past Medical History:
CAD: [**2158**]- stent to prox RCA; [**2161**]-MI with 2 RCA stents; [**2164**] -
MI with PTCA and stent to 90% mid LAD lesion and PTCA to D2;
[**2-25**] - PTCA and brachytherapy to mid-LAD; stents to diag and OM1
branch; [**2166**] - at [**Hospital3 **] - 60% LAD stenosis, no stent
placed.
HTN
morbid obesity
CVA (right MCA) [**2154**] s/p RCEA
NIDDM
COPD
OSA on CPAP
Social History:
Previous Hospitalization: none
Suicide attempts: in [**2155**] after having a stroke, he placed a
shotgun at his chin, pointing upwards, and pulled the trigger,
but the safety was still on, for which he was later grateful.
Assaultive behavior: none
Current treaters: none in mental health
Medication trials: none prior to zoloft
SUBSTANCE ABUSE HISTORY:
EtOH: denies ever using, abstinent his entire life secondary to
hearing other people??????s problems with alcohol
Smoked cigarettes x 20 years, quit 30 years ago
Denies heroin, MJ, cocaine, and all other recreational drugs.
Family History:
non-contributory
Physical Exam:
Sternal wound with erythema, small area of dehiscence, 2+
peripheral edema, exam otherwise unremarkable
Brief Hospital Course:
Admitted on [**2168-8-16**], underwent excisional wound debridement at
bedside, started on IV Vancomycin, and po Levofloxacin. Had
remained hemodynamically stable, progressing with wound care and
antibiotics, being diuresed. On [**2168-8-21**], he had a cardiac
arrest, exhibited by bradycardia progressing rapidly to
asystole. ACLS protocol was initiated, he was intubated, and
transferred to the ICU. He did not wake up appropriately
post-code, and a neurology consult was called. It was felt that
he's suffered a significant CVA during the time of his arrest.
He remained fully ventilated, and hemodynamically stable over
the next few days, but showed no signs of neurologic
improvement. The neurology service believed that he was at best
to remain in a chronic vegetative state. This was discussed
with patient's wife (and other family members). They initially
wanted to give him some more time, an dnot withdraw support.
But, as no neurologic improvement was seen, on [**9-3**],
the patient's wife requested that his ventilator support and
endotracheal tube be discontinued, and that no resuscitative
measures be instituted. He was extubated at 1600, and became
apneic a few hours later. He expired at 2055.
Medications on Admission:
Protonix
ASA
Lipitor
Seroquel
Zetia
Albuiterol
Atrovent
Iron
Vitamins
Carvedilol
Lasix
Insulin
Tylenol
Levaquin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
Sternal wound infection
CVA
anoxic brain injury
Discharge Condition:
expired
Followup Instructions:
n/a
Completed by:[**2168-9-3**]
ICD9 Codes: 4275, 5119, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4371
} | Medical Text: Admission Date: [**2120-4-11**] Discharge Date: [**2120-4-17**]
Date of Birth: [**2093-2-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Elective right heart cath
Major Surgical or Invasive Procedure:
Cardiac catheterization
Central line placement
History of Present Illness:
Patient is a 27 yo man with h/o adriamycin induced
cardiomyopathy who now presents with cardiogenic shock. He was
diagnosed with AML at age 11, at which time he received
intensive chemotherapy, including adriamycin, and apparently
developed heart failure during induction. He was successfully
medically treated for many years with ACE I, and remained quite
active, playing many sports.
He was referred to Dr. [**Last Name (STitle) 171**] in [**7-25**] for follow up of his
cardiomyopathy, at which time he was maintained on his ACE I and
started on a beta blocker. Holter monitoring at this time also
showed only minimal atrial and ventricular ectopy. ECHO at that
time demonstrated mildly dilated LV cavity, EF 20-25%, trivial
MR.
.
Over the past 3 weeks, the patients symtpoms have worsened. He
was in his USOH (very active, no DOE, orthopnea, etc.) until
approx 3 weeks ago when he experienced "a cough and cold".
Denies fevers during this time, but describes a non-productive
cough, + DOE with stairs mainly (becomes dyspnic w/ climbing [**12-23**]
flights of stairs), and + orthopnea. These symptoms occurred
over a 3 day period, and he had a CXR done that demonstrated CHF
- he was hospitalized three weeks ago for CHF, at which time he
was started on a diuretic (aldactone) in addition to the beta
blocker and ace inhibitor. However, since discharge he has
reported continued symptoms, inlcuding decreased appetite,
headaches, GI symptoms including loose stools, and a general
fatigue, along with continued DOE and orthopnea. He saw Dr.
[**Last Name (STitle) 171**] in clinic for these symptoms, at which time his systolic
blood pressure was in the 80??????s (baseline SBP 100), he was
tachycardic, and his JVP as elevated. He therefore was referred
in for a right heart catheterization.
.
Right heart catheterization performed today [**2120-4-11**] demonstrated
mixed venous of 35, CI 1.1. With milrinone mixed venous 56, CI
2.2. Currently patient feels "fine". Denies any SOB, any other
complaints at this time.
Past Medical History:
Acute Myelogenous Leukemia
Cardiomyopathy
Androgen Insuffiency s/p testicular replase of AML
Social History:
He is originally from [**Location (un) **]. He is a post doctorial candidate
and employed at a local [**Location (un) **]. He is single and lives with
fraternity brothers. [**Name (NI) **] does not smoke or drink.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T BP 106/80 HR 106 RR 16 O2 99% 2L NC
Gen: WDWN young male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with elevated JVP per report (could not assess as
pt had to remain flat after cath).
CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi to ascultation of anterior and lateral lung
fields (could not ascultate posteriorly as pt had to remain flat
post cath).
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. R femoral with bandage in
place, no bleeding/eccymoses/bruit/hematoma.
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:
2D-ECHOCARDIOGRAM performed on [**2120-3-20**] demonstrated:
Conclusions:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 11-15mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. There is severe
global left ventricular hypokinesis. No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. There is mild global right ventricular free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**11-21**]+) mitral regurgitation is seen.
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2119-7-17**],
the LV cavity appears more dilated and the mitral regurgitation
has increased.
IMPRESSION: Severe, dilated cardiomyopathy.
.
CARDIAC CATH performed on [**2120-4-11**] demonstrated:
HEMODYNAMICS:
CI: 1.05, On milrinone 2.11
.
Baseline pressures:
RA Pressure: 26
RV Pressure: 60/14
PCWP: 34
LV Presure: 98/18
LVEDP: 37
AO: 103/82
SVO2: 37%
.
Abdominal US [**2120-4-12**]:
The study is limited due to patient's clinical condition. The
liver appears homogeneous, without evidence of focal lesion. The
gallbladder is normal without evidence of gallstones. No
evidence of intra- or extra- hepatic biliary ductal dilatation,
and the common duct measures 2 mm. The main portal vein is
patient with antegrade flow. The pancreas is not visualized due
to overlying intestinal gas. The spleen is normal in size and
echogenicity. The aorta is normal in caliber throughout.
Bilateral small pleural effusions are noted. No evidence of
free fluid within the abdomen.
.
Carotid US [**2120-4-12**]:
No plaque and no hemodynamically significant stenosis in either
carotid.
.
Chest X-ray [**2120-4-16**]:
FINDINGS: Again noted is a Swan-Ganz catheter from a right
internal jugular approach stable in course and position with the
distal tip in the right main pulmonary artery. The lungs remain
clear and appropriately expanded. No effusion or pneumothorax
is evident. Bony bridging is again evident between the left
first and second ribs.
IMPRESSION: Stable examination with no acute pulmonary process.
PA catheter stable in course and position.
.
Microbiology Data:
SEROLOGIES ([**2120-4-11**]):
Varicella IgG - equivocal
CMV IgG and IgM - negative
EBV IgG positive, IgM negative
Toxoplasma IgG and IgM - negative
.
Urine culture [**2120-4-11**] - negative
.
Pertinent pre-tranplant laboratory data:
[**2120-4-16**] 06:30AM BLOOD WBC-6.4 RBC-4.46* Hgb-14.5 Hct-42.4
MCV-95 MCH-32.4* MCHC-34.1 RDW-14.6 Plt Ct-252
[**2120-4-16**] 06:30AM BLOOD PT-12.4 PTT-29.3 INR(PT)-1.1
[**2120-4-11**] 03:56PM BLOOD Ret Aut-3.3*
[**2120-4-11**] 03:56PM BLOOD Fibrino-388
[**2120-4-16**] 06:30AM BLOOD Glucose-97 UreaN-18 Creat-0.9 Na-139
K-4.8 Cl-102 HCO3-27 AnGap-15
[**2120-4-11**] 03:56PM BLOOD ALT-47* AST-27 LD(LDH)-231 CK(CPK)-53
AlkPhos-143* Amylase-40 TotBili-1.1
[**2120-4-11**] 03:56PM BLOOD Lipase-38
[**2120-4-11**] 03:56PM BLOOD TotProt-6.9 Albumin-4.5 Globuln-2.4
Calcium-9.2 Phos-4.1 Mg-1.9 Cholest-152
[**2120-4-11**] 03:56PM BLOOD Triglyc-219*
[**2120-4-11**] 03:56PM BLOOD TSH-3.4
[**2120-4-11**] 03:56PM BLOOD T4-6.1 calcTBG-0.91 TUptake-1.10
T4Index-6.7 Free T4-1.3
[**2120-4-11**] 03:56PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2120-4-11**] 03:56PM BLOOD PSA-1.1
[**2120-4-11**] 03:56PM BLOOD HIV Ab-NEGATIVE
[**2120-4-11**] 03:56PM BLOOD HCV Ab-NEGATIVE
Brief Hospital Course:
Pt is a 27 yo man with history of severe cardiomyopathy
secondary to adriamycin as child, now presents with subacute
heart failure (x past 3 weeks) found to be in severe
cardiomyopathy with cardiac index of 1.1 based on right heart
cath [**2120-4-11**].
.
1) Pump/Cardiomyopathy: Patient has a history of severe
cardiomyopathy secondary to adriamycin as child, last ECHO
[**2120-3-20**] showed EF of 15%. He is on toprol XL, lisinopril, and
aldactone as an outpatient. Had recent hospitalization for CHF,
now presents for elective cardiac cath after experiencing
worsening dyspnea on exertion, fatigue and decreased appetite.
On right heart catheterization the patient was noted to have
severe heart failure with depressed cardiac output and cardiac
index was noted to be 1.1 with a pulmonary capillary wedge
pressure of 37 consistent with cardiogenic shock. The patient
was started on milrinone in cath lab with increase of CI from
1.1 to 2.11 and was admitted to the CCU for further treatment
with swan catheter in place. After his initial response to
milrinone this was continued with symptomatic improvement -
however overnight his first night of hospitalization, his CI
trended down to 1.35 despite uptitrating milrinone. His SVR was
also significantly elevated to >[**2112**] and his PCWP also remained
elevated. He was transitioned to dobutamine with improvement in
CI to 2.4. His PVR normalized on dobutamine. Additionally, he
was given IV lasix prn which brought his PCWP down to within
normal range. Captopril was started for afterload reduction and
weaning dobutamine was attempted. Digoxin was also added to his
medication regimen and his outpatient aldactone was restarted.
Repeated attempts were made to wean off the dobutamine drip, as
his captopril was uptitrated. However, with each attempt at
weaning the dobutamine, his cardiac index would fall to < 1.8.
He was therefore remained on dobutamine drip at 1.0-1.5 and
captopril dose at 100mg TID at time of transfer (along with
aldactone 25 mg daily and digoxin 125mcg daily - no beta blocker
was started given his continued poor cardiac output).
Otherwise the patient was evaluated by the electrophysiologist
cardiologists for ?ICD placement, which was deferred at this
time.
Transplant work up was initiated during his hospital course, and
he had the required serologies and laboratory tests sent, had an
ECHO from his prior hospitalization in [**3-25**], had carotid and
abdominal ultrasounds performed. He has not yet had a
psychiatry or dental consult or pulmonary function tests. He
was transferred to [**Hospital 4415**] for continued
pre-tranplant work up to be placed on the transplant list.
.
2) Rhythm: Patient was monitored on telemetry and remained in
sinus tachycardia throughout his hospital course (HR usually
remained between 100-110). His sinus tachycardia was felt to be
due to compensatory mechanisms given his severe cardiomyopathy.
Given his stable, low EF of 15% he qualified for ICD placement -
this was evaluated by the EP service, but was deferred at this
time.
.
3) History of Androgen Insufficiency: This is secondary to his
prior leukemia and chemotherapy. He was continued on his
outpatient androgen gel.
.
4) Fluids/Electrolytes/Nutrition: He was maintained on a low
sodium diet, his electrolytes were monitered and potassium
repleted to 4.0 and magnesium repleted to 2.0.
.
5) Prophylaxis: He remained on SC heparin for prophylaxis.
.
6) Access: Right IJ central line.
.
7) Code: Full
Medications on Admission:
Toprol XL 25 mg daily
Lisinopril 10 mg daily
Aldactone 25 mg daily
Testim Gel 1% apply 5g daily to skin
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Dobutamine in D5W 1,000 mcg/mL Parenteral Solution Sig: As
needed mcg/mL Intravenous TITRATE TO (titrate to desired
clinical effect (please specify)): Titrate to Cardiac Index >
1.8.
4. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection three times a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
1. Cardiomyopathy s/p daunorubicin
2. CHF with LVEF 15% secondary to cardiomyopathy
.
Secondary Diagnosis:
1. H/o AML
2. Androgen insufficieny
Discharge Condition:
Afebrile. Hemodynamically stable on dobutamine.
Discharge Instructions:
You were admitted to the hospital following cardiac
catheterization which found that you were in severe heart
failure. You were given IV medications to help your heart
function, which were maintained during your hospital course.
You were transferred to [**Hospital 4415**] for further
cardiac tranplant work up.
.
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
spontaneous bleeding or any other concerning symptoms.
.
Please take all your medications as directed.
.
Please keep you follow up appointments as below.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2120-4-22**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2120-4-17**] 11:30
Please contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] on discharge from [**Hospital1 336**] to discuss
plans for ICD placement.
ICD9 Codes: 4254, 4168, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4372
} | Medical Text: Admission Date: [**2136-6-4**] Discharge Date: [**2136-6-15**]
Date of Birth: [**2079-2-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Morphine / Codeine / Lipitor / erythromycin /
Clindamycin / Chlorhexidine / Iodine-Iodine Containing /
adhesive tape / Darvocet-N 100
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Palpitations and syncope
Major Surgical or Invasive Procedure:
[**2136-6-4**] Aortic Valve Replacement (19mm St. [**Male First Name (un) 923**] mechanical),
Mitral Valve Repair (30mm annuloplasty ring), Excision of
[**Company 1543**] Reveal Device from left anterior chest
History of Present Illness:
This is a 54 year old female with significant medical history of
mitral valve prolapse and moderate mitral regurgitation. This
was initially diagnosed 20 years ago when it was picked up on an
echocardiogram which was done in preparation for gynecologic
surgery. Since that time she has been followed with serial
echocardiograms with her most recent showing moderate to severe
mitral regurgitation with increasing LV dimensions. Cardiac cath
in [**Month (only) 547**] showed clean coronaries.
Past Medical History:
-Mitral valve (bileaflet) prolapse and Moderate Mitral
regurgitation
-Longstanding history of palpitations, status post recent
electrophysiology study with subsequent diagnosis of AVNRT
- Ventricular tachycardia
-Pericarditis (Small pericardial effusion) [**2133-8-18**]
-Hyperlipidemia (Elevated Total cholesterol and HDL)
-[**2115**] Endometriosis s/p Total abdominal hysterectomy
-[**2125**] Vaginal Cancer s/p radiation
-Frequent bowel obstruction d/t adhesions from XRT and abdominal
surgeries.
-Recurrent Stomach ulcers
-Gastroesophageal reflux disease and gastric ulcers
-Frequent bowel obstructions
-Atypical tuberculosis in the lung
-Dyslipidemia
-MUGS-abnormal low white blood cell count and low protein.
Followed by Dr. [**Last Name (STitle) 410**] (Heme/Onc)
-Complex migraines
-Syncopal episodes
-[**11/2134**] Lyme disease s/p 6 week treatment with Doxycycline
-Glaucoma
-Seasonal allergies
-Bronchitis
Past Surgical History:
-Tonsillectomy as a child
-Appendectomy as a child
-Right elbow surgery after a fall s/p three surgeries
-s/p TAH
-s/p 7 gynecological surgeries
-s/p Bowel resection
-Reveal implant in left upper chest
Social History:
Lives with: Mother and sister
Occupation: Disability
Tobacco: Never
ETOH: Denies ETOH or illicit drug use
Family History:
Non-contributory
Physical Exam:
Pulse: 92 Resp: 18 O2 sat: 100%
B/P 146/77
Height: 5'7" Weight: 115 lbs
General: WDWN in NAD
Skin: Warm, Dry, intact. No lesions or rashes. Well healed
abdominal incisions. Left upper chest Reveal Monitor noted
subcutaneously.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign. Teeth in
good repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, II/VI holosystolic murmur, Nl S1-Split S2 vs S3
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right: None Left: None
Pertinent Results:
[**2136-6-4**] TEE: Pre CPB: No spontaneous echo contrast or thrombus
is seen in the body of the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. Overall left ventricular systolic
function is normal (LVEF>55%). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. Moderate (2+) aortic regurgitation is seen. There is
moderate bileaflet mitral valve prolapse. Severe (4+) mitral
regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the
results. Post CPB: The patient is in sinus rhythm with a cardiac
output of 4.9L/min on a phenylephrine infusion. The
biventricular systolic function is preserved. There is a mitral
annuloplasty ring seen. There is trivial MR, the mean/peak
gradient across the mitral valve are 4/8mmHg. There is a well
seated mechanical valve in the aortic position. Both leaflets
are seen to move freely, washing jets are noted. The mean/peak
gradients across the aortic valve are 16/30mmHg. The visible
contours of the thoracic aorta are intact.
[**2136-6-4**] 11:15AM BLOOD WBC-5.3# RBC-2.86*# Hgb-8.8*# Hct-25.7*#
MCV-90 MCH-30.7 MCHC-34.2 RDW-13.5 Plt Ct-130*
[**2136-6-7**] 09:58PM BLOOD WBC-7.0 RBC-3.09* Hgb-9.5* Hct-27.1*
MCV-88 MCH-30.7 MCHC-35.1* RDW-14.0 Plt Ct-113*
[**2136-6-14**] 02:02AM BLOOD WBC-5.5 RBC-3.09* Hgb-9.0* Hct-27.5*
MCV-89 MCH-29.0 MCHC-32.5 RDW-14.0 Plt Ct-396
[**2136-6-4**] 11:15AM BLOOD PT-15.8* PTT-30.5 INR(PT)-1.4*
[**2136-6-7**] 01:14PM BLOOD PT-61.0* INR(PT)-6.7*
[**2136-6-8**] 06:04PM BLOOD PT-14.1* PTT-29.8 INR(PT)-1.2*
[**2136-6-13**] 04:15AM BLOOD PT-19.2* PTT-69.0* INR(PT)-1.7*
[**2136-6-14**] 02:02AM BLOOD PT-20.2* PTT-87.2* INR(PT)-1.8*
[**2136-6-14**] 08:43AM BLOOD PT-20.3* PTT-64.5* INR(PT)-1.9*
[**2136-6-4**] 12:55PM BLOOD UreaN-10 Creat-0.6 Na-145 K-3.6 Cl-117*
HCO3-23 AnGap-9
[**2136-6-14**] 02:02AM BLOOD Glucose-115* UreaN-11 Creat-0.7 Na-142
K-4.8 Cl-104 HCO3-32 AnGap-11
[**2136-6-7**] 09:58PM BLOOD ALT-25 AST-36 LD(LDH)-333* AlkPhos-50
Amylase-144* TotBili-0.4
[**2136-6-14**] 02:02AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.7*
[**2136-6-15**] 03:03AM BLOOD PT-23.4* INR(PT)-2.2*
Brief Hospital Course:
The patient was brought to the operating room on [**2136-6-4**] where
he underwent an Aortic Valve Replacement (mechanical), Mitral
Valve repair and excision of Reveal device from left chest.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Post-op day one
he was weaned from sedation, extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact and
hemodynamically stable, weaned from inotropic and vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. She briefly
went into Atrial Fibrillation and converted to sinus rhythm.
Coumadin was started with a Heparin bridge. She had quick
increase in INR on [**6-7**] to 6.7 which was treated with FFP and
Vitamin K. INR trended down and Coumadin was titrated for goal
INR for mechanical valve. Titration of her Coumadin for a goal
INR took much longer than expected and she wasn't discharged
until post-op day 11. The patient was discharged to home in
[**State 5887**] in good condition with appropriate follow up
instructions. Follow up appointments scheduled in [**State 5887**].
Target INR 2.5-3.0 for mechanical AVR. First blood draw [**2136-6-16**].
Coumadin to be managed through Dr.[**Name (NI) 5572**] office over
weekend, then Dr. [**Last Name (STitle) 28224**] will take over on Monday, [**2136-6-18**].
Medications on Admission:
BUTALBITAL-ACETAMINOPHEN-CAFF [ESGIC] - (Prescribed by Other
Provider) - 50 mg-325 mg-40 mg Capsule - one Capsule(s) by mouth
twice a day to three times a day
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution -
injection of 1000 ug once a month
LATANOPROST [XALATAN] - 0.005 % Drops - one drop conjunctiva
daily
MOM[**Name (NI) **] [NASONEX] - (Prescribed by Other Provider) - 50 mcg
Spray, Non-Aerosol - one spray(s) nasally daily - No
Substitution
MONTELUKAST [SINGULAIR] - 10 mg Tablet - one Tablet(s) by mouth
daily
ONDANSETRON HCL - (Prescribed by Other Provider) - 4 mg Tablet
- one Tablet(s) by mouth three times a day breakfast, before
dinner and at bed
PANTOPRAZOLE - (Dose adjustment - no new Rx) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth at breakfast, one
tablet before dinner and one before bed
SUCRALFATE - 1 gram Tablet - one Tablet(s) by mouth four times a
day
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA CONCENTRATED] - 2,400
mg/10 mL Suspension - 3 tbs by mouth nightly
MULTIVITAMIN [CHEWABLE-VITE] - Tablet, Chewable - one
Tablet(s) by mouth daily
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): both eyes.
Disp:*2 bottles* Refills:*1*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
5. 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:*1*
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): may
resume pre-op schedule of dosing.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*1*
10. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dr.
[**Last Name (STitle) 28224**] to manage for goal INR 2.5-3.0, dose may change daily.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Labs: PT/INR
Coumadin for mechanical Aortic Valve
Goal INR 2.5-3.0
First draw [**2136-6-16**] (results to [**Telephone/Fax (1) 170**] over weekend)
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28224**]/coumadin
clinic Results to phone [**Telephone/Fax (1) 111495**]
12. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for rash: DO NOT USE ON CHEST.
Disp:*qs * Refills:*0*
13. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
Q4H (every 4 hours) as needed for itching.
Disp:*QS * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Health Systems
Discharge Diagnosis:
Aortic Insufficiency s/p Aortic Valve Replacement
Mitral Regurgitation s/p Mitral valve repair
Post-op A Fib
PMH:
-Mitral valve (bileaflet) prolapse and Moderate Mitral
regurgitation
-Longstanding history of palpitations, status post recent
electrophysiology study with subsequent diagnosis of AVNRT
- Ventricular tachycardia
-Pericarditis (Small pericardial effusion) [**2133-8-18**]
-Hyperlipidemia (Elevated Total cholesterol and HDL)
-[**2115**] Endometriosis s/p Total abdominal hysterectomy
-[**2125**] Vaginal Cancer s/p radiation
-Frequent bowel obstruction d/t adhesions from XRT and abdominal
surgeries.
-Recurrent Stomach ulcers
-Gastroesophageal reflux disease and gastric ulcers
-Frequent bowel obstructions
-Atypical tuberculosis in the lung
-Dyslipidemia
-MUGS-abnormal low white blood cell count and low protein.
Followed by Dr. [**Last Name (STitle) 410**] (Heme/Onc)
-Complex migraines
-Syncopal episodes
-[**11/2134**] Lyme disease s/p 6 week treatment with Doxycycline
-Glaucoma
-Seasonal allergies
-Bronchitis
Past Surgical History:
-Tonsillectomy as a child
-Appendectomy as a child
-Right elbow surgery after a fall s/p three surgeries
-s/p TAH
-s/p 7 gynecological surgeries
-s/p Bowel resection
-Reveal implant in left upper chest
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2136-6-28**], 1:30
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28224**] [**Telephone/Fax (1) 111495**] [**6-26**] @ 12:30
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22311**] [**Telephone/Fax (1) 111496**] [**6-18**], 9:25am
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for mechanical Aortic Valve
Goal INR 2.5-3.0
First draw [**2136-6-16**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28224**]/coumadin
clinic
Results to phone [**Telephone/Fax (1) 111495**]
**Please call INR results to Dr.[**Name (NI) 5572**] office over weekend
[**Date range (1) 7218**]***
Completed by:[**2136-6-15**]
ICD9 Codes: 4241, 4240, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4373
} | Medical Text: Admission Date: [**2180-1-2**] Discharge Date: [**2180-2-9**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
left carotid stenosis
symptomatic fem-tibial ASO with arterial insuffiency
Major Surgical or Invasive Procedure:
diagnostic angiogram via right sfa access [**1-3**]
left CEa [**1-4**]
left fem at bpg withcomposite reversed and non reversed GSV,
venovenostomy, angioscopy and valve lysis [**2180-1-10**]
left graft thrombectomy [**2180-1-11**]
History of Present Illness:
Patient refered to Dr.[**Last Name (STitle) 1391**] for progressive calf claudication
with associated left foot /toe gangrene and incidental high
grade left carotid stenosis . Admitted for vascular evaluation
and left carotid endartectomy.
Past Medical History:
histroy of hearing loss
history of carotid stenosis by ultra sound exam
Social History:
lives alone, independant ADL's
nonsmoker or drinker
Family History:
mother with PVD s/p amputation
Physical Exam:
Vital signas afebrile
Gen: oriented x3
HEENT: bilateral carotid bruits
Heart: RRR noraml S1S2
Lungs: clear to auscultation
abd: soft nontender , nondistended, bowel sounds present
EXT: left #2 toe with erythema and edema. left foot edematous
Pulses: right: palpable femoral , absent [**Doctor Last Name **], dopperable
monophasic signal of DP/PT
left: palpable femoral, [**Doctor Last Name **],DP dopperable monophasic signal,
absent signal PT.
Neuro: nonfocal
Pertinent Results:
[**2180-1-2**] 02:58PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2180-1-2**] 04:10PM PT-13.7* PTT-32.1 INR(PT)-1.2*
[**2180-1-2**] 04:10PM PLT COUNT-375
[**2180-1-2**] 04:10PM WBC-6.2 RBC-4.61 HGB-13.7 HCT-40.4 MCV-88
MCH-29.7 MCHC-33.9 RDW-12.8
[**2180-1-2**] 04:10PM CALCIUM-9.7 PHOSPHATE-3.2 MAGNESIUM-2.2
[**2180-1-2**] 04:10PM estGFR-Using this
[**2180-1-2**] 04:10PM GLUCOSE-100 UREA N-16 CREAT-0.7 SODIUM-141
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14
Brief Hospital Course:
[**2180-1-2**] admitted IV vanco and cipro and flagyl began for
erythema and dry gangrene of left foot. Iv hydration began for
anticipated angio [**1-3**]
[**2180-1-3**] diagnositc angio via rt. femoral access, postangio
hypertension requiring IV nitro to control blood pressure.
[**2180-1-4**] Ntg weaned . underwent Left CEA. post recovery episodes
secondary to intravascular depletion with hypo tension and low
urinary out put -fluid resustated
[**2180-1-5**] POD#1 requiring adjustment in lopressor dosing and
addition of hydralazine for B/P control. Hct 27.6 transfused one
unit PRBCS.
[**2180-1-6**] POD#2 social service consulted.delined
[**2180-1-7**] POD#3 evaluated by physical thearphy.
[**2180-1-10**] POD#6 left fem- at pbg with composite GSV. graft
failure. IV heparin
[**2180-1-11**] POD#[**5-23**] graft thrombectomy with reocclusion of graft.
[**2180-1-12**] POD#[**6-24**] evaluating vein conduit. pain control.Evaluated
by speeech and swallow, dysphagia secondary to multiple endo
trachial entubations and sedation from narcotic thichkened
liquids and pureed solids recommended.
[**2180-1-17**] POD#13/5 Return to surgery for redo left fem-peroneal
bpg with left arm vein
[**2180-1-18**] POD#14/6/1 left arm bleeding [**First Name9 (NamePattern2) 78182**] [**Last Name (un) **] hemostasis
and transfusion 2 PRBC"S
[**2180-1-19**] POD#14/7/2 remains in VICU requiring med adjustment for
BP control, rebleed from left arm resolved with manual pressure.
transfused 1 unit PRBC's. Still with swallowing
diffculties.Coumadin/IV heparin conversion began
[**2181-1-20**] PICC line placed. TPN started.
[**2180-1-22**] chest pain. enzymes cycled.EKG no alcute changed.
[**2180-1-23**] self d/c'd picc line. attempted to place @
bedside.Continues with intermittent delerium and combativness
requiring haldol.
[**2180-1-24**] INR 5.7 anticoagulation held.repeat bedside swallow
evaluation done improvment in swallowing but continues to
vomit.bleeding from picc line site, resolved with manual
pressure. Transfused.left leg bleeding. INR 17.0 reversed with
FFp 6 units and PRBC"s. hematology consulted current bleeding
problem secondary to malnutritiion and hypercoaguable state from
accumalitve effects of coumadin. Transfered to CVICU.underwent
exploration and evacuatiion of groin hematoma.
[**2180-1-25**] Rt. IJ placed. cxr without infiltrate but increased
pulmonary congestion and
pleural effusions L>R.Geratric consult for postoperative
delerium.Required Vitamin K 10 x2 and additional 2FFp and @
PRBC's for elevated INR.serial Hct. monitered TPN continued.
[**2180-1-26**] started on nicardipine gtt for hypertension. Vanco d/c'd.
[**2180-1-28**] Continues to remain NPO per Speech/Swallow assesment to
somulent to restart po's continue NPO and TPN.Hct. remains
stable Hemetology signs off.
Gertology signsoff.
[**Date range (1) 78183**] underwent barium swallow- no organic findings but
patient does aspirate.Repeat swallowing assesment @ bed side
defered secondary to sedation.
PT contiune to floow patient. ENT consulted for Vocal cord
evaluation secondary to aspiration. VC assesment could not be
commpleted secondary to patient's lack of cooperation and
confusion.
[**2-1**] Trama [**Doctor First Name **] consult for PEG placement.Bed side swallow
evaluation with all food consistanceies no apparent evidence of
signs or symptoms of aspiration. Schedualed a
video swallow for [**2180-2-2**]
[**2180-2-2**] swallow study defered secondary to PEG placement by
Trama Surgery.
[**2180-2-3**] swallow study could not be done- patient refused.
Continue NPO and TPn. Peg feed held secondary to nausea earlier
on [**2-3**].ENT could not visularized cord secondary to patient's
refusal to have procedure done.
Will requir ENT followup post d/c when patient has recovered
from current hospitalization.
[**2180-2-4**] TPN continued. arm skin clips removed.patient to have
small bowel follow thru study to determin if any mechanical
reasons for persistant vomiting.
[**2180-2-4**] SBFT negative for any mechanical reasons . tube feeds
slowly advanced
[**Date range (1) 78184**] left arm staples d/c'd. left upper arm sutures remain
in place and will be d/c'd 10-14day followup kwith Dr.
[**Last Name (STitle) 1391**].Foley d/c'd. Tube feed slowly advanced.
[**2-8**] reglan strated for intermittent nausea and emesis. Tube
feed changes . No further incidences of emesis now on reglan.
[**2180-2-9**] D/c'd to rehab stable.
Medications on Admission:
no meds
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml. PO BID (2
times a day).
3. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q4h prn ().
4. Haloperidol Lactate 5 mg/mL Solution Sig: 0.5 mg Injection
Q4H (every 4 hours) as needed.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day).
8. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
12. 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.
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 units
Injection TID (3 times a day).
14. Xopenex 0.63 mg/3 mL Solution for Nebulization Sig: One (1)
neb Inhalation q4h prn.
15. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
16. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
18. Metoprolol Tartrate 5 mg/5 mL Solution Sig: 7.5 mg
Intravenous Q4H (every 4 hours) as needed for sbp >180 or hr
>100.
19. Haloperidol Lactate 5 mg/mL Solution Sig: 0.5 mg Injection
q4h prn as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
high grade left carotid stenosis, asymptomatic
arterial insuffiency , symptomatic and left foot /toe gangrene
postoperative hypertension uncontrolled, treated
postoperative blood loss anemia, transfused
postoperative graft failure
postoperative dysphagia to solids
postoperative left arm hematoma-stable
postoperative left leg wound bleeding
postoperative failure to thrive-TPN/TF
Discharge Condition:
stable
Discharge Instructions:
left upper arm sutures remain in place until seen in followup
with Dr. [**Last Name (STitle) 1391**] 10-14 days
Followup Instructions:
10-=14 days Dr. [**Last Name (STitle) 1391**]. Call for an appointment [**Telephone/Fax (1) 1393**]
4 weeks [**Hospital **] clinic for VC evalution, call for appointment
[**Telephone/Fax (1) 41**]
Completed by:[**2180-2-9**]
ICD9 Codes: 2851, 5990, 2930, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4374
} | Medical Text: Admission Date: [**2195-7-21**] Discharge Date: [**2195-7-22**]
Date of Birth: [**2141-9-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Right carotid artery stenosis
Major Surgical or Invasive Procedure:
Carotid Angiography
Right Carotid Artery stent placement
History of Present Illness:
Mr. [**Name14 (STitle) 81077**] is a 53 year old man with a history of hypertension,
hyperlipidemia, tobacco abuse, alcohol abuse, and carotid artery
disease s/p bilateral carotid endarterectomy in the past who
presents for elective carotid angiography and stent placement
for critical re-stenosis of the right ICA. The patient
initially presented with transient right sided vision loss in
[**2189**] and was found to have 90% right sided carotid artery
stenosis, for which he underwent a CEA. In [**2192**], the patient
underwent CEA of his left carotid artery when he was discovered
to have an 80% stenosis on serial ultrasounds. He had been
following up regularly for his carotid artery disease with no
further neurologic symptoms, and was noted to have an 80% right
ICA stenosis on surveillance ultrasound at [**Hospital **] hospital in
[**Month (only) 956**] of this year. The patient followed up on [**2195-3-28**] with
a neck CTA here at [**Hospital1 18**] where it was confirmed that he had a
significant right ICA stenosis, though CTA estimated the
stenosis to be ~55-60% at the origin of the right ICA/ carotid
bulb. Given the results of his CTA, he was referred for
elective carotid stent placement and also enrolled in the [**Last Name (un) 81078**]
study.
.
Prior to admission, the patient states that he has been feeling
well without any neurologic symptoms of blurred vision, amarosis
fugax, slurred speech, facial droop, or focal extremity
weakness. He denies any history of stroke, pulmonary embolism,
chest pain, palpitations, shortness of breath, syncope, cough,
abdominal pain, diarrhea, black stools, paresthesias, muscle
weakness, or recent fevers, chills or rigors. All of the other
review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
.
#Carotid artery disease
- s/p right carotid endarterectomy in [**2189**] and a left carotid
endarterectomy in [**2192**]
- Amarosis Fugax of the Right eye prior to R CEA in [**2189**]
- [**2195-3-11**]: Carotid Duplex ([**Hospital **] Hospital) tight right 80% ICA
carotid stenosis, minimal (20-49%) Left ICA stenosis.
- [**2195-3-28**] [**Hospital1 18**] ~55-60% stenosis at the origin of the right ICA/
carotid bulb with a calcified plaque.
# Laryngeal CA Dx in '[**93**] s/p XRT, no chemo, no surgical
resection
Social History:
-Tobacco history: (+) - 60 pk year history of tobacco use, but
quit in '[**93**] after laryngeal CA diagnosis
-ETOH: (+) 4-8 beers daily, up to 20 beers in one day, last
drink the evening prior to admission 1.5 beers. Denies history
of DTs or seizures related to alcohol withdrawl.
-Illicit drugs: None
- Lives at home with his wife, works as a tractor [**Last Name (un) 28523**] driver
6 days/week driving up to 400 miles/day
Family History:
Mother died of MI age 53, Father with asbestosis related lung
CA, sister with skin CA, no other family history of arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS: T=afebrile BP=142/83 HR=72 RR=17 O2 sat=97% on RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Poor dentition with no upper teeth.
NECK: Supple without distended JVP. Carotid endarterectomy scars
noted bilaterally.
CARDIAC: Regular rate, normal S1, S2. No extra heart sounds, no
rubs, no thrills, or lifts.
LUNGS: Unlabored respirations, no accessory muscle use. Mild
upper airway inspiratory/expiratory wheezes near trachea, no
crackles, or rhonchi.
ABDOMEN: Soft, NTND. No tenderness. Abd aorta not enlarged by
palpation.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: Warm and well perfused without rash
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
Morning of [**7-22**]:
WBC 6.5, Hct 36.9, Plt 242
Na 138, K 4.3, Cl 105, CO2 23, BUN 14, Cr 1.0, Gl 105, Ca 8.7,
Mg 2.2, PO4 4.3
Brief Hospital Course:
53 year old man with history of tobacco abuse, alcohol abuse,
carotid artery disease s/p bilateral endarterectomies, who
presents for elective carotid angiography and stent placement
for asymptommatic critical right ICA stenosis.
Hospital course by problem:
.
#Carotid artery disease: Had successful stent placement to the
right carotid artery [**7-21**] without complications. When he first
arrived he was on a Nitro drip for blood pressure control. This
was weaned off without any need for additional medications. The
morning of [**7-22**] he was slightly hypertensive after walking
around and was given an extra 10mg of lisinopril on top of his
home dose of 20mg. His neurologic status did not change and his
peripheral pulses remained strong. He continued his home dose
of Aspirin, Plavix and Lipitor and was discharged on 30mg of
lisinopril daily. The morning prior to discharge he had some
soreness at his femoral access site that resolved with Percocet.
.
#Alcohol abuse: Patient has a history of heavy alcohol use,
typically 4-8 beers a day. He denies any previous history of
withdrawal symptoms or seizures, and says that his last drink
was [**7-20**], the day prior to surgery. He was monitored closely
with a CIWA scale, and was given three 10mg doses of Valium
because he was feeling anxious and was noted to be tremulous.
He did not want to talk to social work about his drinking habit.
Medications on Admission:
Lipitor 10 mg po daily
Plavix 75 mg po daily (started [**2195-7-14**])
Lisinopril 20mg po daily
Aspirin 325mg po daily
Folic Acid 3mg po daily
Vitamin B daily
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. Folic Acid 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Carotid Artery Stenosis
Discharge Condition:
Stable
Discharge Instructions:
You had a stent placed in your right carotid artery because
increasing stenosis (blockage) of the artery was putting you at
risk for a stroke. You were then admitted to the cardiac care
unit overnight for close observation of your blood pressure and
neurologic status. Your blood pressure was high at first, but
stabilized and you are now ready to go home.
.
The following changes were made to your medication regimen:
1) Your dose of lisinopril was increased from 20mg once daily to
30mg once daily.
2) You were given a small amount of Percocet for pain relief for
the next day. You should only take this medication as needed for
severe pain. You should not drive, operate heavy machinery, or
make important decisions while taking this medication.
Please make sure you continue taking Aspirin, Plavix, Crestor,
Folic Acid and Vitamin B every day. Do not stop taking any of
your medications without checking with your doctor.
.
Please call you doctor immediately or go to the emergency room
if you develop any symptoms of slurred speech, weakness of your
legs or arms, blindness, or drooping of one side of your face.
Followup Instructions:
Please follow up with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3100**], the nurse practitioner who
works with Dr. [**Last Name (STitle) 911**] in one month. They will contact you to
make an appointment, but if they do not, please call ([**Telephone/Fax (1) 3942**].
.
You should also follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 31446**] [**Name (STitle) 8521**] from [**Hospital **] Medical Associates within 1-2 weeks.
You can contact his office at [**Telephone/Fax (1) 54268**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2195-7-23**]
ICD9 Codes: 4439, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4375
} | Medical Text: Admission Date: [**2146-5-10**] Discharge Date: [**2146-5-21**]
Date of Birth: [**2092-3-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Vancomycin / Ciprofloxacin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
[**2146-5-16**]
1. Coronary artery bypass grafting x 3 with left internal
mammary artery graft to left anterior descending and
reverse saphenous vein graft to the diagonal and the
posterior descending artery.
2. Ligation of a LAD pseudoaneurysm.
History of Present Illness:
54 year old female with knowncoronary artery disease, with
history of multiple (4) stents,HTN, hyperlipidemia, and positive
tobacco use presented [**Hospital 85297**] hospital with unstable angina
and a marginally elevated troponin. Cardiac cath revealed
mltivessel coronary disease with in-stent stenosis. She was
transferred to [**Hospital1 18**] for surgical evaluation of coronary
revascularization.
Past Medical History:
CAD-s/p PCI and multiple coronary stents [**2139**]/[**2140**]/[**2142**]
HTN
hyperlipidemia
Social History:
Occupation:manages real estate property
Tobacco: current 1/2-1 ppd; >30 PY
ETOH:previous 2 "large" scotches/day-has been cutting down over
last month to 1 shot/day-last drink Friday
denies other illicit drugs
Family History:
Father died of liver cancer. Mother is 92
Physical Exam:
Pulse:65 Resp:16 O2 sat: 99 on RA
B/P Right:99/64
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema/Varicosities:
None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right: 2+-cath site w/o hematoma Left: 2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: none Left:none
Pertinent Results:
Intra-Op Echo [**2146-5-16**]
PRE-BYPASS: The left atrium and right atrium are normal in
cavity size. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. The right ventricular cavity is mildly dilated with
normal free wall contractility. The ascending aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. 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. Trivial mitral regurgitation is
seen. There is no pericardial effusion.
POST CPB:
1. Preserved [**Hospital1 **]-ventricular systolci function.
2. No change in valve structure and function.
3. Intact aorta
[**2146-5-20**] 05:40AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.5* Hct-27.9*
MCV-93 MCH-31.5 MCHC-34.0 RDW-14.7 Plt Ct-240#
[**2146-5-20**] 05:40AM BLOOD Plt Ct-240#
[**2146-5-20**] 05:40AM BLOOD UreaN-10 Creat-0.7 Na-138 K-3.5 Cl-99
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2146-5-16**] where the patient underwent CABG x 3
as detailed in the operative report. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Vancomycin was used for surgical
antibiotic prophylaxis, given the preoperative LOS of greater
than 24 hours. POD 1 found the patient extubated, alert and
oriented and breathing comfortably. By POD 2 the patient was
hemodynamically stable, weaned from vasopressor/inotropic
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without incident. Ms.
[**Known lastname 85298**] was evaluated by the physical therapy service for
evaluation of her strength and mobility. By the time of
discharge on POD five the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was cleared by Dr [**Last Name (STitle) 914**] for discharge to home on
POD# five. All follow up appointments were advised.
Medications on Admission:
Plavix 75(1)/Zetia 10(1)/Metoprolol
12.5(2)/Lipitor 40(1)/Gemfibrozil 600 (2)/HCTZ 25(1)/Wellbutrin
150(2)-tobacco cessation
Discharge Medications:
1. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for stents.
Disp:*30 Tablet(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days.
Disp:*40 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): while taking percocet, for constipation.
Disp:*60 Capsule(s)* Refills:*2*
13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Doctor Last Name **]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
PMH:
CAD-s/p PCI and multiple coronary stents [**2139**]/[**2140**]/[**2142**]
HTN
hyperlipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2146-6-23**] 1:00
Please call to schedule appointments
Cardiologist Dr. [**Last Name (STitle) 8579**] [**Telephone/Fax (1) 23882**] in [**11-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2146-5-21**]
ICD9 Codes: 4111, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4376
} | Medical Text: Admission Date: [**2116-1-23**] Discharge Date: [**2116-2-7**]
Date of Birth: [**2047-11-30**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**1-24**]: Stereotactic 3rd ventriculostomy
[**1-31**]: Suboccipital craniotomy for mass resection
History of Present Illness:
68M with known posterior fossa mass was admitted s/p fall with
an increased of cerebellar density on CT. Pt denied any LOC,
headache, visual changes, new difficulties with speech or any
other motor or sensory loss. Pt did report a gradual increas in
difficulty walking forcing him to use a cane to walk. Pt
reports falling 2X. Pt has a laceration on the bridge of his
nose.
Past Medical History:
Stage III esophageal cancer
R eye prosthesis
HTN
DOE
BPH chronic foley
Diabetes
h/o trach/PEG in [**11/2113**]
h/o anemia in [**12/2113**]
s/p cholecystectomy
cognitive impairment s/p MVC
Social History:
Pt lives alone. Pt denies alcohol use. Pt has 80 pack-year
smoking history, quit 9-10 years ago.
Family History:
Remarkable for mother with diabetes and a brother with diabetes
and prostate cancer.
Physical Exam:
On Admission:
O: T: 97.6 BP: 137/68 HR: 66 R 16 O2Sats 100%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Nasal bridge laceration
Pupils: 3mm R, 2.5 mm L, ->2 mm EOMs
Neck: C-collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Mild confusion.
Orientation: Oriented to person, place, and date.
Language: Dysarthria. Answers inappropriate. Speech garbled at
times.
Cranial Nerves:
I: Not tested
II: Left pupils equally round and reactive to light, to
mm, left visual fields are full to confrontation. R eye loss of
vision, no accomodation
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice, not finger rub
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-14**] throughout. No pronator drift.
Spastic, unable to relax lower extremities for exam.
Sensation: Intact to light touch, temperature, and pinprick
bilaterally. Unable to relax LE for appropriate proprioception
exam
Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ hypreflexive, triple flexes to babinski exam
Left 2+ 2+ 2+ hypreflexive, triple flexes to babinski exam
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger right, abnormal
finger-to-nose on left, normal rapid alternating movements and
heel to shin.
On Discharge:
XXXXXXXXXXXXXXX
Pertinent Results:
Labs on admission:
[**2116-1-23**] 07:50AM BLOOD WBC-4.8 RBC-4.37* Hgb-13.5* Hct-39.8*
MCV-91 MCH-30.8 MCHC-33.8 RDW-14.8 Plt Ct-159
[**2116-1-23**] 07:50AM BLOOD Neuts-81.8* Lymphs-12.1* Monos-4.5
Eos-1.2 Baso-0.4
[**2116-1-23**] 07:50AM BLOOD PT-13.5* PTT-27.5 INR(PT)-1.2*
[**2116-1-23**] 07:50AM BLOOD Glucose-105 UreaN-23* Creat-0.9 Na-143
K-4.2 Cl-103 HCO3-33* AnGap-11
[**2116-1-23**] 07:50AM BLOOD ALT-32 AST-18 LD(LDH)-160 AlkPhos-70
Amylase-21 TotBili-0.6
[**2116-1-23**] 07:50AM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.1 Mg-1.8
Iron-61
[**2116-1-23**] 07:50AM BLOOD calTIBC-270 Ferritn-117 TRF-208
[**2116-1-30**] 05:59AM BLOOD %HbA1c-6.3*
Misc. Significant Lab studies:
[**2116-2-2**] 03:08AM BLOOD WBC-12.5* RBC-3.48* Hgb-11.2* Hct-31.8*
MCV-92 MCH-32.1* MCHC-35.1* RDW-15.2 Plt Ct-168
[**2116-2-3**] 12:29AM BLOOD WBC-20.2*# RBC-3.88* Hgb-12.9* Hct-35.4*
MCV-92 MCH-33.2* MCHC-36.3* RDW-14.9 Plt Ct-188
[**2116-2-4**] 05:14AM BLOOD WBC-43.6*# RBC-4.79 Hgb-15.4 Hct-44.7#
MCV-93 MCH-32.1* MCHC-34.4 RDW-14.9 Plt Ct-252
[**2116-2-4**] 11:30AM BLOOD WBC-32.4* RBC-4.61 Hgb-14.7 Hct-42.3
MCV-92 MCH-31.9 MCHC-34.9 RDW-15.1 Plt Ct-262
[**2116-1-23**] 07:50AM BLOOD Neuts-81.8* Lymphs-12.1* Monos-4.5
Eos-1.2 Baso-0.4
[**2116-2-4**] 11:30AM BLOOD Neuts-93.9* Lymphs-3.0* Monos-2.9 Eos-0
Baso-0.1
[**2116-2-3**] 12:29AM BLOOD PT-17.6* PTT-36.7* INR(PT)-1.6*
[**2116-2-3**] 12:29AM BLOOD Plt Ct-188
[**2116-2-4**] 03:20PM BLOOD PT-15.6* PTT-29.2 INR(PT)-1.4*
[**2116-2-5**] 09:44AM BLOOD PT-27.2* PTT-44.2* INR(PT)-2.7*
[**2116-2-5**] 09:44AM BLOOD Glucose-75 UreaN-71* Creat-2.2*# Na-146*
K-5.7* Cl-112* HCO3-13* AnGap-27*
[**2116-2-4**] 05:14AM BLOOD Glucose-96 UreaN-45* Creat-1.0 Na-136
K-5.1 Cl-108 HCO3-16* AnGap-17
[**2116-1-23**] 07:50AM BLOOD ALT-32 AST-18 LD(LDH)-160 AlkPhos-70
Amylase-21 TotBili-0.6
[**2116-2-4**] 05:14AM BLOOD ALT-144* AST-171* LD(LDH)-536* AlkPhos-94
Amylase-43 TotBili-0.9
[**2116-2-5**] 01:20AM BLOOD CK(CPK)-559*
[**2116-2-5**] 09:44AM BLOOD ALT-183* AST-203* AlkPhos-160*
TotBili-1.2
[**2116-2-5**] 09:44AM BLOOD Albumin-2.7* Calcium-8.0* Phos-5.9*#
Mg-2.2
[**2116-2-4**] 05:14AM BLOOD Albumin-3.0* Calcium-8.5 Phos-3.8 Mg-1.9
[**2116-1-23**] 07:50AM BLOOD calTIBC-270 Ferritn-117 TRF-208
Labs on Discharge:
XXXXXXXXXXXXXXXXXXXXX
EKG [**1-24**]:
Sinus rhythm. Probable old septal myocardial infarction. Low QRS
limb lead
voltage. Otherwies, normal tracing. Compared to the previous
tracing of [**2115-12-25**] no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 152 86 [**Telephone/Fax (2) 70523**]
Imaging:
Head CT [**1-23**]:
IMPRESSION:
Interval increase in size of patient's known left cerebellar
hemorrhagic mass with surrounding vasogenic edema. Mass effect
and partial effacement of the fourth ventricle and left
posterior aspect of the perimesencephalic cistern with no
evidence of hydrocephalus. An MRI is recommended for further
evaluation.
Bilateral nasal ala and nasal septum fractures with adjacent
soft tissue
edema.
CT C-Spine [**1-23**]:
IMPRESSION:
1. Multilevel degenerative disc disease with no evidence of
acute fracture.
2. Soft tissue density adherent to the right tracheal wall which
may
represent mucus versus polyp. Further imaging on a non-emergent
basis may be obtained as deemed clinically necessary.
MRI Head [**1-24**]:
IMPRESSION:
1. Left cerebellar mass with hemorrhagic foci and surrounding
edema causing
effacement of the fourth ventricle and quadrigeminal cistern.
Differential
diagnosis includes lymphoma and metastatic disease.
2. Chronic right frontal lobe changes consistent with prior
history of trauma and contusion.
CTA Head [**1-25**]:
IMPRESSION:
1. Status post gastric pull-through for esophageal carcinoma,
with no
definite metastatic disease.
3. Stable 15-mm right hepatic lesion with suggestion of
peripheral
enhancement, and which may represent a hemangioma. This lesion
is stable from [**2114-12-13**].
3. New rib fractures involving the left sixth and right tensor
ribs, without definite underlying lytic lesion or associated
soft tissue mass. Correlation should be made to the patient's
trauma history. If there is no history of trauma, bone scan may
be beneficial to exclude osseous metastases.
4. T10 compression fracture, of indeterminate age but new since
[**2115-7-12**].
5. Sclerosis and cystic changes in the bilateral femoral heads,
which can be seen with avascular necrosis, particularly in
patients on steroid therapy.
6. Prostatic enlargement.
MRI Head [**2-3**](post-op):
IMPRESSION: Status post left occipital craniotomy. Resection of
the
previously demonstrated infiltrative mass lesion on the left
cerebellar
hemisphere. Residual pattern of enhancement in the surgical bed
with a
nodular area of enhancement as described above, measuring
approximately 19 x 9 mm in size possibly related with volume
averaging, persistent edema in the posterior fossa involving the
left cerebellar hemisphere. Unchanged
microvascular ischemic disease in the periventricular white
matter. Small
amount of intraventricular hemorrhage. Blood products identified
in the
surgical bed. Followup MRI is recommended to demonstrate any
further change or stability in the pattern of enhancement in the
surgical area.
Head CT [**2-3**]:
IMPRESSION:
1. Status post occipital craniotomy with surgical changes in the
craniotomy
bed and edema in the left cerebellar hemisphere, similar in
extent to MR done on [**2116-2-1**]. Similar degree of mass
effect on the fourth ventricle.
2. Trace intraventricular hemorrhage layering in the posterior
horns of the
lateral ventricles. No new intracranial hemorrhage.
3. Slightly increased size of the lateral ventricles.
Bilateral Knee images [**2-4**]:
IMPRESSION: No acute fracture detected on either side. Stable
medial tibial
plateau fracture on left, with marked medial compartment
narrowing on the
left.
RUQ Ultrasound [**2-5**]:
IMPRESSION: Limited study but with normal portal and hepatic
veins. Status
post cholecystectomy. No evidence of biliary dilatation.
Brief Hospital Course:
Pt was admitted on [**1-23**] s/p fall. He underwent MRI which
revealed progression of the previously seen lesion. As pt was
unable to urinate in the ED s/p mannitol, the urology was
[**Month/Year (2) 4221**] for foley placement. On [**1-24**], pt underwent a third
ventriculostomy without complications. Staging for esophageal
carcinoma was performed. No sites of metastasis were
identified. On [**1-25**], the pt was transferred to the stepdown
unit. On [**1-27**], [**Last Name (un) **] was [**Last Name (un) 4221**] for increased blood
glucose. CTA/V of the head was performed which demonstrated no
evidence of venous sinus thrombosis. On [**1-31**], he went to the OR
for suboccipital craniotomy for mass resection. Post operatively
he was transferred to the ICU for continued monitoring. On
[**2-1**], post-operative MRI was performed and he was subsequently
extubated. MRI revealed a gross total resection of the lesion.
He was moving all extremities purposefully, spontaneous eye
opening, with some bouts of agitation. On [**2-2**], his coagulation
studies were found to be slightly elevated. Hematology was
[**Month/Year (2) 4221**], and this was thought to be due to Vitamin K
deficiency, and he subsequently received 10mg of Vitamin K. On
[**2-3**], he was transferred to the neurosurgery floor. Repeat
speach and swallow study was perfomed, but due to agitation, and
complaince, they were not able to complete their examination.
On [**2-4**], he was much more awake, and following simple commands
consistently. However routine CBC evaluation revealed a white
blood count of 40, which had doubled in 24hrs. This was
repeated to ensure no error, and the repeat revelaed a WBC of
34. He was also found to have transamintis. Medicine and the ID
services were [**Month/Year (2) 4221**] to help determine the causation of the
elevated WBC and transaminitis. They recommended, multiple
laboratory studies, and ultrasound of the right upper quadrent
to evaluate hepatic blood flow. All work up were negative
including a stool specimen for C. diff.
On the evening of [**2-4**] and into the early morning of [**2-5**], Mr.
[**Known lastname 70518**] became much more tachycardic(EKG showing sinus tach), and
had low blood pressures(SBP 80-90). His peripheral IV
infiltrated and he had no access. The IV team tried repeatedly
to place a new line but were unsuccessful. Finally, his
Port-a-Cath was accessed and he was able to receive fluids
through that line. His heart rate temporarily decreased from 140
to 120s but that only lasted a short time. Medicine team was
again called, and it was collaboratively decided that his
present condition would be best monitored and treated further in
the ICU. At approximately 6am on [**2-5**] the patient was
transferred to the SICU.
The patient became progressively lethargic required intubation.
He subsequently suffered multi-organ failure including hepatic
failure, renal failure, and profound coaguloathy. He remained
hypotensive requiring aggressive fluid resuscitation. While his
blood pressure had subsequently stabilized, he subsequently
suffered ARDS with progressive worsening of his ventilation
status. Because of volume overload, he was started on CVVH for
ARF.
Given the progressive worsening of the patient's status despite
aggressive measures and the poor prognosis associated with
esophageal metastasis, the family decided to make the patient
CMO. The patient expired shortly thereafter.
Medications on Admission:
Amantidine
Citalopram 10 mg
Finasteride 5 mg
Lactulose 30 ml PRN
Lansoprazole 30 mg q day
Metformin 500 mg
Metoprolol XL 25 mg
Flomax 0.4 mg
Trazadone 50 mg QHS:PRN
Colace 100 mg [**Hospital1 **]
MVI
B12
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
Completed by:[**2116-2-7**]
ICD9 Codes: 5849, 0389, 2930, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4377
} | Medical Text: Admission Date: [**2198-4-16**] Discharge Date: [**2198-4-20**]
Date of Birth: [**2145-1-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
[**2198-4-16**] CABG x 4 (LIMA->LAD, SVG->RCA sqeuential OM1, OM2)
History of Present Illness:
53 yo Caucasian male with family history of premature CAD and
positive ETT. Referred for cath which showed EF 45%, 60-70% LAD,
CX 100%, OM 2 100%, 90% RCA. Referred for surgical
revascularization.
Past Medical History:
elev. chol.
tonsillectomy
exc. pilonidal cyst
Social History:
car salesman
35 cigarettes per week
no alcohol
lives with wife
Family History:
father with MI at 53
Physical Exam:
HR 66 RR 19
6'1" 88.5 kg
NAD
skin/ HEENT unremarkable
neck supple, full ROM
lungs CTAB
RRR
soft, NT, ND, + BS
warm, well-perfused, no edema, no varicosities
neuro grossly intact
left fem 2+
DP/PT/radials 2+ bilat.
R hand perfused with occluded right radial on exam
no carotid bruits
Pertinent Results:
[**2198-4-18**] 06:02AM BLOOD WBC-19.9* RBC-3.67* Hgb-11.7* Hct-33.5*
MCV-91 MCH-32.0 MCHC-35.0 RDW-12.3 Plt Ct-262
[**2198-4-19**] 06:08AM BLOOD WBC-12.0* Hct-29.6*
[**2198-4-20**] 06:38AM BLOOD Hct-30.3*
[**2198-4-18**] 06:02AM BLOOD Plt Ct-262
[**2198-4-18**] 06:02AM BLOOD Glucose-135* UreaN-16 Creat-0.9 Na-136
K-4.2 Cl-99 HCO3-27 AnGap-14
[**2198-4-20**] 06:38AM BLOOD K-4.2
[**2198-4-18**] 06:02AM BLOOD Mg-1.8
Brief Hospital Course:
Admitted on [**4-16**] and underwent CABG x4 with Dr. [**Last Name (STitle) 914**].
Transferred to the CSRU in stable condition on nitroglycerin and
propofol titrated drips. Extubated later that afternoon
neurologically intact. Chest tubes removed on POD #1, off all
drips and transferred to the floor to begin increasing his
activity level. On POD #2, beta blockade was titrated and gentle
diuresis was continued. Pacing wires were removed without
incident on POD #3. He continued to make excellent progress and
was cleared for discharge to home with services on POD #4. He is
to follow up with PCP, [**Name10 (NameIs) 2085**] and surgeon as outlined in
the discharge instructions.
Medications on Admission:
ASA 325 mg daily
lipitor 10 mg daily
toprol 25 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1
weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
8. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD s/p cabg x4
Hyperlipidemia
s/p T&A
s/p pylonidal cyst removal
Discharge Condition:
Good.
Discharge Instructions:
Calll with fever, redness or drainge from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Completed by:[**2198-4-20**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4378
} | Medical Text: Admission Date: [**2103-10-23**] Discharge Date: [**2103-10-31**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
unresponsive with right sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is an [**Age over 90 **] yo RH woman with PMH sig for HTN who was
in USOH and at baseline she is ambulatory and talkative who
after
eating dinner around 8PM, she was noted by her family to be
unresponsiveness with left eyeward deviation and with
right-sided
weakness. Se had previously had no headaches, vertigo,
dysarthria, dysphagia, visual changes. She was brought by EMS
for
likely acute stroke to the [**Hospital1 18**].
On initial exam, she had an NIH score = 28. Her head CT shows
b/l
basal ganglia calcifications but no bleed and cerebral atrophy.
Her BP was 208/104 and required several doses of labetolol prn
to
bring her SBP < 180mm Hg so that IV TPA could be given. TPA was
given approximately 2 hours into the event.
ROS negative for fever, URI sxs, cough, N/V/D, dysuria. Denies
cp, sob.
Past Medical History:
HTN, ECHO with EF 45% (unclear if hypertensive
cardiomyopathy vs CAD); Hx of syncopal episodes of unclear
etiology
Social History:
No hx of smoking, ETOH, drugs
Physical Exam:
Vitals: 99.8 70's 208/104 16
Gen: NAD, eyes deviated to left; spontaneous picking movements
of
left hand
Neuro: awake, no verbal output; doesn't follow commands
pupils equal and reactive b/l; EOMI with left eye deviation and
unable to Doll's eye to midline; No nystagmus, right facial
droop
at rest
Moves left arm spontaneously and can hold up for several
seconds.
She did not withdraw her left arm or leg to noxious stimuli.
reflexes 2+ in UE b/l and 2+ in LE b/l at knees; no ankle jerks
b/l; toes moot b/l;
sensory exam: withdrew left arm and leg to noxious stim; no
movement with right side
Coordination: could not test
Gait: deferred
Pertinent Results:
[**2103-10-23**] 08:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2103-10-23**] 08:45PM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2103-10-23**] 08:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2103-10-23**] 08:45PM PT-13.0 PTT-29.2 INR(PT)-1.1
[**2103-10-23**] 08:45PM PLT COUNT-145*
[**2103-10-23**] 08:45PM NEUTS-59.5 LYMPHS-29.7 MONOS-6.3 EOS-4.2*
BASOS-0.2
[**2103-10-23**] 08:45PM WBC-5.5 RBC-4.55 HGB-14.0 HCT-43.4 MCV-96
MCH-30.7 MCHC-32.2 RDW-13.4
[**2103-10-23**] 08:45PM GLUCOSE-94 UREA N-33* CREAT-0.9 SODIUM-145
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-14
[**10-23**] Head CT: no bleed; b/l basal ganglia calcifications;
cerebral
atrophy and likely ventriculomegaly ex vacuo
[**10-24**] repeat head CT post TPA: large hyperdensity in L MCA
territory c/w new infact as well as R sided parietotemporal
hemorrhage
Brief Hospital Course:
Pt was initially evaluated by Drs [**Name5 (PTitle) **] & [**Doctor Last Name **] from the Stroke
service. She was given IV TPA in ER and then transferred to ICU
for further management.
Neuro: Clinically exam was unchanged during her course. Follow
up head CT showed contralateral hemorrhage as well as marked
hyperdensity consistent with L MCA stroke.
CV: BP intiially required nipride drip, she was weaned off the
drip by ICU day 3 and SBP was stable without intervention
She also had troponin leak with elevated CK's. Cardiology
consulted and thought leak was due to intracranial hemorrhage,
no interventions made. An ECHO was performed that showed stable
EF of 45% and mild MR.
RESP: stable on room air
FEN/GI: unable to PO given mental status. recommended NG feeds.
Continued on pepcid.
ID: Pt had U/A suggestive of UTI, started on levofloxacin. She
was afebrile during her stay.
DISPO: Pt was made DNR/DNI upon admission. Pt transferred to
floor on [**10-26**] with continued SBP control and neuro checks. After
lengthy discussion with family, pt made CMO on [**10-29**]. Pt NPO, and
morphine and scopolomine continued, all other interventions and
medications d/c'd. Dispo planning was initiated and Pt d/c'd to
hospice care on [**10-31**].
Medications on Admission:
aspirin 325mg qd, lisinopril 5mg qd
Discharge Medications:
1. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q 3 DAYS ().
2. Morphine Sulfate 10 mg/5 mL Solution Sig: One (1) PO Q4H
(every 4 hours) as needed.
3. Morphine Sulfate 10 mg Suppository Sig: One (1) Suppository
Rectal Q4H (every 4 hours) as needed: Please use if oral route
not available.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
L MCA infarct and R temporo-parietal hemorrhage
Discharge Condition:
Guarded
Discharge Instructions:
Please continue comfort measures only
Followup Instructions:
None
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2103-10-31**]
ICD9 Codes: 431, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4379
} | Medical Text: Admission Date: [**2164-10-3**] Discharge Date: [**2164-10-7**]
Date of Birth: Sex: F
Service: Neuro ICU
HISTORY OF PRESENT ILLNESS: 51-year-old female with known
headaches underwent coiling and stenting of known wide neck R
right coronary artery aneurysm. Procedure went without
complications, and she was admitted to the Neuro Intensive
Care Unit for hemodynamic and neuro monitoring.
PAST MEDICAL HISTORY:
1. Headaches.
2. Hyperlipidemia.
PAST SURGICAL HISTORY: Nothing.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Zomig.
2. Nortriptyline.
PHYSICAL EXAMINATION ON ADMISSION TO THE INTENSIVE CARE UNIT:
Temperature 97.3, blood pressure 122/67, pulse oximetry 79,
respirations 27, 100% 2 liters nasal cannula. In general,
she is awake, alert, in no acute distress. Lungs are clear
bilaterally. Cardiac: Regular rhythm and rate. Abdomen is
soft, nontender. Extremities are warm. Neurologically, she
is awake, alert, moving all extremities.
LABORATORY DATA: White count was 15.2, hematocrit 31.2,
platelets 379, PT 15.6, PTT 146.6 on Heparin, INR was 1.6,
sodium 143, potassium 3.6, chloride 109, bicarbonate 24, BUN
9, creatinine 0.6, glucose 145, calcium 8.4, magnesium 1.6,
phosphate 3.6, ABG 7.37, 42, 160, 25, and 0.
HOSPITAL COURSE: Patient underwent an angiogram with coiling
embolization and a Neuroform stent placement of her right
internal carotid artery. Postoperatively, she is awake,
alert, and oriented times three, following commands. No
drift bilaterally in upper extremities. Moved lower
extremities on command. Pupils are equal and reactive times
light and accommodation. EOMs are full. Patient denies
headache or any nausea. Systolic blood pressure is 110. Neo
drip was ordered. Intravenous fluids 150 an hour, and a
Heparin drip was at 900 an hour. Currently PTT was pending.
The lungs were clear; regular rate. Abdomen: Soft,
nontender. Extremities: Without edema.
Patient was followed in the Intensive Care Unit overnight,
where her Heparin goal was 60 to 80. She was started on
Plavix at 75 mg p.o. q. day and aspirin 325 p.o. q. day.
Systolic blood pressure 120 to 150.
On her first postoperative day she was awake, alert, and
oriented. Her son was available for translation. Her
extraocular muscles are intact; no diplopia. Face is
symmetric. IPs were [**6-4**]. Distal pulses palpable. Left
groin was slightly oozing. Her blood pressures were kept in
the 120 to 150 range.
On [**2164-10-5**] she had an angiogram to assess the coiling and
the stenting which showed slight improvement in stenosis of
the right internal carotid artery with no evidence of branch
occlusion and slow, persistent opacification of the anterior
portion of the aneurysm. Patient tolerated the procedure
well. Postoperatively, groin site was intact. The sheaths
were in place bilaterally. There was no bleeding. Heparin
was discontinued. The sheaths remained in overnight. She
remained awake, alert, and oriented without any problems.
On [**2164-10-6**] she was sent down to the Surgical floor, where
she remained awake, alert, and oriented. No difficulty while
on the floor. She was ambulating and tolerating a full diet
without any problems and complained of a mild headache. On
[**2164-10-7**] she was discharged home, continued to complain of
a mild headache. She had good femoral pulses. She was awake
and alert, moving all extremities, and ambulating well.
DISCHARGE INSTRUCTIONS:
1. Follow up with Dr. [**Last Name (STitle) 1132**] in two weeks time.
2. Watch groin incision site for any signs of infection.
3. Do not lift anything greater than 25 pounds.
4. Continue on her aspirin and Plavix as ordered.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern4) 26792**]
MEDQUIST36
D: [**2165-3-7**] 12:42
T: [**2165-3-7**] 17:26
JOB#: [**Job Number 52232**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4380
} | Medical Text: Admission Date: [**2103-10-22**] Discharge Date: [**2103-11-2**]
Date of Birth: [**2028-2-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
nausea/vomiting for cath
Major Surgical or Invasive Procedure:
[**10-22**] Cardiac catheterization
[**2103-10-26**] Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to
OM)
History of Present Illness:
Mrs. [**Known lastname **] is a 75 y/o female with severe DM II, insulin dependent
x 13 years, who presented to the ER at [**Hospital6 33**] on
[**10-17**] with c/o nausea, vomiting, elevated blood sugars, and
diarrhea. She was treated with IV fluids and insluin and
discharged that evening. Early the next morning she returned to
the ER with continued nausea and vomiting with blood sugar in
the 600's. On this visit, she was noted to have questioning of
new EKG changes. She was admitted to the floor at the OSH where
she had a peak ck/mb 194/9.4 & trop peak at 0.19. Her ETT last
Saturday exhibited suspicion for apical ischemia and was
positive for epigastric pain. This morning, the patient
underwent diagnostic cath which revealed LAD & OM disease and
was transferred to [**Hospital1 18**] for planned intervention.
Past Medical History:
Diabetes Mellitus, Hypertension, Hyperlipidemia, s/p
Hysterectomy, s/p Bladder suspension surgery
Social History:
The patient lives alone and is employed part-time as real estate
broker. She has 3 adult children. She denies ETOH or tobacco
abuse.
Family History:
(-) FHx CAD: unknown as pt is adopted
Physical Exam:
Vitals: T 96.9, BP 166/66, HR 68, R 16 with O2 sats 94% on RA
Gen: Well nourished elderly female in NAD, lying flat in bed
HEENT: PERRL. EOMI. OP clear. MMM.
Neck: No carotid bruits. No thyromegaly or lymphadenopathy.
Heart: Normal S1S2, RRR, (-) M/R/G
Lungs: clear anteriorly
Abd: Soft, non-distended, (+) BS
R Fem Site arterial sheath still in place, no hematoma or ooze
No femoral bruits auscultated
DP/PT 1+ bil, feet cool
No LE Edema
Neuro: A&O X 3. Speaking clearly in full sentences. Moving all
extremities.
Pertinent Results:
[**10-22**] Cath: Selective coronary angiography revealed a left
dominant anatomy with two vessel disease. The LMCA had no
lesions. The LAD had proximal 60% lesion involving the ostium.
It also had serial mid and distal lesions of 70-80%. The LCX did
not have any lesions. How ever a large OM1 had serial prxoimal
and mid lesions up to 90%. The RCA was non dominant and had a
mid 80% lesion.
[**10-23**] CNIS: Minimal bilateral plaque, no associated ICA or CCA
stenosis.
[**10-26**] Echo: PRE-BYPASS: 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 mildly depressed. Right ventricular chamber
size and free wall motion are normal. There are complex (>4mm)
atheroma in the aortic arch. There are complex(>4mm) atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. Trivial mitral regurgitation is seen.
POST-BYPASS: Preserved systolic function post cpb. On
phenylephrine, LVEF now 45-50%. Trace AI,MR, TR as described.
Normal aortic contour
[**11-1**] CXR: Comparison is made with the prior chest x-ray of
[**10-29**]. Bilateral pleural effusions are present; small on
the right side, somewhat larger on the left. Some atelectasis of
the left base behind the heart is present. The heart remains
somewhat enlarged with evidence of prior CABG. The lung fields
are otherwise clear.
[**2103-10-22**] 02:45PM BLOOD WBC-5.7# RBC-3.92* Hgb-13.1 Hct-39.0
MCV-99* MCH-33.3* MCHC-33.5 RDW-16.5* Plt Ct-222
[**2103-11-1**] 07:45AM BLOOD WBC-8.9 RBC-3.92* Hgb-12.5 Hct-37.2
MCV-95 MCH-31.9 MCHC-33.7 RDW-16.5* Plt Ct-258
[**2103-10-23**] 06:50AM BLOOD PT-12.5 PTT-25.3 INR(PT)-1.1
[**2103-10-28**] 02:10AM BLOOD PT-12.9 PTT-30.2 INR(PT)-1.1
[**2103-10-22**] 02:45PM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-140
K-4.3 Cl-103 HCO3-26 AnGap-15
[**2103-10-31**] 07:50AM BLOOD Glucose-96 UreaN-12 Creat-0.8 Na-141
K-3.9 Cl-106 HCO3-29 AnGap-10
[**2103-10-30**] 03:01AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.8
[**2103-10-25**] 08:21PM BLOOD %HbA1c-7.7* [Hgb]-DONE [A1c]-DONE
[**2103-10-23**] 10:37AM URINE Blood-LGE Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname **] was transferred from OSH to
[**Hospital1 18**] for cardiac cath. Cath revealed 2 vessel disease and she
was referred for surgery. She underwent usual pre-operative
testing and on [**2103-10-26**] she was brought to the operating room
where she underwent a coronary artery bypass graft x 2. 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 patient was
weaned from sedation, awoke neurologically intact and was
extubated. On post-op day two/three her chest tubes and
epicardial pacing wires were removed. She was also transfused
one unit of PRBC's for low HCT. She was started on beta blockers
and diuretics. She was diuresed towards her pre-op weight
post-operatively. She appeared to be doing well and was
transferred to the SDU on post-op day three. Later on this day
she was transferred back to the CSRU secondary to highly
elevated blood sugar requiring an Insulin gtt. [**Last Name (un) **] was also
contact[**Name (NI) **] on this day to improve diabetes management. On post-op
day four she was again transferred back to the SDU. She
continued to do well with adjustments in her beta blockers and
diabetes management. She was started on antibiotics on post-op
day five for slight sternal drainage. She otherwise appeared to
be doing quite well and was discharged home on post-op day seven
with VNA services and the appropriate follow-up appointments.
Medications on Admission:
Admission Medications:
Lantus 25units QHS
Novolog sliding scale with meals
From OSH: atenolol 25mg daily, ASA 325mg Daily & Plavix 600
loaded
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
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 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Packet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*1*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
9. Insulin sliding scale and fixed dose
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
PMH: Diabetes Mellitus, Hypertension, Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incisions and gently pat dry.
Do no take bath or swim.
Do no apply lotions, creams, ointments or powders to incisons.
Do not drive for 1 month.
Do not lift greater than 10 pounds for 2 months.
Please call to schedule all follow-up appointments.
If you develop a fever, redness or drainage from incisions,
please contact office.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Cardiologist in [**3-16**] weeks
Dr. [**Last Name (STitle) 16308**] in [**2-12**] weeks
[**Hospital **] [**Hospital 982**] Clinic in 4 weeks #[**Telephone/Fax (1) 2384**] (any physician
[**Name Initial (PRE) **])
Completed by:[**2103-11-2**]
ICD9 Codes: 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4381
} | Medical Text: Admission Date: [**2150-2-21**] Discharge Date: [**2150-3-6**]
Date of Birth: [**2107-10-10**] Sex: M
Service:
This dictation covers hospital stay through [**2150-3-6**].
Remainder of hospital course will be dictated by subsequent
intern.
HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old
male with no significant past medical history who presents
with 3 weeks of fevers, diarrhea, and abdominal pain. The
patient was in his usual state of health until approximately
3 weeks prior to admission when he noted the onset of left
lower quadrant abdominal pain. He described it as a
squeezing or wringing sensation, which did not radiate. He
also noted profuse diarrhea with approximately 5 to 8 bowel
movements per day. He described his stool as tan and watery
and intermittently greenish in color. He also noted high
fevers as high as 102 at home. He then went to an outside
hospital emergency department for evaluation. He was
admitted for workup. He had an abdominal CT, which did note
some large lymph nodes in his abdomen, but otherwise no
focality. He also had an upper GI series with a small bowel
followthrough study, which showed some duodenal thickening,
and otherwise was unremarkable. The patient was started on
antibiotics, initially Cipro and then switched to Flagyl. He
was discharged on a regimen of p.o. Flagyl to be taken for 10
days. Initially, he had several days without diarrhea on
this regimen and also improvement in his fevers for several
days; however, then his diarrhea returned as above. In
addition to his loose green stools, which he noted to be foul
smelling, and he also had increased flatulence. He denied
any bright red blood per rectum or melena. His abdominal
pain continued as noted as above. He also continued to have
high fevers to 102 for approximately the week prior to
admission. He also noted some chills and night sweats with
these fevers. He had approximately a 10-pound weight loss
over the previous few weeks. He also noted general fatigue
and weakness and malaise since his symptoms began.
REVIEW OF SYSTEMS: Review of systems are positive and are as
per above. He also notes mild anorexia over the previous few
weeks. No history of similar symptoms. No nausea or
vomiting. No shortness of breath, cough, chest pain,
headache, dizziness or other complaints.
PAST MEDICAL HISTORY: Herniated disc, status post discectomy
in [**12-13**].
History of abnormal LFTs, approximately 6 years prior to
admission, reportedly with negative liver biopsy.
History of mononucleosis in [**8-14**].
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No alcohol, drug or tobacco use. No recent
travel. No pets.
PHYSICAL EXAMINATION: On admission, VITAL SIGNS:
Temperature 102.2 degrees, pulse 103, blood pressure 116/76,
and respirations 20. GENERAL: A cachectic and ill-appearing
male, appearing mildly uncomfortable. HEENT: Pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements intact. Sclerae anicteric. Bilateral
temporal wasting and dry mucous membranes. CARDIOVASCULAR:
Regular rate. No murmurs, rubs or gallops. LUNGS: Clear to
auscultation and equal bilaterally. ABDOMEN: Positive bowel
sounds and soft. Minimally tender to palpation in the left
lower quadrant without any rebound tenderness or guarding.
No hepatosplenomegaly. EXTREMITIES: Warm and dry. No
clubbing, edema or cyanosis. NEUROLOGICAL: Nonfocal. SKIN:
Very faint trace maculopapular rash on bilateral upper
extremities with dry skin.
LABORATORY DATA: White count 9.8, hematocrit 39.9, and
platelets 441,000. Differential, 83 neutrophils, 14
lymphocytes, and 2 monocytes. Sodium 135, potassium 3.5,
chloride 96. BUN 10 and creatinine 0.7. ALT 62, AST 96,
amylase 43, alkaline phosphatase 397, and total bilirubin
0.7.
HOSPITAL COURSE: Abdominal pain. The patient admitted with
approximately 3 weeks of left lower quadrant abdominal pain
in concurrence with high-grade temperatures and profuse
diarrhea. He had had abdominal imaging at an outside
hospital and an empiric course of antibiotics without any
focal findings nor any improvement in his symptoms. At the
time of presentation, the patient did not have any focal
findings on his abdominal exam, however, there was concern
for underlying pathology. Given his ill-appearance, high-
temperatures, and constellation of clinical symptoms, there
was concern for an acute infection following attainment of
cultures. He was then started empirically on Levaquin and
Flagyl. Repeat abdominal CT was obtained, which again showed
diffuse lymphadenopathy in the mesentry with the largest node
seen in the left lower quadrant measuring approximately 2.9 x
2.0 cm. There were, otherwise, no focal findings on the CT.
Multiple laboratory studies were sent. These were
significant only for an elevated LDH, which was found to be
394. On admission, his LFTs were otherwise markedly
elevated. On initial presentation, a GI consult was
obtained. The patient continued to have progressive
abdominal pain and was somewhat tender on exam. Given his
some abnormal findings on CT and continued diarrhea, the
patient underwent an exploratory laparotomy. Upon opening of
the abdomen, we noted to have thick purulent fluid in his
abdomen, and he was then converted to an open abdominal
surgery. He was found to have approximately 20 masses in his
abdomen and 4 areas of microperforation, which were resected.
Multiple biopsies were also obtained. These biopsies later
came back showing celiac sprue associated T-cell lymphoma; in
addition, his anti-TIG antibody was positive.
Hematology/Oncology consult was obtained with plans for the
patient to begin chemotherapy following clinical
stabilization. He did complete a 10-day course of
antibiotics given the findings in his abdomen. He did
continue to spike fevers following antibiotics. Repeat
cultures and other infectious workup was nonrevealing and
thought his fevers were most likely related to his oncologic
diagnosis as opposed to any active infection. He also
continued to have diarrhea, which also was attributed to his
oncologic diagnosis.
Celiac sprue associated T-cell lymphoma. The patient newly
diagnosed with lymphoma at this hospitalization as per above.
An Oncology consult was obtained. At the time of dictation,
the patient was to be transferred to the Bone Marrow
Transplant Service for initiation of chemotherapy.
Celiac sprue. The patient newly diagnosed with celiac sprue.
He was placed on a low-gluten diet and had multiple nutrition
counseling sessions. Multiple vitamin levels were sent
including calcium and vitamin D levels, and all of these came
back normal. Given his weight loss and uncompromised
clinical status, he was started on TPN for supplemental
nutrition. His TPN was cycled in the evenings with the
patient taking orals during the day.
Infection. The patient was status post abdominal exploratory
laparotomy, which was then converted to open surgery given
normal findings on exam. The patient developed an abdominal
wound infection at the site of surgical closure, this was
also complicated by wound dehiscence. Surgery Service, which
had performed the abdominal surgery, continued to follow
this. Following completion of IV antibiotics and dressing
changes, his wound did slowly heal. At the time of
dictation, his wound infection continues to resolve.
Tachycardia. The patient was sinus tachycardic throughout
the hospitalization, which was more pronounced in the setting
of his fevers. He had multiple EKGs, which showed that he
was in sinus tachycardia. He also underwent an echo.
Initially, there had been concern for a pericardial effusion
following a CT; however, on echo found this to be an artifact
and there was no evidence of a pericardial effusion. His
tachycardia was thought to be most likely due to his
underlying malignancy. He continued to receive supportive
care and had no symptoms or hemodynamic compromise related to
his tachycardia.
Infectious Disease. The patient was febrile throughout the
hospital stay. Multiple blood cultures were obtained as well
as urine. Chest x-ray and CT scans with no other foci of
infection noted. He did complete empiric antibiotics given
bowel perforations. Given the negative infectious workup,
his fevers were thought to be most likely due to his
underlying malignancy. He continued to receive Tylenol,
cooling blankets and other supportive care as needed for his
fevers.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 33899**]
Dictated By:[**Last Name (NamePattern1) 14186**]
MEDQUIST36
D: [**2150-5-18**] 10:25:52
T: [**2150-5-18**] 18:28:23
Job#: [**Job Number 55186**]
ICD9 Codes: 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4382
} | Medical Text: Admission Date: [**2169-1-14**] Discharge Date: [**2169-1-19**]
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
PICC Line
Bronchoscopy [**1-15**] and [**1-16**]
History of Present Illness:
Ms. [**Known lastname 84119**] is an 85 year-old woman with resp failure/vent
dependent s/p trach, recent PEs, sCHF (EF 25%), AF, and PVD who
is transferred from rehab because of unresponsiveness and low
tidal volumes and is admitted to MICU for further management.
.
She was discharged on [**2169-1-13**] from the thoracics service after
presenting from an OSH with tracheal laceration in the setting
of traumatic intubation and sub-cutaneous emphysema
post-intubation. Her recent history prior to that includes a
fall on [**10-31**] with a C2 odontoid fracture and diagnosis of PEs
in the setting of dyspnea on [**2168-12-10**] requiring intubation
(complicated by trach injury) for hypercapnea. On the thoracics
service, she [**Date Range 1834**] multiple bronchoscopies and trach
placement ((#7 [**Last Name (un) 295**]) and revisions with clot demonstrated in
posterior trachea and trach dislodgement. She was discharged on
trach cpap with cmv onvernight. She was transitioned from CMV
ventilation to CPAP, and was able to tolerate trach collar for
unspecified periods of time.
.
At rehab, she had AMS/unresponsiveness which is different from
her baseline, and low tidal volumes on pressure support and was
transferred to the [**Hospital1 18**] for further management. ABG 7.24/44/91
(?may be an error) and 98.6 74 26 95/61 92% on fio2 40% per
rehab notes.
.
In the ED, vital signs were initially: 99 61 106/49 100% on
vent. CXR showed pleural effusions but no acute findings and IP
was consulted and felt trach was in good position and she did
not need urgent intervention. Thoracics was also notified and
will follow the patient. Head CT neg. UA was grossly positive
and cipro was started. She was also on a heparin gtt on arrival
and this was stopped when coags returned within INR 6. She was
then admitted for further management.
Past Medical History:
1. Possible CAD
2. Congestive heart failure, possible EF of 25% (per report)
3. COPD
4. Atrial fibrillation
5. LBBB
6. PVD
7. Arthritis
8. MRSA infection in the pasy
9. squamous cell carcinoma of right arm
10. dementia
11. Odontoid fracture in [**Location (un) **] collar
12. Hyperlipidemia
Social History:
+ tobacco, recently quit. No illicits or EtOH per report.
Widowed, lives with son [**Name (NI) **]. Healthcare proxy is son [**Name (NI) **].
Family History:
No CAD or arrhythmia
Physical Exam:
Tmax: 37.7 ??????C (99.8 ??????F)
Tcurrent: 37.6 ??????C (99.6 ??????F)
HR: 65 (48 - 82) bpm
BP: 99/41(56) {90/21(39) - 135/71(82)} mmHg
RR: 18 (13 - 22) insp/min
SpO2: 100%
Heart rhythm: AF (Atrial Fibrillation)
Height: 61 Inch
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, trach
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse) Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Extremities: Right lower extremity edema: 3+, Left lower
extremity edema: 3+ (bilaterally to the thighs)
Skin: Not assessed, No(t) Rash:
Neurologic: Minimally Responds to: Verbal stimuli, Movement:
Spontaneous, Tone: Not assessed, PERRL, withdraws to painful
stimuli, Upgoing toesNeurologic: Responds to: Not assessed,
Movement: Not assessed, Tone: Not assessed
Pertinent Results:
Admission:
[**2169-1-13**] 02:18AM BLOOD WBC-8.0 RBC-2.95* Hgb-9.4* Hct-30.2*
MCV-102* MCH-31.8 MCHC-31.0 RDW-16.7* Plt Ct-218
[**2169-1-14**] 12:15PM BLOOD Neuts-92.7* Lymphs-3.7* Monos-3.3 Eos-0.2
Baso-0.1
[**2169-1-13**] 02:18AM BLOOD PT-16.3* PTT-55.8* INR(PT)-1.4*
[**2169-1-13**] 02:18AM BLOOD Glucose-153* UreaN-24* Creat-0.3* Na-143
K-3.7 Cl-115* HCO3-24 AnGap-8
[**2169-1-14**] 12:15PM BLOOD ALT-21 AST-24 LD(LDH)-188 CK(CPK)-16*
AlkPhos-44 TotBili-0.2
[**2169-1-14**] 10:30AM BLOOD Lipase-29
[**2169-1-13**] 02:18AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2
[**2169-1-14**] 12:15PM BLOOD VitB12-471 Folate-GREATER TH
[**2169-1-14**] 12:15PM BLOOD TSH-1.0
[**2169-1-14**] 12:15PM BLOOD Free T4-1.1
[**2169-1-14**] 10:30AM BLOOD Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2169-1-14**] 12:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2169-1-14**] 12:39PM BLOOD Type-[**Last Name (un) **] pO2-87 pCO2-52* pH-7.26*
calTCO2-24 Base XS--4 Comment-GREEN TOP
[**2169-1-14**] 11:17AM BLOOD Glucose-158* Lactate-2.0 Na-145 K-4.5
Cl-112 calHCO3-24
Discharge:
[**2169-1-19**] 04:22AM BLOOD WBC-4.5 RBC-2.65* Hgb-8.7* Hct-25.7*
MCV-97 MCH-33.0* MCHC-34.0 RDW-16.8* Plt Ct-129*
[**2169-1-19**] 04:22AM BLOOD PT-17.2* PTT-30.3 INR(PT)-1.5*
[**2169-1-19**] 04:22AM BLOOD Glucose-114* UreaN-26* Creat-0.5 Na-139
K-3.7 Cl-107 HCO3-25 AnGap-11
[**2169-1-18**] 02:50PM BLOOD LD(LDH)-194 TotBili-0.5
[**2169-1-14**] 12:15PM BLOOD Lipase-27
[**2169-1-15**] 03:17AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2169-1-14**] 12:15PM BLOOD cTropnT-0.03*
[**2169-1-19**] 04:22AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.1
[**2169-1-18**] 02:50PM BLOOD Hapto-168
[**2169-1-18**] 11:00 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2169-1-18**]):
[**10-16**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
[**2169-1-16**] 8:30 pm URINE Source: Catheter.
**FINAL REPORT [**2169-1-19**]**
URINE CULTURE (Final [**2169-1-19**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 32 I
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
URINE CULTURE (Final [**2169-1-18**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R <=2 S
CEFAZOLIN------------- =>64 R <=4 S
CEFEPIME-------------- 32 R <=1 S
CEFTAZIDIME----------- R <=1 S
CEFTRIAXONE----------- =>64 R <=1 S
CIPROFLOXACIN--------- =>4 R <=0.25 S
GENTAMICIN------------ 2 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I <=16 S
PIPERACILLIN/TAZO----- 32 I <=4 S
TOBRAMYCIN------------ 4 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
Blood Cultures: NGTD
CT Head [**1-14**]
IMPRESSION:
1. No definite acute intracranial pathology. No bleed or
evidence for acute
vascular territorial infarction. However, if there is concern
for acute
infarct, MRI with diffusion- weighted imaging, if feasible, is
more sensitive.
2. Chronic small vessel microvascular infarction and global
parenchymal
atrophy.
3. Secretions within bilateral sphenoid and right mastoid apical
air cells,
some of which may relate to the (reported) presence of
tracheostomy.
CXR [**1-18**]:
The ET tube tip is 4 cm above the carina. Cardiomediastinal
silhouette is
unchanged. There is slight interval improvement in vascular
engorgement. No
change in bibasal left more than right atelectasis is seen.
Brief Hospital Course:
# Acute on Chronic respiratory failure: The patient was
admitted due to altered mental status and low tidal volumes.
The patient with known traumatic intubation at OSH c/b tracheal
injury, and trached here requiring multiple revisions. Also
with COPD. Patient went into respiratory distress with hypoxia
and hypotension. She was started on levophed and [**Month/Year (2) 1834**]
emergent bronch. The bronch showed granulation tissue
obstructing 95% of her tube. The tube was passed farther down
past the site of obstruction and the patient's respiratory
status improved and was weaned off levophed. The patient then
[**Month/Year (2) 1834**] repeat bronch the following day on [**1-15**] that showed
the tube to be patent and the tracheal laceration to be healing
well. The patient's respiratory status remained stable and her
ventilator settings at the time of dicharge were: CMV, Vt
(Set):450, RR (Set): 14, PEEP: 5 cmH2O, and FiO2: 40%. The
patient was also treated for a VAP based on CXR (left
retrocardiac opcaity and increasing sputum). She was started on
Vanco/Cefepime on [**1-16**] for presumed VAP. She was then changed
to Vanco/Meropenem given her ESBL urine cx results. Her sputum
subsequently grew out GNR and she will continue vancomycin and
meropenem for a planned 8 day course (last day:[**1-24**]). A PICC
line was placed on [**1-18**]. The patient did have a low grade temp
of 100.5 at the time of discharge. This was discussed with Dr.
[**Last Name (STitle) 84121**] at [**Hospital1 **] and is aware.
#. VAP: See above for respiratory course. Patient with planned
8 day course of meropenem with final day being [**2169-1-24**]. Sputum
is currently growing GNR and needs to be followed up for final
speciation and sensitivities.
#UTI: The patient was intially treated with ciprofloxacin on
admission for a positive UA. She was then broadened to
Vanco/Cefepime given she was at rehab for resistant organisms.
The UCx returned ESBL E. Coli and was switched to meropenem for
a planned 8 day course (last day [**2169-1-24**]).
# Altered mental status: The patient came in minimally reactive
which was a change from her baseline per the family. Her change
in mental status was attributed to her infection and after
treatment for her VAP and UTI her mental status returned to
baseline. She is able to follow very simple commands and answer
some simple yes/no questions.
# CHF: The patient had an EF 25% per report. Her metoprolol
and lisinopril was held given her infection and normal blood
pressure. Additionally, her lasix was initially held. The
patient was restarted on her metoprolol at 12.5mg [**Hospital1 **], but
several doses were held secondary to hypotension and
bradycardia. Her blood pressure and heart rate should be
monitored at rehab and titrate metoprolol accordingly. The
patient was restarted on her lasix 20mg po BID given her volume
overload. Her weight, respirtory status and I/O should be
monitored and lasix titrated at rehab.
#Anemia: The patient admission Hct was 26 and slowly trended
down to Hct 21. Her hemolysis labs were negative and there were
no signs of active bleeding. Her guaiac was negative. She was
trnasfused one unit [**1-18**] and her Hct remained stable. Upon
discharge her Hct was 25.7.
# PEs: Patient with recent diagnosis in [**11-30**]. The patient was
continued on coumadin 3mg daily and brdiged with lovenox 60mg
q12 for a subtherapeutic INR. Upon discharge her coumadin was
increased to 5mg daily and continued on lovenox 60mg [**Hospital1 **] until
INR >2.0.
# C2 fracture: Patient with C2 fracture after a fall on [**10-31**].
She was maintained on a [**Location (un) 2848**] J-collar. The patient should have
follow-up with neurosurgery as an outpatient.
# AFib: Patient's metoprolol was initially held due to ongoing
infection. Her metoprolol was restarted on 12.5mg [**Hospital1 **] and
continued on systemic coagulation.
Medications on Admission:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Six (6) Puff Inhalation Q4H (every 4 hours).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q4H (every 4 hours).
5. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
6. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
7. Potassium Chloride 20 mEq Packet [**Hospital1 **]: One (1) packet PO twice
a day: adjust as labs or lasix adjusted.
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: Five (5)
ML PO Q6H (every 6 hours) as needed for pain.
9. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: Three (3) ML
[**Hospital1 **]
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: Three (3) ml Inhalation [**Hospital1 **] (2 times a day).
11. Warfarin 3 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime: goal
INR for afib [**1-25**]. rehab MD to adjust coumadin dose based on INR.
stop heparin gtt once INR >2.0.
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One PO
DAILY
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
14. Lisinopril 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily
15. Simvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.
16. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution [**Last Name (STitle) **]: Seven Hundred (700) units Intravenous ASDIR (AS
DIRECTED): adjust for PTT 60-80. check q 6 hrs or per protocol
if stable >24 hrs. stop when INR >2.0.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6)
Puff Inhalation QID (4 times a day).
4. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: Five (5)
ML PO Q6H (every 6 hours) as needed for pain.
6. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day) as needed for mouthcare.
7. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO daily
().
10. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
11. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for thick
secretions.
12. Enoxaparin 60 mg/0.6 mL Syringe [**Hospital1 **]: One (1) Subcutaneous
Q12H (every 12 hours).
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezes.
14. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
15. Warfarin 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Once Daily at 4
PM.
16. Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every
12 hours).
17. Meropenem 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
18. Vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) Intravenous Q
24H (Every 24 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Urinary tract Infection- E.coli (ESBL)
Pneumonia
Discharge Condition:
Level of Consciousness:Lethargic but arousable
Activity Status:Bedbound
Mental Status:Patient has trach, arousable but not following any
commands
Discharge Instructions:
You were admitted to the hospital for concerns of a urinary
traction infection and pneumonia. You were treated with
antibiotics and will need to complete this course while at
rehab.
Followup Instructions:
Completed by:[**2169-1-19**]
ICD9 Codes: 5990, 5119, 4280, 4439, 496, 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4383
} | Medical Text: Admission Date: [**2133-5-13**] Discharge Date: [**2133-5-19**]
Date of Birth: [**2067-12-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
flail post. MV leaflet, mod.-severe MVP found on follow up echo.
known MVP/MR [**First Name (Titles) **] [**Last Name (Titles) 10718**] of endocarditis in '[**18**].
Major Surgical or Invasive Procedure:
Mitral Valve repair (#34mm CE physio ring)[**5-13**]
History of Present Illness:
65yo male with known MVP/MR diagnosed '[**18**] after an [**Year (2 digits) 10718**] of
endocarditis. He only admits to mild PND at high altitude. He
now presents for surgical evaluation. Cardiac echo [**10-30**] reveals
mod-severe MVP,3+MR with partial mitral post. flail leaflet.
DR.[**Last Name (STitle) **] was consulted for MVrepair.
Past Medical History:
MVP/MR, hyperlipidemia, endocarditis'[**18**], GERD, RLL nodule, Left
periaortic mass c/w esoph. cyst vs. bronchogenic cyst stable
since '[**19**], right knee surgery, torn left rotator cuff, ?OSA
Social History:
retired engineer, denies tobacco, 2-3 beers/week.
Family History:
father with PPM at age [**Age over 90 **], brother and son with heart
murmurs.lives in [**Location **] with wife.
Physical Exam:
Admission Physical Exam
afebrile, Pulse:72, RR:14, BP:146/78, Ht:72",Wt:188lb
General: A&Ox3, NAD
HEENT: [**Last Name (un) **], NC/AT, carotids: neg. bruits/JVD
CVS:RRR, Nl S1-S2, III/VI holosystolic murmur
Lungs:CTA
ABD:benign
EXT:0 C/C/E, no varicosities
Discharge EXAM
T:99.1, P:81,BP:136/88, RR:18, O2SAT: 96%, Wt:85.9KG
General:A&Ox3,NAD
HEENT:AT/NC, [**Last Name (un) **]
CVS:RRR
Lungs:CTA
ABD:benign
EXT: neg. C/C/E
Pertinent Results:
[**2133-5-18**] 09:00PM BLOOD WBC-8.8 RBC-3.54* Hgb-11.2* Hct-31.6*
MCV-89 MCH-31.7 MCHC-35.5* RDW-15.1 Plt Ct-242#
[**2133-5-13**] 12:22PM BLOOD WBC-18.0*# RBC-3.62* Hgb-11.2*# Hct-32.4*
MCV-90 MCH-31.0 MCHC-34.6 RDW-14.8 Plt Ct-159
[**2133-5-17**] 02:40PM BLOOD Glucose-133* UreaN-16 Creat-0.8 Na-135
K-3.9 Cl-101 HCO3-28 AnGap-10
[**2133-5-13**] 01:18PM BLOOD UreaN-17 Creat-0.9 Cl-113* HCO3-24
Approved: FRI [**2133-5-15**] 2:59 PM
[**2133-5-18**] 09:00PM BLOOD WBC-8.8 RBC-3.54* Hgb-11.2* Hct-31.6*
MCV-89 MCH-31.7 MCHC-35.5* RDW-15.1 Plt Ct-242#
[**2133-5-18**] 09:00PM BLOOD Plt Ct-242#
[**2133-5-15**] 12:25AM BLOOD PT-15.9* PTT-29.3 INR(PT)-1.4*
[**2133-5-17**] 02:40PM BLOOD Glucose-133* UreaN-16 Creat-0.8 Na-135
K-3.9 Cl-101 HCO3-28 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 28207**], [**Known firstname 870**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 3947**] [**Hospital1 18**] [**Numeric Identifier 28208**]Portable
TTE (Focused views) Done [**2133-5-14**] at 4:17:57 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2067-12-14**]
Age (years): 65 M Hgt (in): 70
BP (mm Hg): 118/65 Wgt (lb): 190
HR (bpm): 83 BSA (m2): 2.04 m2
Indication: LV function; status post mitral valev repair
ICD-9 Codes: 424.1, 424.0, 424.2
Test Information
Date/Time: [**2133-5-14**] at 16:17 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **],
MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 2270**]
[**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2008W033-0:00 Machine: Vivid [**6-28**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *6.3 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.0 cm <= 5.0 cm
Left Ventricle - Ejection Fraction: 70% >= 55%
Left Ventricle - Peak Resting LVOT gradient: *12 mm Hg <= 10
mm Hg
Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *25 < 15
Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec
Mitral Valve - Mean Gradient: 5 mm Hg
Mitral Valve - E Wave: 1.6 m/sec
Mitral Valve - A Wave: 1.4 m/sec
Mitral Valve - E/A ratio: 1.14
Mitral Valve - E Wave deceleration time: *260 ms 140-250 ms
TR Gradient (+ RA = PASP): *18 to 30 mm Hg <= 25 mm Hg
Findings
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Mild resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Myxomatous
mitral valve leaflets. Mitral valve annuloplasty ring.
Well-seated mitral annular ring with normal gradient. [**Male First Name (un) **] of
mitral valve leaflets. No MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Normal tricuspid valve supporting structures. No TS. Mild [1+]
TR. Borderline PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - bandages,
defibrillator pads or electrodes.
Conclusions
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 70%) There is a mild resting
left ventricular outflow tract obstruction. Right ventricular
chamber size and free wall motion 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. The mitral valve leaflets
are myxomatous. A mitral valve annuloplasty ring is present. The
mitral annular ring appears well seated and is not obstructing
flow. There is systolic anterior motion of the mitral valve
leaflets. No mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2133-4-30**], the mitral valve has been repaired (ring
annuloplasty); however, there is now systolic anterior motion of
the anterior mitral leaflet with mild left ventricular outflow
tract obstruction.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2133-5-14**] 17:01
Brief Hospital Course:
On [**2133-5-13**] Mr [**Known lastname **] was taken to the OR where he underwent a
Mitral Valve repair with #34mm CE physio ring. Please refer to
DrKhabbaz's operative note for further details. Cross clamp
time:49" Cardiopulmonary bypass time:64". He was transferred to
the CVICU intubated on propofol and Neo to optimize his blood
pressure and cardiac output. He was extubated without incident
and tubes and lines were discontinued in a timely fashion. POD#1
he had a near syncopal [**Known lastname 10718**] and was treated with volume for
orthostatic hypotension. EKG changes postop were evident with ST
elevations and a intermittent LBBB. Mr [**Known lastname **] was started on
Ibuprofen for pericarditis. POD #2 he was doing well and
transferred to the floor. Further tele monitoring revealed LBBB
resolved. Beta blocker was optimized and he remains
hemodynamically stable. On [**2133-5-19**] it was felt that Mr [**Known lastname **]
was doing well and was ready to be discharged to home with VNA
services.
Medications on Admission:
Lipitor 5(1),Aciphex 15(1), Lisinopril 40(1),Amoxicillin prn
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:*1 30* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed: 1 month only.
Disp:*90 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*
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
status post Mitral Valve repair (#34mm CE physio ring)
PMH: MVP/MR,hyperlipidemia, endocarditis'[**18**], GERD, RLL nodule, L
periaortic mass c/w esophageal cyst vs. bronchogenic cyst stable
since '[**19**],torn left rotator cuff, ?OSA, right knee surgery
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:
wound clinic in 2 weeks
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 1 week ([**Telephone/Fax (1) 28209**]) please call for
appointment
appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2133-5-20**]
ICD9 Codes: 4240, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4384
} | Medical Text: Admission Date: [**2109-3-7**] Discharge Date: [**2109-3-20**]
Date of Birth: [**2034-4-19**] Sex: M
Service: [**Company 191**]
CHIEF COMPLAINT: Unable to swallow.
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
male with multiple medical problems and recent
hospitalization for left lower extremity ulcer infected with
methicillin-resistant Staphylococcus aureus.
The patient was directly admitted from home for a decreasing
ability to take p.o. secondary to throat pain when
swallowing. The patient has a history of throat cancer and
status post surgery and radiation therapy. The patient
denies abdominal pain and nausea but does admit to lack of
appetite. He says his clothes are fitting loosely and has
apparently lost a lot of weight in the last month or two.
The patient states that he was admitted "to get a feeding
tube."
Of note, the patient has old pacemaker wires in his abdomen
which may complicate percutaneous endoscopic gastrostomy tube
placement. The patient is also on Coumadin for atrial
fibrillation and reportedly has not taken his Coumadin in
three days. However, his latest INR drawn on [**3-6**]
was 9.5. The patient undergoes hemodialysis on Monday,
Wednesday and Friday which should be continued while in the
hospital.
PAST MEDICAL HISTORY:
1. Congestive heart failure with an ejection fraction of
less than 15% by echocardiogram in [**2108-12-21**].
2. End-stage renal disease (on hemodialysis three times per
week).
3. Coronary artery disease; status post myocardial
infarction times two, with percutaneous transluminal coronary
angioplasty to the circumflex.
4. Chronic obstructive pulmonary disease.
5. Paroxysmal atrial fibrillation (on Coumadin).
6. History of ventricular tachycardia; status post
implantable cardioverter-defibrillator placement.
7. Pulmonary hypertension and pulmonary fibrosis secondary
to amiodarone toxicity.
8. Hypertension.
9. Status post throat cancer for which he was treated with
radiation therapy.
10. History of diabetes.
11. History of colon cancer, status post colectomy.
12. History of gout.
13. Hypothyroidism.
14. Peripheral vascular disease with chronic lower extremity
ulcer.
MEDICATIONS ON ADMISSION: Digoxin 0.125 mg p.o. q.d.,
Colace 100 mg p.o. q.d., Synthroid 50 mcg p.o. q.d., Coumadin
4 mg p.o. q.h.s., Tums 1 tablet p.o. t.i.d., Nephrocaps 1
tablet p.o. b.i.d., Xanax 0.25 mg p.o. q.h.s., pravastatin 20
mg p.o. q.h.s., trazodone 50 mg p.o. q.h.s., Tylenol No. 3
p.r.n., levofloxacin 250 mg p.o. q.o.d., Flagyl 500 mg p.o.
b.i.d., vitamin C, and vancomycin (which is dosed at
dialysis).
ALLERGIES:
SOCIAL HISTORY: The patient lives with wife at home. He has
a daughter who is a nurse and extremely involved in his care.
He has no history of tobacco, and no current alcohol use.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature of 95.9,
blood pressure of 86/63, heart rate of 88, respiratory rate
of 20, satting 100% on room air. The patient was a pale,
cachectic male lying in bed, and appeared sleepy. Pupils
were equal, round, and reactive to light. Mucous membranes
were dry. Tongue was red and smooth. Extraocular movements
were intact. Heart was irregular. No murmurs. The point of
maximal impulse was laterally displaced. Chest had bibasilar
crackles, and a pacemaker was noted in the right upper chest
wall. The abdomen was soft, normal active bowel sounds,
wires were noted in the right abdominal wall. Extremities
revealed bilateral pitting edema. Venous stasis changes
bilaterally. The patient had a dressing over the left lower
leg. His toes were cool with nonpalpable dorsalis pedis
pulses. Neurologic examination revealed cranial nerves were
intact. The patient was weak but moved all four extremities.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed a white blood cell count of 10.9,
hematocrit of 51, platelets of 189 (70 neutrophils, 4 bands,
12 lymphocytes). Sodium of 142, potassium of 5.5, chloride
of 104, bicarbonate of 22, blood urea nitrogen of 51,
creatinine of 6.2, blood sugar of 131. Albumin of 3.2,
calcium of 9.6, phosphate of 4.6, magnesium of 2.1. Iron
of 100. INR of 5.1. Digoxin level of 4.2.
HOSPITAL COURSE: The [**Hospital 228**] hospital course was quite
complicated and marked by two trips to the Intensive Care
Unit. Of note, on admission, the patient was noted to be
digoxin toxic, and his digoxin was held throughout his
hospitalization. There were no electrocardiogram changes
concerning for digoxin toxicity, and the patient was
asymptomatic. The patient's blood pressure on admission was
notably low, in the 80s/50s. According to his family, his
blood pressure did run on the low side. It was felt by the
team that he was severely dehydrated due to poor oral intake
over the past few weeks. He was gently hydrated due a known
ejection fraction of 10%.
On [**3-8**], status post dialysis, the patient became
hypotensive to the 70s and was admitted to the Intensive Care
Unit briefly for further monitoring. He received more
intravenous fluids at that point. The Medical Intensive Care
Unit stay was short, and he was called back out to the floor
on [**3-9**].
A percutaneous endoscopic gastrostomy tube was placed on
[**3-11**]; and, of note, the patient got 600 cc of lactated
Ringer's intraoperatively as well as Fentanyl.
Overnight, following the procedure, the patient was
persistently hypotensive in the 70s/30s and did not respond
to fluid boluses. The patient was admitted back to the
Medical Intensive Care Unit on [**3-10**] for hypotension
refractory to intravenous fluids. The patient was maintained
on a dopamine drip for several days for a blood pressure in
the 90s. There was some confusion as to his volume status,
not being clear whether he was dehydrated or volume
overloaded, and with his low ejection fraction, he had been
pushed off the Starling curve.
On [**3-15**], the patient was dialyzed off 2 liters of fluid
which then enabled the dopamine to be weaned off. Again, on
[**3-16**], an additional 2 liters were dialyzed off. The
patient was stable off dopamine for 24 hours with a blood
pressure in the 90s, and he was transferred out to the floor
on [**3-16**].
The patient initially was stable on the floor but was noted
to have increasing tachypnea over [**3-17**] and [**3-18**]. On
[**3-19**], upon evaluation by the team, the patient was
increasingly tachypneic, more somnolent, and was feeling very
poorly to the point where he said, "I just want to die." An
arterial blood gas was done and revealed an acidosis with a
pH of 7.22, a PCO2 of 50, and a PO2 of 129 on 4 liters nasal
cannula. A STAT chest x-ray revealed a large right-sided
pleural effusion, and when compared with previous x-rays was
read as increasing bilateral effusions, right greater than
left. The effusion was drained by ultrasound guidance by
the Radiology team, and approximately 1.2 liters were taken
off. The patient had improved respiratory status after and
appeared more comfortable. Fluid studies were pending at the
time of this dictation.
Other issues during this hospitalization included his
nutritional status. The patient was originally treated with
intravenous fluid hydration as noted above prior to
percutaneous endoscopic gastrostomy tube placement.
A gastrojejunostomy tube was placed by Interventional
Radiology on [**3-11**] without any complications. The patient
tolerated the procedure well and was immediately started on
.................... for tube feeds. This was changed to
Nepro on [**3-19**] due to his renal failure. The patient
continued to tolerate tube feeds well and will be sent home
on Nepro tube feeds with a goal of 50 cc per hour.
The patient's renal status was basically stable throughout
this hospitalization. He continued to be dialyzed on Monday,
Wednesday and Friday. There were no complications.
Infectious Disease issues included continuation of Flagyl,
levofloxacin, and vancomycin for his left lower extremity
ulcer. The Vascular team did come by and see the patient and
recommended continuing wet-to-dry dressing changes b.i.d. as
well as to keep pressure off the leg. The patient was kept
in multipoultice boots to prevent further skin breakdown.
Hematologic issues included the need for reversal of his
supratherapeutic INR which was 9.2 on admission. On the
first two days of his hospitalization the patient received
several doses of p.o. vitamin K to help reverse his INR. The
patient was kept off Coumadin status post percutaneous
endoscopic gastrostomy tube placement during his Medical
Intensive Care Unit stays and was restarted on Coumadin on
[**3-18**]. His INR will need to be followed closely.
Social and disposition issues during this hospitalization
included the overall goals of care. Initially, the patient
and family were very adamant that he should be full code and
wanted everything done. It became more clear to the family
and the patient during this hospitalization that he was very
sick and had multiple medical problems.
On [**3-19**], after a thoracentesis, the patient and family
had a discussion with the attending and the decision was made
to change the patient to do not resuscitate/do not intubate.
The plan was to send the patient home with services. Further
discussions about goals of care may be carried out with the
attending at a future date.
DISCHARGE DIAGNOSES:
1. End-stage renal disease.
2. Congestive heart failure with an ejection fraction
of 15%.
3. Peripheral vascular disease with chronic left leg ulcer
infected with methicillin-resistant Staphylococcus aureus.
4. Bilateral pleural effusions.
5. Chronic atrial fibrillation.
6. Ventricular tachycardia/ventricular fibrillation with
implantable cardioverter-defibrillator placement.
7. Status post gastrojejunostomy tube for odynophagia.
MEDICATIONS ON DISCHARGE:
1. Nepro tube feeds 50 cc per hour.
2. Coumadin 2 mg p.o. q.h.s.
3. Colace 100 mg p.o. b.i.d.
4. Trazodone 50 mg p.o. q.h.s.
5. Xanax 0.5 mg p.o. q.h.s.
6. Metronidazole 500 mg p.o. b.i.d.
7. Prevacid 30 mg p.o. q.d.
8. Synthroid 50 mcg p.o. q.d.
9. Nephrocaps 1 tablet p.o. q.d.
10. Tums 1 tablet p.o. with meals.
11. Vitamin C 1000 IU p.o. q.d.
12. Levofloxacin 250 mg p.o. q.i.d.
13. Senna 2 tablets p.o. q.d.
14. Vancomycin intravenously (to be dosed at hemodialysis).
DISCHARGE STATUS: The patient will be discharged home with
services. He will require [**Hospital6 407**] for
dressing changes of his leg. The patient will also require
close monitoring of his INR and continued followup of his
digoxin level.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**]
Dictated By:[**Last Name (NamePattern1) 6765**]
MEDQUIST36
D: [**2109-3-19**] 19:02
T: [**2109-3-19**] 20:25
JOB#: [**Job Number 42677**]
ICD9 Codes: 2765, 4280, 496, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4385
} | Medical Text: Admission Date: [**2147-10-11**] Discharge Date: [**2147-10-20**]
Date of Birth: [**2079-5-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
lisinopril / Iodine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
mitral and tricuspid regurgitation
Major Surgical or Invasive Procedure:
[**2147-10-12**] - 1. Radical mitral valve repair with a extensive
posterior leaflet (P2) triangular resection with plasty of the
P3 segment of the posterior leaflet and ring annuloplasty using
a 36-mm [**Doctor Last Name **] physio II ring. Ring data: model number 5200,
serial #[**Serial Number 96775**].
2. Tricuspid valve valvuloplasty with a 32-mm [**Doctor Last Name **] MC cubed
ring, model #4900, serial #[**Serial Number 96776**].
3. Full left-sided Maze procedure with resection of left atrial
appendage using the Atricure synergy bipolar RF system and the
cryo cath.
History of Present Illness:
This 68 year old female experiences paroxysmal episodes of
atrial fibrillation. She has been on amiodarone since at least
[**2142**]. She had a recurrence of atrial fibrillation the spring of
thids year, associated with progressive shortness of breath and
chest pain. She had an extensive work up at that time including
a cardiac catheterization, transthoracic echocardiogram,
transesophageal echocardiogram and a stress test.
Ultimately, she was diuresed, her amiodarone was increased to
200 mg daily and she underwent cardioversion which restored
sinus rhythm at which point she felt significantly better. She
continued on Coumadin. Shenow states to Dr. [**Last Name (STitle) **] she feels
periodic shortness of breath with significant
exertion or climbing stairs and feels her energy level is
declining. She was noted to be back in AF at her most recent
visit and has been followed by Dr. [**Last Name (STitle) **]. She is reporting
increasing shortness of breath over the past month. She is
admitted now for a Heparin bridge with plans for surgery in the
AM.
Past Medical History:
paroxysmal atrial fibrillation
mitral valve regurgitation/ prolapse
hypertension
coronary artery disease
basal and squamous cell skin carcinomas
hematuria (cystoscopy negative)
varicose veins with stasis
bilateral feet neuropathy
s/p appendectomy
s/p cholecystectomy
s/p reduction mammoplasties
s/p total abdominal hysterectomy
s/p phlebectomies
Social History:
Patient lives alone. She works in Food and Beverage Services as
a manager.
-Tobacco history: denied
-ETOH: occasional
-Illicit drugs: denied
Family History:
Grandfather with DM and MI in his 50's
Father with HTN and CAD
Physical Exam:
Pulse:82 Resp:18 O2 sat: 100% RA
B/P Right: 118/77 Left:
Height: 64" Weight:160
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera
Neck: Supple [x] Full ROM [x]no JVD appreciated
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [x] grade 3/6 systolic
radiates best to apex and B carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no HSM; well healed scars
Extremities: Warm [x], well-perfused [x] Edema [] none
Varicosities: severe BLE, multiple healed tiny sites
Neuro: Grossly intact [x]; MAE [**5-4**] strengths, nonfocal exam
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:trace Left:trace
Radial Right:2+ Left:2+
Carotid Bruit murmur radiates to B carotids
Pertinent Results:
ECHO [**2147-10-12**]
PREBYPASS:
The left atrium is markedly dilated. The coronary sinus is
dilated. No spontaneous echo contrast or thrombus is seen in the
body of the left atrium or left atrial appendage. The left
atrial appendage emptying velocity is depressed (<0.2m/s). No
thrombus is seen in the left atrial appendage. The right atrium
is markedly dilated. No atrial septal defect is seen by 2D or
color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is top normal/borderline dilated.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45%) with intrinsic function depressed in the presence of
MR.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild to moderate ([**1-1**]+) aortic
regurgitation is seen.
The mitral valve leaflets are myxomatous. There is
moderate/severe bileaflet mitral valve prolapse. Moderate to
severe (3+) mitral regurgitation is seen.
The tricuspid valve is abnormal. Moderate to severe [3+]
tricuspid regurgitation is seen. IVC is dilated and is not
changing in size with ventilation.
There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in
person at the time of the study.
POSTBYPASS:
The patient is AV paced on Milrinone, Norepinephrine and
Vasopressin infusions. Biventricular function is maintatined.
There are no wall motion abnormalities.
There is a well seated annuloplasty ring in the mitral position.
There is mild mitral regurgitation. There is no stenosis. There
is no evidence of [**Male First Name (un) **] or LVOTO obstruction.
There is a well seated annuloplasty ring in the tricuspid
position. There is trace tricuspid regurgitation. There is no
stenosis.
The mild to moderate aortic insufficiency is unchanged. The
aorta remains intact.
[**2147-10-18**] 05:11AM BLOOD WBC-5.9 RBC-3.71* Hgb-10.4* Hct-32.1*
MCV-86 MCH-28.1 MCHC-32.6 RDW-14.3 Plt Ct-239
[**2147-10-19**] 04:10AM BLOOD PT-16.0* INR(PT)-1.4*
[**2147-10-19**] 04:10AM BLOOD PT-16.0* INR(PT)-1.4*
[**2147-10-18**] 05:11AM BLOOD PT-15.8* PTT-26.5 INR(PT)-1.4*
[**2147-10-17**] 04:54AM BLOOD PT-16.7* PTT-27.0 INR(PT)-1.5*
[**2147-10-16**] 01:43AM BLOOD PT-14.8* PTT-26.6 INR(PT)-1.3*
[**2147-10-15**] 01:54AM BLOOD Plt Ct-139*
[**2147-10-15**] 01:54AM BLOOD PT-14.5* PTT-27.9 INR(PT)-1.2*
[**2147-10-14**] 09:10AM BLOOD PT-14.2* PTT-26.8 INR(PT)-1.2*
[**2147-10-19**] 04:10AM BLOOD UreaN-12 Creat-0.5 Na-140 K-3.9 Cl-103
[**2147-10-20**] 06:15AM BLOOD WBC-10.3# RBC-4.10* Hgb-11.7* Hct-35.8*
MCV-87 MCH-28.4 MCHC-32.6 RDW-14.6 Plt Ct-333
[**2147-10-20**] 06:15AM BLOOD PT-20.1* INR(PT)-1.8*
[**2147-10-20**] 06:15AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-138
K-4.4 Cl-102 HCO3-27 AnGap-13
Brief Hospital Course:
Ms. [**Known lastname 21721**] was admitted to the [**Hospital1 18**] on [**2147-10-11**] for surgical
management of her mitral and tricuspid valve disease. She was
placed on Heparin as she had been off Coumadin for 4 days. She
was worked up in the usual preoperative manner.
On [**2147-10-12**], she was taken to the Operating Room where she
underwent mitral and tricuspid valve repair as well as a MAZE
procedure and left atrial appendage ligation. Please see
operative note for details. Postoperatively she was taken to the
intensive care unit for monitoring on Vasopressin, Milrinone and
levophed infusions. She remained sedated and intubated
overnight. Slowly her pressors were weaned.
On postoperative day one, she awoke neurologically intact and
was extubated. Beta blockade, aspirin and a statin were resumed.
However, soon afterwards she experienced Wenckebach dysrhythmia
and her beta blockade was held. The Electrophysiology Service
was consulted. They felt that a permanent pacemaker was not
warranted after her rhythm recovered but they felt beta blockade
should be held for at least two weeks. She will be discharged
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor and will follow up with Dr.
[**Last Name (STitle) **]. Her epicardial wires were removed as were CTs
without incident.
Coumadin was resumed for her history of atrial fibrillation.
Physical Therapy worked with her for strength and mobility. She
was diuresd towards her preoperative weight.
Arrangements were made for Coumadin to be managed by [**Hospital 191**]
[**Hospital 2786**] clinic for Dr. [**Last Name (STitle) **]. The goal INR is 2-2.5.
Medications on Admission:
***COUMADIN 3 mg MWF, 2 mg T TH S,S - last dose [**2147-10-7**]
ASA 82 mg daily
amiodarone 200 mg daily - stopped 1 week ago
amlodipine 2.5 mg daily
lasix 20 mg daily
atenolol 50 mg daily
HCTZ 25 mg daily - stopped 1 week ago
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
5. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*2*
6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: resume
daily dosing after 1 week course of [**Hospital1 **] dosing.
Disp:*30 Tablet(s)* Refills:*2*
8. warfarin 1 mg Tablet Sig: as directed Tablet PO once a day:
take daily as directed based upon INR results.
Disp:*100 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2-2.5
First draw [**2147-10-21**]
Results to phone [**Telephone/Fax (1) 2173**], [**Company 191**] coumadin clinic for Dr.
[**Last Name (STitle) **]
10. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
coronary artery disease
mitral regurgitation
tricuspid regurgitation
s/p mitral valve repair, MAZE,tricuspid repair, ligation of left
atrial appendage
paroxysmal atrial fibrillation
hypertension
basal cell carcinoma skin
squamous cell carcinoma skin
varicose veins with venous stasis
s/p bilateral phlebectomies
s/p appendectomy
s/p cholecystectomy
s/p reduction mammoplasties
s/p total abdominal hysterectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema :none
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2147-11-28**] 1:15
Cardiologist: Dr. [**Last Name (STitle) **] on [**2147-10-24**] 4:20
[**First Name11 (Name Pattern1) 1521**] [**Last Name (NamePattern1) 1522**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2147-11-16**] 11:00
Please call to schedule appointments with:
Primary Care: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 250**]) in [**4-4**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2-2.5
First draw [**2147-10-21**]
Results to phone [**Telephone/Fax (1) 2173**], [**Company 191**] coumadin clinic for Dr.
[**Last Name (STitle) **]
Completed by:[**2147-10-20**]
ICD9 Codes: 4240, 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4386
} | Medical Text: Admission Date: [**2103-7-18**] Discharge Date: [**2103-7-24**]
Date of Birth: [**2061-7-31**] Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
This is a 41-year-old woman with a past medical history
significant for obesity hypoventilation, apparent reactive
airway disease, hypertension, hyperlipidemia who presented to
the ED with shortness of breath and chest tightness since last
night. According to the ED, this was worsening throughout the
day today, so patient called EMS. On EMS arrival, she was
tachypneic and placed on a nonrebreather.
On arrival to the ED, initial vitals were 98.5 105 170/120 20
100% on NRB. She was given duonebs x 2, 125 IV solumedrol.
Initial VBG showed 7.32/67/76. She was trialed on BiPAP,
however, became increasingly somnolent, snoring, dropping O2
sats to 70s/80, so was intubated. Per the ED resident, the
intubation was difficult requiring three attempts, placed [**8-2**]
tube. After the intubation, there was blood suctioned from the
ETT that cleared with a minilavage by respiratory. On transfer,
her vent settings were CMV Fi02 100 5 PEEP, TV 450 on propofol
50, vitals 99 114/51 100%. A RIJ was placed in the ED. CTA done
to r/o PE was performed prior to transfer to the ICU.
Of note, she was recently discharged on [**6-17**] for hypercarbic
respiratory failure and reactive airway disease, recovered with
BiPAP, nebulizers, steroids, and azithromycin. She was also
given a dose of 20 IV lasix, even though she has no history of
heart failure. Patient was supposed to have outpatient sleep
study and pulmonary evaluation.
Past Medical History:
Obesity Hypoventilation Syndrome
Glaucoma
HLD
HTN
Schizophrenia
Depression (per her report)
Morbid obesity
Reactive airway disease
History of Positive PPD
History of resolved HEPATITIS B VIRUS
Social History:
Lives in a group home, unemployed. Smoked for many years but has
quit. No ETOH or IVDA. Has three daughters. Not married.
Patient was born and raised by parents in [**Country 2045**]. Moved
to U.S. at age 16.
Family History:
Brother is healthy. Parents died of unknown cause.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 99.9F, BP 154/84, HR 83, R 20, O2-sat 97% RA
GENERAL - Cushingoid appearing female in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
chelitis noted on R lip angle
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - bibasilar inspiratory dry crackles, R>L, good air
movement, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), tenderness over elbow, knee, MTP joints, costal margin
b/l, no dramatic joint deformities noted
SKIN - no rashes or lesions, overall ruddy complexion, no silver
plaques
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, moving all extremities, Kernig and
Brudzkinski negative
Pertinent Results:
[**2103-7-18**] 09:28PM TYPE-CENTRAL VE PO2-59* PCO2-85* PH-7.20*
TOTAL CO2-35* BASE XS-2
[**2103-7-18**] 09:28PM LACTATE-0.9
[**2103-7-18**] 09:28PM freeCa-1.13
[**2103-7-18**] 09:09PM UREA N-7 CREAT-0.7 SODIUM-128* POTASSIUM-4.9
CHLORIDE-85*
[**2103-7-18**] 09:09PM OSMOLAL-256*
[**2103-7-18**] 09:09PM URINE HOURS-RANDOM UREA N-515 CREAT-184
SODIUM-<10 POTASSIUM-30 CHLORIDE-17 URIC ACID-152.7
[**2103-7-18**] 09:09PM URINE OSMOLAL-405
[**2103-7-18**] 06:20PM GLUCOSE-106* UREA N-7 CREAT-0.7 SODIUM-121*
POTASSIUM-4.7 CHLORIDE-85* TOTAL CO2-29 ANION GAP-12
[**2103-7-18**] 06:20PM estGFR-Using this
[**2103-7-18**] 06:20PM OSMOLAL-252*
[**2103-7-18**] 06:20PM TSH-0.39
[**2103-7-18**] 06:20PM WBC-10.0 RBC-4.97 HGB-14.4 HCT-46.2 MCV-93
MCH-29.0 MCHC-31.2 RDW-14.9
[**2103-7-18**] 06:20PM NEUTS-82.9* LYMPHS-14.8* MONOS-1.4* EOS-0.6
BASOS-0.4
[**2103-7-18**] 06:20PM PLT COUNT-206
[**2103-7-18**] 06:20PM PT-11.5 PTT-27.2 INR(PT)-1.1
[**2103-7-18**] 05:47PM URINE HOURS-RANDOM
[**2103-7-18**] 05:47PM URINE UCG-NEGATIVE
[**2103-7-18**] 05:47PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2103-7-18**] 05:47PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2103-7-18**] 05:47PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2103-7-18**] 02:54PM TYPE-ART PO2-76* PCO2-67* PH-7.32* TOTAL
CO2-36* BASE XS-5 INTUBATED-NOT INTUBA
.
CTA [**2103-7-19**]:
TECHNIQUE: MDCT-acquired axial images were obtained through the
chest without
intravenous contrast. Subsequently, images were obtained
through the chest
and arterial phase after the uneventful administration of 100 cc
of omnipaque
contrast media. Multiplanar reformations were prepared.
FINDINGS: The pulmonary arterial tree is well opacified without
evidence of
embolism. The aorta and major branches are normal in caliber
and patent, with
note made of a bovine aortic arch. Heart and pericardium are
normal without
pericardial effusion. The esophagus is normal. Nasogastric
tube curled to
the stomach. There is no axillary, mediastinal, hilar, or
pathologic
adenopathy, though nonenlarged mediastinal nodes up to 9 mm and
left hilar
node up to 8 mm are noted. The trachea and central airways are
patent to
segmental level with endotracheal tube terminating appropriately
in the mid
trachea. Right greater than left moderate bibasilar atelectasis
is seen, with
otherwise well aerated lungs. There is at most trace pleural
effusion.
Imaged upper abdomen is unremarkable.
OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion
to suggest
osseous malignancy.
IMPRESSION: No acute aortic syndrome or pulmonary embolus.
Moderate right
greater than left basal atelectasis.
.
ECHO [**2103-7-20**]:
Poor image quality. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is low normal (LVEF 50-55%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
.
CXR [**2103-7-22**]:
FINDINGS: The ET tube has been removed. Right IJ line tip is
in the right
atrium. The right hemidiaphragm is mildly elevated and there
are slightly low
lung volumes. There is pulmonary vascular redistribution and
perihilar haze.
There is dense retrocardiac opacity, consistent with volume
loss/infiltrate/effusion. Compared to the prior study, the lung
volumes are
lower and pulmonary edema slightly worse. An underlying
infectious infiltrate
cannot be excluded.
Brief Hospital Course:
This is a 41-year-old woman with a past medical history
significant for reactive airway disease, obesity hypoventilation
syndrome, likely OSA who presents with acute respiratory
failure.
# RESPIRATORY FAILURE: Patient has components of obstructive
and reactive airway disease and obesity hypoventilation
syndrome. She has had admissions for respiratory failure in the
past and unfortunately has not had recent PFTs or a sleep study.
It is even possible that initially, BIPAP worsened patient's
respiratory failure, decreasing her PC02 and in turn her
respiratory drive. She was intubated in the ED and admitted to
the MICU. Patient subsequently self-extubated on [**7-21**] and did
well on 2-3L of NC. She was diuresed in the MICU, though never
clear evidence that she was in heart failure. Also started on
antibiotics for PNA, but these were stopped once sputum culture
was negative. Patient continued to improve from a respiratory
standpoint and she was transferred out of the ICU. Patient was
seen by pulmonary who recommended starting Advair, stopping
ipratropium, and avoiding empiric BIPAP. She was continued on a
steroid taper for 1 week. She was also discharged on O2 to use
at night. Patient should have close follow-up; she will need
outpatient PFTs and a specialized sleep study.
# TACHYCARDIA: Patient was slightly tachycardic throughout
admission in 90s-100s. No PE as per CTA on admission. ECHO
unchanged from prior. Her sinus tachycardia was attributed to
frequent albuterol usage and deconditioning. This issue can be
assessed further by PCP.
# ? ANGIOEDEMA: There was a question about a swollen tongue in
the ED. Patient had was recently starting on lisinopril and as
such there was concern for angioedema. Labs were sent for C1
esterase inhibitor and C1 inhibitor. Patient may benefit from
an allergy evaluation.
# SCHIZOPHRENIA: Abilify was continued.
# DM: Metformin was held and patient was started on an insulin
sliding scale.
# HTN: Patient was normotensive. Her lisinopril was continued
as above.
# HYPERLIPIDEMIA: Pravastatin was continued.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO TID:PRN pain
2. Lisinopril 20 mg PO DAILY
3. Aripiprazole 10 mg PO QHS
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Senna 2 TAB PO DAILY:PRN no BM in 2 days
7. Pravastatin 40 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
9. Ibuprofen 600 mg PO Q8H:PRN for pain
10. Aspirin EC 81 mg PO DAILY
11. albuterol sulfate *NF* 2.5 mg /3 mL (0.083 %) nebulizer q4h
as needed
12. albuterol sulfate *NF* 90 mcg 2 puffs q4h PRN Inhalation
q4h problems breathing
use with aerochamber
Discharge Medications:
1. Oxygen
2L continuous pulse dose for portability. Dx: obesity
hypoventilation syndrome, restrictive lung disease. MH#
[**Telephone/Fax (5) 45596**]. At rest room air sat 88%. Patient needs
portability 4-6 hours per week for activities and doctors'
appointments.
2. Aripiprazole 10 mg PO QHS
3. Docusate Sodium 100 mg PO BID
4. Pravastatin 40 mg PO DAILY
5. Senna 2 TAB PO DAILY:PRN no BM in 2 days
6. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO TID:PRN pain
7. Aspirin EC 81 mg PO DAILY
8. Ibuprofen 600 mg PO Q8H:PRN for pain
9. MetFORMIN (Glucophage) 500 mg PO BID
10. PredniSONE 10 mg PO DAILY Duration: 1 Weeks
Take 3 pills [**7-25**] and [**7-26**]. Take 2 pills [**7-27**] and [**7-28**]. Take 1
pill [**7-29**], [**7-30**], and [**7-31**].
Tapered dose - DOWN
RX *prednisone 10 mg Take 3 pills [**7-25**] and [**7-26**]. Take 2 pills
[**7-27**] and [**7-28**]. Take 1 pill [**7-29**], [**7-30**], and [**7-31**]. Tablet(s) by mouth
Daily Disp #*13 Tablet Refills:*0
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
RX *Advair Diskus 250 mcg-50 mcg/Dose 1 puff inhaled twice a day
Disp #*1 Inhaler Refills:*2
12. albuterol sulfate *NF* 2.5 mg /3 mL (0.083 %) nebulizer q4h
as needed
13. albuterol sulfate *NF* 90 2 puffs INHALATION Q4H:PRN
problems breathing
Take 2 puffs every 4 hours as needed for breathing trouble. Use
with aerochamber
RX *albuterol sulfate 90 mcg 2 puffs inhaled Q4H:PRN Disp #*1
Inhaler Refills:*2
14. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg One Capsule(s) by mouth Three times a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
city psych
Discharge Diagnosis:
Hypercarbic respiratory failure
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Sometimes tangential and perseverates but able to
respond to questions. A+O x 3.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during your admission to
[**Hospital1 69**]. As you know, you came to
the hospital because you had trouble breathing and your oxygen
levels were low. While you were here, your breathing trouble got
worse and we put a tube in your throat to help you breath. Your
breathing got better and we took out the tube. Your oxygen
levels also got better but they are still below normal,
especially when you sleep.
When you go home, DO NOT RESTART YOUR LISINOPRIL. Lisinopril is
a blood pressure medicine you were taking before you came to the
hospital. It is possible that the medicine made your breathing
worse, so please do not take it until we know more.
When you go home, it is important that you wear oxygen while you
sleep. Wear it every night, even if you don't feel short of
breath. It is very important that you have a test of your lung
function to help us understand what is causing your breathing
trouble. You will also have a "sleep study," to tell us more
about how you breath when you are asleep.
In terms of medications, you will finish a taper of prednisone.
Your prednisone pills have 10 mg each and you should take this
number of pills each day:
3 pills on Wednesday, [**7-25**] (tomorrow)
3 pills on Thursday, [**7-26**]
2 pills on [**Last Name (LF) 2974**], [**7-27**]
2 pills on Saturday, [**7-28**]
1 pill on Sunday, [**7-29**]
1 pill on Monday, [**7-30**]
1 pill on Tuesday, [**7-31**]
You will also take a new inhaler called Advair once a day every
day. You should still take your albuterol if you have trouble
breathing.
If you have any questions about your care, please call your
doctor as soon as possible. Once again, it was a pleasure caring
for you.
Sincerely,
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: THURSDAY [**2103-7-26**] at 3:00 PM
With: [**First Name8 (NamePattern2) 22866**] [**Last Name (NamePattern1) 3240**], RN [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**2103-7-27**] 02:40p LE [**Last Name (LF) **],[**First Name3 (LF) **]
[**Hospital1 **] ([**Location (un) **], MA), [**Location (un) **] [**Hospital1 7975**]
NUTRITION
Create Visit Summary
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: MONDAY [**2103-7-30**] at 3:45 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 8268**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**2103-7-31**] 12:40p [**Last Name (LF) 22387**],[**First Name3 (LF) **]
[**Hospital1 **] ([**Location (un) **], MA), [**Location (un) **] [**Hospital1 7975**] MENTAL
HEALTH
Create Visit Summary
[**2103-8-9**] 02:40p [**First Name9 (NamePattern2) 1570**] [**Hospital Ward Name **] 7 - RM 1
[**Hospital6 29**], [**Location (un) **]
PULMONARY LAB
Create Visit Summary
[**2103-8-9**] 03:00p [**Month/Day/Year 1570**],INTERPRET W/LAB NO CHECK-IN
[**Month/Day/Year 1570**] INTEPRETATION BILLING
[**2103-8-9**] 03:00p GOLD/BEACH COPD,TCC
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
PULMONARY UNIT-CC7 (SB)
Create Visit Summary
ICD9 Codes: 2761, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4387
} | Medical Text: Admission Date: [**2152-9-26**] Discharge Date: [**2152-10-3**]
Date of Birth: [**2106-1-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
transferred with PEs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 46 year-old Greek-speaking female with a history of
asthma, morbid obesity, DM2, and HTN who presented to the
[**Hospital 882**] Hospital on [**9-26**] with severe bilateral calf pain (RLE
[**9-6**], LLE [**6-6**]) progressing over 3d and increasing SOB x 1 day.
The patient presented to the OSH where she had negative
bilateral LENIs, however, CTA showed large bilateral segmental
PEs. She was started on heparin gtt and transferred to [**Hospital1 18**] for
possible embolectomy. On arrival to [**Hospital1 18**] the patient was
admitted to the MICU, where VS: AF, HR 102, BP 148/88, RR 18,
94% on 4L NC. Patient complained of mild SOB and persistent calf
pain. She was continued on heparin gtt. EKGs were without
evidence of acute ischemia, but evidence of new TWI in V1-V3.
She had 3 sets of cardiac enzymes negative. TTE was performed.
The patient remained hemodynamically stable, with O2 sats in the
low- to mid-90s on 6L nasal cannula. She was transferred to the
floor in stable condition.
.
The patient denied any F/C, HA/ dizziness, CP, palpitations,
cough, hemoptysis, abdomenal pain, n/v/d/constipation, dysuria,
weakness/ numbness/ paresthesias, or swelling in extremities.
She denies any recent history of travel or prolonged inactivity.
No previous history of blood clots or PE. Patient does not
report using oxygen at home.
Past Medical History:
1) Asthma
2) Morbid Obesity
3) DM2
4) HTN
5) Anxiety/depression
6) Recent admission 3wks ago for cellulitis/ fungal infection
7) s/p partial small bowel resection 1 year ago - obstruction
[**12-31**] cyst
8) s/p chole
9) s/p hysterectomy and BSO 20yrs ago
10) s/p transsphenoidal resection (?) years ago in [**Country 5881**]
Social History:
30 pk yr smoking hx - stopped since 2 weeks ago when she started
taking Chantix. No alcohol, no drug use. Greek-speaking only.
Lives alone, but has supportive son and daughter-in-law living
nearby.
Family History:
no history of blood clots. patient's father passed away from
"liver cancer" (unclear history) 5 years ago, diagnosed in
[**Country 5881**]. [**Name (NI) **] mother, siblings, and children otherwise alive
and healthy.
Physical Exam:
VS: Temp:97.5 BP:154/89 HR:94 RR:20 O2sat: 93% 6L NC
GEN: Obese, comfortable, NAD.
HEENT: PERRL, EOMI, anicteric, MMM
RESP: Good air movement throughout. + end-expiratory wheezing
CV: RR, S1 and S2 wnl, no m/r/g
ABD: obese. nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: No calf tenderness or erythema
SKIN: No rashes
NEURO: AAOx3. CN II-XII intact. 5/5 strength throughout.
Pertinent Results:
EKG: Nml sinus 98. Nml axis, nml intervals. New TWI in V1-V3.
.
LABS:
.
[**2152-9-26**] 10:20PM WBC-7.6 RBC-4.37 HGB-13.9 HCT-41.3 MCV-95
MCH-31.8 MCHC-33.6 RDW-14.5
[**2152-9-26**] 10:20PM NEUTS-71.6* LYMPHS-20.9 MONOS-6.2 EOS-1.1
BASOS-0.1
[**2152-9-26**] 10:20PM PLT COUNT-236
[**2152-9-26**] 10:20PM PT-13.2* PTT-95.7* INR(PT)-1.2*
[**2152-9-26**] 10:20PM GLUCOSE-174* UREA N-20 CREAT-0.8 SODIUM-147*
POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-21* ANION GAP-18
[**2152-9-26**] 10:20PM CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-1.6
[**2152-9-26**] 10:20PM CK(CPK)-138/ CK-MB-6 / cTropnT-0.01
[**2152-9-27**] 06:13AM BLOOD CK(CPK)-103/ CK-MB-5/ cTropnT-0.02*
[**2152-9-27**] 02:28PM BLOOD CK(CPK)-86/ CK-MB-NotDone/
cTropnT-0.02*
[**2152-10-3**] 05:50AM BLOOD PT-20.4* PTT-75.3* INR(PT)-2.0*
.
IMAGING:
.
[**9-27**] TTE: IMPRESSION: Right ventricular cavity enlargement with
free wall hypokinesis and moderate tricuspid regurgitation and
moderate pulmonary artery systolic hypertension c/w primary
pulmonary process (e.g., pulmonary embolism). Mild symmetric
left ventricular hypertrophy with preserved regional and global
systolic function (LV EF 60-65%).
.
OSH Imaging: CTA - Bilateral segmental pulmonary emboli with
mild leftward bowing of interventricular septum.
Brief Hospital Course:
The patient is a 46 year-old female with asthma, morbid obesity,
DM2, and hypertension transferred from an outside hospital with
bilateral segmental PEs.
.
# Pulmonary Embolism: The patient was transferred from the
[**Hospital 882**] Hospital with bilateral segmental pulmonary emboli
noted on CT scan. The etiology of this was felt to be secondary
to patient's smoking history (of note, she reports quitting 9
days before admission) and morbid obesity (BMI 50). The patient
has an up-to-date negative cancer screening (mammogram, Pap,
colonoscopy), no history of prolonged travel, and no trauma or
recent injuries that may have precipitated this. Upon transfer
cardiac enzymes were negative x 3 and the patient was ruled out
for MI. EKG showed evidence of minor ST elevations in V1-V3,
consistent with PE. TTE showed evidence of right heart strain
with increased right-sided pressure, right free wall
hypokinesis, pulmonary hypertension, and moderate TR. The
patient, however, was hemodynamically stable and therefore was
not felt to be a candidate for thrombolysis. Bilateral LE
Doppler US were negative for evidence of blood clots, and it was
felt that IVC filter was not indicated at this time. The patient
was placed on high flow oxygen (6L by NC) to maintain oxygen
saturations < 90% and was monitored on telemetry with no
evidence of arrhythmias. The patient was continued on a heparin
gtt, and started on a bridge to coumadin on [**9-27**]. Lovenox was
tried on [**9-28**] for a bridge, but discontinued on [**9-30**] when the
patient developed a rash. (Rash was treated well with Atarax prn
and began to resolve upon discontinuing lovenox.) The patient
was resumed on coumadin, and reached therapeutic levels on [**10-2**].
The patient was discharged on [**10-3**] maintaining oxygen
saturations in the mid-90%s on RA (likely bsaeline) without any
symptoms of dyspnea. The patient was set up with VNA services to
check INR upon discharge with coumadin management to be done by
her PCP. [**Name10 (NameIs) **] workup will be performed as an
outpatient.
.
# DM2: The patient takes outpatient glyburide and metformin with
poor glycemic control, usually in the 200s. The patient has been
reluctant to take insulin in the past given fear of
administering injections. While in-house oral agents were
initially held in favor of an insulin sliding scale. She was
restarted on oral outpatient medicine prior to discharge.
Diabetes management is closely followed by PCP.
.
# HTN: The patient's outpatient nifedipine was held initially
given concern for hemodynamic instability with PE; however,
blood pressure was well-controlled for remainder of admission
with SBPs in 110s-120s without additional agents so nifedipine
was not restarted. This may be re-started by the patient's PCP.
(ACEI may also be considered given the patient's history of
diabetes.)
.
# Depression/Anxiety: The patient was continued on her
outpatient regimen of aripiprazole, fluoxetine, and klonapin
prn.
.
# Tobacco: the patient was continued on a nicotine patch while
inhouse.
.
# Asthma: The patient was continued on outpatient Advair and
albuterol nebulizers prn.
.
# The patient was discharged on [**10-3**] in good condition,
afebrile, VSS, ambulating well and tolerating po well. She was
discharged with VNA services to check INR upon discharge, with
coumadin to be managed by the patient's PCP.
Medications on Admission:
Metformin 1g [**Hospital1 **]
Glyburide 5mg [**Hospital1 **]
Miconazole
Vit D3 400
Ca 500 [**Hospital1 **]
Aripiprazole 10
Fluoxetine 20
Nifedipine XL 30
Oxybutynin 10
Advair IH [**Hospital1 **]
Klonipin prn
Chantix
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
Disp:*30 Tablet(s)* Refills:*2*
8. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed.
Disp:*20 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: segmental PE; drug hypersensitivity, possibly to
lovenox
Secondary: morbid obesity (BMI 50), DM2, HTN, hyperlipidemia,
depression, anxiety, hx of fungal cellulitis
Discharge Condition:
Good; afebrile, VSS, O2 sat in mid-90%s on RA, ambulating
pain-free, tolerating po well.
Discharge Instructions:
You were admitted with multiple blood clots that traveled your
lungs (pulmonary embolism). You were treated with blood thinners
for this, and are being discharged on a new medication,
coumadin. You will need to take this medication daily, as
directed by your PCP. [**Name10 (NameIs) **] will also need to have levels checked
regularly by VNA. During the admission your blood pressure
medication, nifedipine, was held because of a risk of low blood
pressure with pulmonary emboli. Your blood pressures have been
well-controlled without this. Please follow up with your PCP
about restarting this.
.
If you experience any severe HA/ dizziness, chest pains,
shortness of breath, severe abdominal pain/ nausea/ vomiting,
pain or urination, or weakness/ numbness/ change in sensation
please contact your PCP or go to the Emergency Room for further
evaluation.
Followup Instructions:
Please follow-up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge.
VNA will do a blood test to check your INR on Thursday and
Monday. Results are to be faxed to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 75959**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4388
} | Medical Text: Admission Date: [**2101-4-14**] Discharge Date: [**2101-4-22**]
Service: MICU
CHIEF COMPLAINT: Abdominal pain, vomiting and diarrhea.
HISTORY OF PRESENT ILLNESS: A 78-year-old woman with a
history of multiple psychiatric admissions for bipolar
disorder as well as hypertension, chronic obstructive
pulmonary disease, diverticulosis, Barrett's esophagus who
was recently on ciprofloxacin for a urinary tract infection
for the past three days and was found on the floor by her
husband covered in brown feces and vomit. She was noted to
then be vomiting dark brown material. She reported abdominal
pain that was right-sided, crampy and nonradiating on the
night prior to admission also associated with vomiting and
diarrhea. She also noted fatigue. The husband called 911
and the patient was seen by Emergency Medical Services at the
scene with vital signs: Heart rate 98, blood pressure
138/palp, respiratory rate 16, oxygen saturation 96% on four
liters nasal cannula.
On arrival to the Emergency Department, her vital signs were
150/82, 92, 18, 100% on room air with a temperature of 96.2.
She vomited a small amount of coffee ground material times
two. An NG tube was placed to suction and the patient
subsequently had bright red blood per rectum. Two peripheral
IV's were placed. Labs were notable for a WBC count of 26.5,
hematocrit of 47 and a BUN/creatinine of 35/1.4. She
received two liters of normal saline, levofloxacin and Flagyl
as well. CT of the abdomen was performed which demonstrated
diffuse colonic thickening.
Surgery was consulted who considered ischemic versus
infectious colitis.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Chronic obstructive pulmonary disease on two liters nasal
cannula home oxygen.
3. Bipolar disorder.
4. Barrett's esophagus.
5. Osteoporosis.
6. Macular degeneration.
7. Status post cholecystectomy.
8. History of thrush.
9. Multiple psychiatric admissions for bipolar disorder,
most recent [**3-1**] to [**2101-3-31**].
10. Urinary tract infections.
11. Echocardiogram [**11/2099**] with ejection fraction of 65-70%.
12. Constipation and abdominal pain of long-standing
duration.
13. Diverticulosis.
ALLERGIES: Prednisone, sulfa, calcium channel blockers,
Keflex, Benadryl and beta blockers.
MEDICATIONS:
1. Clonidine patch 0.2 q. week.
2. Cozaar 50 mg p.o. b.i.d.
3. Albuterol p.r.n.
4. Atrovent two puffs q.i.d.
5. Flovent 110 mcg two puffs b.i.d.
6. Prilosec 20 mg p.o. b.i.d.
7. Seroquel 200 mg p.o. q. hs.
8. Lasix 40 mg p.o. q. day.
9. Lactulose p.r.n.
10. Aspirin 81 mg p.o. q.o.d.
11. Cipro 250 mg p.o. b.i.d.
12. Depakote 500 mg p.o. q. hs.
13. Hydralazine 25 mg p.o. b.i.d.
14. K-Dur 10 mEq p.o. q. day.
15. Dulcolax p.r.n.
16. Two liters nasal cannula oxygen.
17. Os-Cal.
18. Milk of magnesia.
19. Nitro patch ?
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: The patient is a former heavy tobacco smoker
who quit 13 years ago. No history of alcohol abuse. She
lives alone. She is separated from her husband who does
provide some support as well as her daughter. [**Name (NI) **] history of
drugs or herbal supplement use.
PHYSICAL EXAMINATION: 101.2, 128/47, 107, 28, 90% on room
air. General: This is an elderly woman lying on her left
side with an NG tube in place. Declining to lie flat for an
examination but otherwise in no acute distress. HEENT:
Right pupil surgical. Left pupil 2 mm, nonreactive. No
scleral icterus. Mucus membranes moist. No lesion. Neck
supple. No lymphadenopathy. No bruits. Jugular venous
pressure could not been seen. Cor regular rate and rhythm.
Normal S1, S2. Grade [**2-10**] holosystolic murmur at the right
upper sternal border without radiation. No S3 or S4
appreciated. Lungs: Diffusely decreased breath sounds
bilaterally. No crackles, wheezes or rhonchi. Abdomen:
Protuberant, distended, no obvious surgical scars.
Examination limited by patient refusing to lie flat.
Positive high pitched bowel sounds. Soft, diffusely tender,
no rebound or guarding. Extremities warm, well perfused, 2+
dorsalis pedis pulses bilaterally. Rectal: Guaiac positive.
Skin warm, dry, no rashes.
LABORATORY: WBC 26.5, hematocrit 47, platelet count 324,000.
84 bands, 3L4. BUN/creatinine 35/1.4. Anion gap 15. Urine
tox negative. Serum tox negative. ABG 7.3/49/65.
RADIOLOGY: KUB without volvulus or intestinal obstruction.
Probable distended bladder. Chest x-ray: No free air.
ELECTROCARDIOGRAM: Normal sinus rhythm, normal axis,
intervals, no ectopy. Left atrial enlargement, no Q-waves.
J-point elevation in V1 and V2. One millimeter ST depression
in 2, 3 and F. Positive left ventricular hypertrophy. When
compared to EKG in [**2100-2-5**], the ST depressions were
new.
HOSPITAL COURSE:
1. Colitis: While in the MICU, the patient had spiked a
fever to 101.2 and had significant bandemia. She had an
anion gap of 15 with a lactate of 4.1. She continued to note
abdominal pain with diarrhea initially. Was being treated
with vancomycin, levofloxacin and Flagyl and received
aggressive intravenous fluid hydration. Clostridium
difficile and stool cultures were sent and were all negative.
It was unclear whether or not the patient had infectious
colitis versus ischemic colitis with super infection from
transmutation of flora. Gastroenterology was consulted who
could not provide a definitive diagnosis either. Due to the
patient's cardiac issues the patient was not sent for scope.
Over the course of several days, the patient's fever went
down and her white count decreased. She was taken off the
vancomycin and maintained on levofloxacin and Flagyl. She
will continue a 14 day course of these medications. She
should have an outpatient colonoscopy performed by
Gastroenterology.
No source of upper GI bleeding was noted. It is possible
that this could have been from her lower GI sources.
Outpatient workup is indicated. She was tolerating a regular
diet at the time of discharge.
2. Atrial fibrillation: The patient's blood pressure
medications were held on admission due to concern over
gastrointestinal bleeding. On the day after admission the
patient was noted to be atrial fibrillation with a rapid
ventricular response. She was given Lopressor IV push that
resulted in a six second pause. Given the patient's reported
history to beta blockers and calcium channel blockers,
Electrophysiology was consulted, especially with the concern
of AV nodal disease. The patient was started on a verapamil
drip. She was then changed to p.o. verapamil 80 mg p.o.
t.i.d. The patient fluctuated between atrial fibrillation
and normal sinus rhythm with a well controlled rate. The
verapamil was discontinued on hospital day three. The
patient was transferred to the floor for additional workup of
her GI issues. On the night she was sent to the floor the
patient again had atrial fibrillation with a rapid
ventricular response with a heart rate in the 150's to 170's
with a blood pressure in the 70's systolic. She was brought
back to the MICU and placed on a verapamil drip with good
control of her blood pressure. She was then changed to
verapamil 40 mg p.o. t.i.d. with good control of her
ventricular response. She went back and forth between atrial
fibrillation and normal sinus rhythm. Decision was made not
to anticoagulate given her gastrointestinal issues and recent
GI bleed.
Electrophysiology continued to consult and directed that if
her rate was not well controlled with the p.o. verapamil that
additional nodal blockade with amiodarone or other agents may
be necessary and might require a pacemaker. They were not
willing to do this procedure at this time due to her stable
condition and GI issues.
3. Chronic obstructive pulmonary disease: This patient was
maintained on her albuterol, Atrovent and Flovent inhalers.
She did not experience any COPD exacerbations. She was
maintained on her home oxygen requirement and was discharged
on one liter of home oxygen.
4. Hypertension: The patient has likely poorly controlled
hypertension as an outpatient. She had her antihypertensives
held and then restarted. The patient was on Cozaar as an
outpatient and was placed on captopril as an inpatient. She
did not have any adverse reactions to this medication. She
was maintained on low dose to keep her blood pressure
systolic greater than 120 give a question of ischemic
colitis. She was discharged on verapamil and lisinopril.
5. Bipolar disorder: The patient was initially seen with
Depakote 500 mg p.o. q. hs. and Seroquel 200 mg p.o. q. hs.
The patient was seen to be very somnolent during her
admission in the MICU on this dose of Seroquel. The dose was
decreased to 100 mg p.o. q. hs. and the patient was more
alert. She will be discharged on this dose with follow up
with her psychiatrist.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Patient will be discharged to
rehabilitation. She will follow up with Psychiatry,
Gastroenterology and Cardiology.
DISCHARGE DIAGNOSES:
1. Colitis, ischemic versus infectious.
2. Atrial fibrillation complicated by rapid ventricular
response and hypotension.
3. Lower gastrointestinal bleed.
4. Upper gastrointestinal bleed.
5. Chronic obstructive pulmonary disease on home oxygen.
6. Bipolar disorder.
DISCHARGE MEDICATIONS:
1. Tylenol 325 mg to 650 mg p.o. q. 4h. p.r.n.
2. Atrovent two puffs q.i.d.
3. Albuterol two puffs q.i.d. p.r.n.
4. Depakote 500 mg p.o. q. hs.
5. Flagyl 500 mg p.o. t.i.d. for five days until [**2101-4-27**].
6. Simethicone 80 tabs 1.5 tabs q.i.d. p.r.n.
7. Levofloxacin 250 mg p.o. q. day for five days until
[**2101-4-27**].
8. Seroquel 100 mg p.o. q. hs.
9. Prevacid 30 mg p.o. q. day.
10. Verapamil 40 mg p.o. t.i.d.
11. Lisinopril 10 mg p.o. q. day.
11. Calcium and vitamin D.
12. Aspirin 81 q.o.d. held due to lower GI bleed.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 17420**]
MEDQUIST36
D: [**2101-4-22**] 12:37
T: [**2101-4-22**] 12:23
JOB#: [**Job Number 101226**]
ICD9 Codes: 2765, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4389
} | Medical Text: Admission Date: [**2140-8-25**] Discharge Date: [**2140-8-29**]
Date of Birth: [**2067-3-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest and arm pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x3, (left internal mammary
artery, left anterior descending coronary artery; reverse
saphenous vein single graft from the aorta to the ramus
intermedius coronary artery; as well as reverse saphenous vein
graft from the aorta to the distal right coronary artery) on
[**2140-8-25**]
History of Present Illness:
73 year old female who began to develop exertional arm and chest
pain this past [**Month (only) 547**]. She was referred to a cardiologist who
performed an exercise tolerance test which was positive for
ischemia. She underwent a cardiac catheterization which revealed
severe coronary artery disease with a 50% left main stenosis,
80%
LAD and 90% RCA. Given these findings, she has been referred for
surgical evaluation.
Past Medical History:
Hypertension
Hyperlipidemia
Chronic renal insufficiency - Stage III
Anemia
Obesity
COPD
Hypothyroid
Osteoporosis
Past Surgical History
Abd. surgery for perforated ulcer
Right knee surgery
Hysterectomy with Bladder resuspension [**2137**]
Social History:
Race: Caucasian
Last Dental Exam: full dentures
Lives with: husband
Occupation: N/A
Tobacco: quit [**2102**]
ETOH: denies
Family History:
non-contributory
Physical Exam:
Admission Physical Exam
Pulse: 64 Resp: 16 O2 sat: 98%
B/P Right: 147/62 Left: 150/75
Height: 59" Weight: 200
General: Well-developed obese female with in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Expiratory wheeze bilateral
Heart: RRR [X] Irregular [] Murmur -
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] large LE Edema: 2+
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2140-8-28**] 09:46AM BLOOD WBC-10.8 RBC-3.43* Hgb-9.9* Hct-29.3*
MCV-85 MCH-28.8 MCHC-33.7 RDW-16.4* Plt Ct-133*
[**2140-8-25**] 03:10PM BLOOD WBC-8.0 RBC-3.14* Hgb-9.2* Hct-26.4*
MCV-84 MCH-29.4 MCHC-35.0 RDW-15.9* Plt Ct-106*#
[**2140-8-25**] 04:23PM BLOOD PT-14.3* PTT-33.3 INR(PT)-1.2*
[**2140-8-25**] 03:10PM BLOOD PT-14.6* PTT-33.0 INR(PT)-1.3*
[**2140-8-28**] 09:46AM BLOOD UreaN-20 Creat-0.8 Na-137 K-4.1 Cl-102
[**2140-8-25**] 04:23PM BLOOD UreaN-20 Creat-0.8 Na-143 K-4.0 Cl-114*
HCO3-23 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 87588**] (Complete)
Done [**2140-8-25**] at 1:07:41 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2067-3-15**]
Age (years): 73 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Chest pain. Coronary artery disease. Shortness of
breath. For CABG.
ICD-9 Codes: 402.90, 786.05, 786.51
Test Information
Date/Time: [**2140-8-25**] at 13:07 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18397**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW1-: Machine: siemens
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: 0.30 >= 0.29
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Ascending: 2.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Aortic Valve - Mean Gradient: 7 mm Hg
Aortic Valve - LVOT diam: 1.8 cm
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 2.67
Findings
LEFT ATRIUM: Mild spontaneous echo contrast in the body of the
LA. Depressed LAA emptying velocity (<0.2m/s)
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD or PFO by 2D, color
Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Three aortic valve leaflets. No AR.
MITRAL VALVE: Mild (1+) MR.
TRICUSPID VALVE: Physiologic TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. Results were
Conclusions
Pre CPB:
Mild spontaneous echo contrast is seen in the body of the left
atrium. The left atrial appendage emptying velocity is depressed
(<0.2m/s).
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %).
Right ventricular chamber size and free wall motion are normal.
There are three aortic valve leaflets. No aortic regurgitation
is seen.
Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) 914**] was notified
in person of the results.
Epi-Aortic ultrasound performed prior to cannulation.
Post CPB:
Aortic contours intact.
No change in mild MR.
Preserved or slightly improved biventricular systolic function.
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) **] [**2140-8-25**] 17:04
?????? [**2132**] CareGroup IS. All rights reserved.
Brief Hospital Course:
[**2140-8-25**] Ms. [**Known lastname **] was taken to the operating room and
underwent Coronary artery bypass grafting x3,(left internal
mammary artery, left anterior descending coronary
artery; reverse saphenous vein single graft from the aorta to
the ramus intermedius coronary artery; as well as reverse
saphenous vein graft from the aorta to the distal right coronary
artery) with Dr.[**Last Name (STitle) 914**]. Please see operative report for further
details. She tolerated the procedure well and was transferred to
the CVICU intubated and sedated in critical but stable
condition. She awoke neurologically intact and was weaned to
extubate without difficulty. All lines and drains were
discontinued [**Female First Name (un) **] timely fashion. Beta-Blocker/Statin?aspirin and
diuresis was initiated. POD#2 she was transferred to the step
down unit for further monitoring. Physical Therapy was consulted
for evaluation of strength and mobility. The remainder of her
post operative course was essentially uneventful. She continued
to progress and was cleared by Dr.[**Last Name (STitle) 914**] for discharge to home
with VNA on POD#4. All follow up appointments were advised.
Medications on Admission:
Aspirin 325mg daily
Crestor 20mg daily
Imdur 30mg daily
Zetia 10mg daily
Atenolol 25mg twice daily
Lisinopril 40mg daily
Clonidine 0.3mg twice daily
Lasix 40mg twice daily
Potassium chloride 8mEq three times daily
Nitroglycerin 0.3mg PRN
Fosamax 70mg weekly
Synthroid 100mcg daily
Combivent 1 puff every 4 hours
Tums
Ferous fumarate 38mg daily
Procrit 10,000 units SC every 2 weeks
Ambien 5mg at bedtime
Glucosamine/Chondroitin
Magnesium oxide 400mg daily
Loratidine 10mg daily
Discharge Medications:
1. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
Disp:*12 Tablet(s)* Refills:*2*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
Disp:*120 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*qs * Refills:*2*
15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA & Hospice
Discharge Diagnosis:
1.Severe 3-vessel coronary disease.
2. Severe obesity.
3. Chronic obstructive pulmonary disease.
4. Diabetes.
5. Chronic renal insufficiency-stage III.
Hypertension
Hyperlipidemia
Anemia
Hypothyroid
Osteoporosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr[**Last Name (STitle) 5305**] office will contact you to arrange a
follow up appointment, (#[**Telephone/Fax (1) 170**],)and with your
Cardiologist:Dr.[**Last Name (STitle) 13310**]
Completed by:[**2140-8-29**]
ICD9 Codes: 496, 2724, 2859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4390
} | Medical Text: Admission Date: [**2126-8-21**] Discharge Date: [**2126-8-30**]
Service: MEDICINE
Allergies:
Celexa
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Urosepsis
Major Surgical or Invasive Procedure:
History of Present Illness:
HPI: 87-year-old male w PMH significant for CAD, CRI, AFib, B
SDH [**3-2**] requiring craniotomy, and dementia who was transferred
from [**Location (un) 620**] for possible percutanouus decompression of
gallbladder for cholecystitis in association with sepsis.
.
Pt was in his usual state of health until 2 days prior to
admission to OSH when he developed bilateral lower back
discomfort, generalized weakness, and F/C. In ED at [**Location (un) 620**] on
[**8-19**], pt found to have temp of 104.9 with ?rigors, UTI +/- ? LLL
PNA given dirty UA and possible LLL infiltrate on CXR. Pt given
ceftriaxone, azithromycin and Levo and 2L NS. He was then in
shock c sBPs in 70s on arrival to the floor and was transferred
to the ICU where he recieved 6L IVF. Blood pressure stabilized
transiently. Within the same day the pts Cr bumped from 1.8 to
2.6 (felt to be secondary to ATN/sepsis) and his AST/ALT
increased from the 40s to the 500s (felt to be due to shocked
liver). Further fluid resuscitation was aborted due to high CVP
and CHF picture on CXR. The pt was hypoxemic and placed on NRB,
felt to be secondary to fluid overload. Intubation was never
required. The pt was also in NSR on admission and converted
back into a fib. On HD2 at the OSH, the pt again became
hypotensive with SBP in 70s, requiring pressure support with
levophed. On [**8-20**] the pt's WBC increased from 4 on admission to
46 and his bands increased from 5% on admission to 25%. Blood
cultures grew [**3-1**] GNRs( sensitive to ceftazidime and resistant
to ceftriaxone) and urine culture grew E coli. The patient was
switched to ceftazidime.
.
Also on HD2 at the OSH, the pt complained of right lower
quadrant pain, and a RUQ ultrasound was performed that showed:
cholecystitis with contracted gallbladder with thickening and
edema but no stone/ductal dilatation. As the pt was having
diarrhea, there was also a concern for C diff so flagyl was
added. Finally, one dose of gentamicin was given for double
coverage for gram negative sepsis.
Pt was transferred to [**Hospital1 18**] for percutaneous placement of
cholecystostomy tube to decompress the gallbladder.
.
In the MICU at [**Hospital1 18**], levofloxacin was discontinued, and blood
cx/UA/CXR were repeated. Pt was transferred on NRB--satting at
100%, which was quickly changed to 6LNC. CXR revealed LLL
infiltrate with probable associated small L pleural effusion.
Blood cx thus far reveals gram neg rods in the anaerobe cx,
multidrug resistant including to CTX, cefazolin, amp, gent,
fluoroquinolones, bactrim. Initially the pt was on levophed but
this was held as his SBP was in the 100s. IVF was also held
given pts CVP was 18. Pt was given Lasix 20 mg IV x1 with
improved oxygenation. HIDA scan was performed which revealed
normal gallbladder filling, and surgery did not think this is
c/w cholecystitis. As there was concern after pts platelets had
been 140 on admission to OSH and dropped to 61 here, DIC panel
was ordered and was negative, ASA held. Amiodarone was
increased for tachycardia.
.
Prior to transfer to the floor, the pt was noted to be
hemodynamically improved with SBP of 120, slightly tachy in afib
with HR in 100s-120s, oxygenating well on 6L NC, afebrile, Cr
down to 2, ALT down to 453, AST down to 286.
Past Medical History:
PAST MEDICAL HISTORY:
- CVA
- atrial fibrillation on amiodarone
- coronary artery disease
- chronic right-sided subdural hematoma.
- Subdural hematoma bilaterally status post craniotomy for a
right-sided subdural.
- BPH s/p TURP in [**5-2**]
- dememtia
- glaucoma
- CRF( Cr 1.0-1.4 at baseline)
Social History:
Social: patient lives with wife at home, no tobacco /ETOH use.
His son [**Name (NI) **] is involved in his care
Family History:
Family: noncontributory
Physical Exam:
On exam at admission:
T m/c 97.4 HR 106-126 afib BP 96-136/73-99 (117/99) CVP 3-11 RR
18-26 Sat 90-96% 6L NC I; 1640 O: 2215
Gen- alert elderly man, agitated, talking loudly, not oriented
HEENT- anicteric, slightly dry MM, poor dentition
Neck: supple, R IJ line with dried blood on dressing
CV- irregularly irregular, distant heart sounds, no r/m/g
resp- CTAB anteriorly but LLL rales noted posteriorly
abdomen- soft, NTND, NABS, no palpable HSM, no palpable masses
extremities- no edema, DP/PT 2+ b/l, L wrist restraint and L
arterial line in place
GU: foley with light yellow urine collected (now dc'd)
neuro- confused, agitated, uncooperative in performing CN exam,
moving all 4 extrem
Skin: large eccymosis on L forearm
Pertinent Results:
[**2126-8-21**] 02:06PM GLUCOSE-100 UREA N-58* CREAT-2.0* SODIUM-144
POTASSIUM-4.1 CHLORIDE-113* TOTAL CO2-20* ANION GAP-15
[**2126-8-21**] 02:06PM ALT(SGPT)-532* AST(SGOT)-438* LD(LDH)-227 ALK
PHOS-131* TOT BILI-0.8
[**2126-8-21**] 02:06PM ALBUMIN-2.5* CALCIUM-8.0* PHOSPHATE-3.5
MAGNESIUM-2.0
[**2126-8-21**] 02:00PM URINE HOURS-RANDOM CREAT-90 SODIUM-LESS THAN
[**2126-8-21**] 02:00PM URINE OSMOLAL-532
[**2126-8-21**] 02:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2126-8-21**] 02:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2126-8-21**] 01:50AM FDP-10-40
[**2126-8-21**] 01:28AM TYPE-ART TEMP-36.8 RATES-/21 O2 FLOW-12
PO2-107* PCO2-34* PH-7.31* TOTAL CO2-18* BASE XS--8
[**2126-8-21**] 01:28AM LACTATE-3.7*
[**2126-8-21**] 01:16AM GLUCOSE-68* UREA N-48* CREAT-2.2*# SODIUM-141
POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-17* ANION GAP-18
[**2126-8-21**] 01:16AM LIPASE-14
[**2126-8-21**] 01:16AM CK-MB-NotDone cTropnT-0.06* proBNP-[**Numeric Identifier 54496**]*
[**2126-8-21**] 01:16AM ALBUMIN-2.7* CALCIUM-8.2* PHOSPHATE-4.4#
MAGNESIUM-1.9
[**2126-8-21**] 01:16AM WBC-46.2*# RBC-4.31* HGB-13.1* HCT-40.3
MCV-94 MCH-30.3 MCHC-32.4 RDW-15.5
[**2126-8-21**] 01:16AM NEUTS-82* BANDS-10* LYMPHS-1* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2126-8-21**] 01:16AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-3+
HOW-JOL-OCCASIONAL
[**2126-8-21**] 01:16AM PLT SMR-VERY LOW PLT COUNT-70*#
[**2126-8-21**] 01:16AM PT-15.8* PTT-34.3 INR(PT)-1.6
[**2126-8-21**] 01:16AM FIBRINOGE-687*
[**2126-8-28**] 10:15AM BLOOD WBC-10.2 RBC-3.81* Hgb-11.1* Hct-35.3*
MCV-93 MCH-29.1 MCHC-31.5 RDW-16.4* Plt Ct-229
[**2126-8-28**] 10:15AM BLOOD Plt Ct-229
[**2126-8-28**] 10:15AM BLOOD Glucose-122* UreaN-21* Creat-1.2 Na-146*
K-4.1 Cl-109* HCO3-34* AnGap-7*
[**2126-8-27**] 09:26AM BLOOD ALT-90* AST-41* AlkPhos-194* TotBili-0.9
[**2126-8-25**] 04:54AM BLOOD ALT-183* AST-112* LD(LDH)-186
AlkPhos-277* TotBili-1.9*
[**2126-8-23**] 06:39PM BLOOD CK-MB-2 cTropnT-<0.01
[**2126-8-28**] 10:15AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.1
[**2126-8-22**] 10:17AM BLOOD Lactate-2.3*
[**2126-8-21**] 03:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
Microbiology:
[**2126-8-21**] 1:45 am BLOOD CULTURE
**FINAL REPORT [**2126-8-28**]**
AEROBIC BOTTLE (Final [**2126-8-28**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2126-8-24**]):
GRAM NEGATIVE ROD(S).
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 54497**]
FROM [**2126-8-21**].
[**2126-8-21**] 1:35 am BLOOD CULTURE
**FINAL REPORT [**2126-8-28**]**
AEROBIC BOTTLE (Final [**2126-8-28**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2126-8-25**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 54498**] AT 4:58A [**2126-8-22**].
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Trimethoprim/Sulfa sensitivity available on request.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing E. coli and Klebsiella species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
Abd U/S ([**2126-8-25**]):
IMPRESSION:
1. No evidence of biliary ductal dilatation.
2. Mild persistent gallbladder wall edema in a nondistended
gallbladder,
which could represent sequelae of concurrent illness or
intrinsic liver
disease.
CXR ([**8-21**]):
IMPRESSION: Small left pleural effusion with a patchy opacity
in the left
lower lobe likely consolidations/atelectasis.
2) Right basilar atelectasis.
HIDA scan ([**2126-8-21**]):
IMPRESSION: No evidence of acute cholecystitis. Normal
gallbladder study.
Brief Hospital Course:
A/P:
88yo M with h/o afib, bilateral subdural hematomas [**3-2**]
requiring craniotomy, dementia, transferred from OSH where he
had been treated for sepsis growing GNR from blood, UTI, [**Doctor First Name 48**],
LLL PNA. Pt was transferred for tx of presumed acalculous
cholecystitis, however here pt is negative for cholecystitis and
continuing tx of UTI/PNA/post-sepsis/[**Doctor First Name 48**].
.
# s/p Septic Shock: Patient initially hypotensive and briefly
required Levophed to maintain adequate blood pressures. Lactate
elevated and overall picture c/w sepsis. Interventional
radiology and surgery were consulted during the patient's stay
and did not believe the patient had acute cholecystitis and
therefore did not feel that percutaneous drainage was necessary.
Other etiology could be from LLL PNA. Normal response to
cortisol stim test. Etiology most likely secondary to urosepsis
as urine cx positive for E. Coli. At outside hospital had been
treated with Ceftazidime as inital cultures showed
susceptibility. However cultures obtained here grew out E coli
resistant to Ceftazidime so patient was started on Meropenem
which the E coli was sensitive to. Flagyl was given for several
days as organisms had been growing in anaerobic bottle but was
discontinued several days prior to discharge. Patient to
complete a 14 day course that will be completed on [**2126-9-3**]. A
PICC line was placed prior to discharge so that patient could
finish this course after discharge. Pt has been afebrile,
normotensive, with no pressors or fluid boluses needed in the
days prior to discharge. WBC within normal limits prior to
discharge but had been as high as 46.2.
.
.
#UTI: Likely cause of urosepsis as noted above and was treated
as previously mentioned. Patient initially had foley catheter in
place. Patient voiding well since catheter removed.
.
#LLL PNA: Likely CAP as pt had this infiltrate upon arriving at
OSH. Patient treated with a course of azithromycin during his
stay
.
#CHF: Pt with h/o CHF and EF of 30% on TTE from [**8-20**], BNP of
60k here but baseline unknown. Pt was likely volume overloaded
on transfer given aggressive hydration. Once normotensive IVF
were discontinued and several doses of lasix were given for
diuresis. Patient no longer volume overloaded clinically and
has maintained good oxygen saturations.
.
# acalculous cholecystitis: Likely not acute cholecystitis. On
US at OSH there was gallbladder wall edema and thickening but no
stones. Repeat US done here did not reveal evidence of
cholecystitis or biliary obstruction. HIDA on [**8-21**] revealed
complete filling. Pt seen by both surgery and IR, who agreed
that no evidence of acute cholecystitis.
.
#Transaminitis: LFTs now resolving as perfusion improving
suggesting shock liver at time of transfer from OSH. Statin
initially held for potential liver toxicity but restarted once
improved LFTs. Would recommend that patient have LFTs rechecked
as outpatient.
.
# atrial fibrillation/ tachycardia: Pt with h/o paroxysmal afib
previously on amiodarone. Pt was in NSR initially on admission
to OSH, but converted into Afib at OSH and has been in afib
while here but with good rate control. Amiodarone stopped and
patient started on metoprolol with good effect while still in
afib. No coumadin or heparin given recent subdural hematomas and
concern that patient may be at risk for falls. Patient reverted
back to NSR during admission so amiodarone was restarted.
Metoprolol was stopped as patient not tachycardic and son
reports h/o hypotensive episodes in the past.
.
# thrombocytopenia: Platelets dropped below 70 during course of
admission, likely secondary to HIT I versus sepsis. Pt without
purpura or anemia, making TTP less likely. HIT Type II unlikely
given negative HIT ab. Peripheral smear showed only Burr cells
attributable to liver disease or more likely uremia. SC Heparin
and aspirin were held while platelets low but restarted once
normalized. Patient's platelets returned to [**Location 213**] prior to
discharge.
.
# Acute Renal Failure: Likely related to hypotension/ATN. FeNA
less than 1% on admission. Cr 1.0 on [**2126-3-26**], up to 2.8 at OSH.
Cr improved during admission and returned to baseline. While in
ARF medications had been renally dosed.
.
# dementia: Patient initially experienced sundowning overnight
requiring sitter. Increased home dose of zyprexa. Patient's
mental status improved significantly in the days prior to
discharge and he was at baseline as per son. Continued home
Aricept.
.
#Decreased anion gap: Patient has had decreased anion gap during
admission. Would recommend following as outpatient, potentially
with SPEP to r/o hyperproteinemia.
.
# CAD- Continued Aspirin once platelets normalized as noted
above.
.
#BPH- started on Finasteride during admission with good effect.
.
# communication
- [**First Name8 (NamePattern2) **] [**Known lastname 54499**](son) [**Telephone/Fax (1) 54500**]
.
# code- apparently full code
-will address code status with son
.
# access- patient initially had R IJ catheter. This was removed
and PICC line was placed.
.
# PPx- pneumoboots, hold heparin until HIT negative, PPI
Medications on Admission:
MEDICATIONS ON ADMISSION:
aricept 10 QD
folic acid 1 QD
amiodarone 200 [**Hospital1 **]
zyprexa 2.5 QD
ASA 325 QD
protonix 40 QD
Lescol 80 QD
colace 100 [**Hospital1 **]
KCL 20 [**Hospital1 **]
timolol [**Hospital1 **]
Ditropan XL 10 QD
ceftaz
genta x1
azithro 500 QD
levaquin 500 QD
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
3. Donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO HS (at bedtime).
6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO DAILY (Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day): until mobile.
9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Meropenem 1 g Recon Soln Sig: One (1) gram Intravenous Q8H
(every 8 hours) for 1 weeks: for E coli urosepsis, resistant to
most other antibiotics.
12. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Urosepsis
Pneumonia
Discharge Condition:
Hemodynamically stable, breathing comfortably on room air with
O2 sats in mid-90s%, afebrile
Discharge Instructions:
Please continue to take all medications as prescribed and follow
up with your doctors. [**First Name (Titles) 357**] [**Last Name (Titles) 54501**] with the healthcare team
at the rehabilitation facility.
Return to the nearest Emergency Room if you have shortness of
breath, chest pain, confusion, or any other concerning symptoms.
Followup Instructions:
Please follow up with your Primary Care Physician within one
week of discharge from acute rehabilitation. Please bring a
copy of your discharge paperwork so that you physician is
updated on your hospital stay. Please have you physician
perform follow up blood work including chemistries, complete
blood count, and liver function tests.
Completed by:[**2126-8-30**]
ICD9 Codes: 5990, 486, 4280, 2875, 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4391
} | Medical Text: Admission Date: [**2164-9-12**] Discharge Date: [**2164-9-25**]
Date of Birth: [**2094-8-24**] Sex: F
Service: OMED
Allergies:
Bactrim / Clarithromycin / Doxycycline
Attending:[**Last Name (NamePattern1) 2499**]
Chief Complaint:
Cough and Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 yo female with a hx of small cell lung CA s/p RUL resection
recently started on taxotere, COPD, bronchitis admitted for
cough and hypoxia in clinic. Pt began experiencing cough and
sputum production on [**9-7**] although d/c summary from previous
hospitalization reported 2-3wk hx of weakness and SOB. Pt
reported cough intially productive of green sputum. She denied
any fever or chills, recent sick contacts. Pt went to clinic 1
and appeared tachypneic and was sent to the ED. Pt was admitted
initially for brochitis vs PNA and started on MDI's and
levofloxacin. Chest CT revealed no infiltrate suggestive of PNA
and she was easily weaned off of oxygen overnight so antibiotics
were stopped. Interventional pulmonary team was consulted since
the mass impinging on the rt main stem bronchus appeared larger,
but no intervention made since it was lesss that 80% obstructed
and unlikely the cause of hypoxia. Pt was dischaged on [**9-9**]
without antibiotics and off of o2. Pt continued to be short of
breath at home and continued cough productive of brown sputum.
No fevers or chills were present, but reported diarrhea prior to
and throughout her hospitalization w/o melena or hematochezia.
Pt denied PND, but had orthopnea and reported new LE edema,
although pt has no hx of CHF and echo from [**9-18**] was normal. Pt
presented to clinic on [**9-11**] for taxotere tx but med was held
due to poor PO intake, diarrhea, and weakness and instead was
given 1L IVF. She came back to clinic for 2U PRBC transfusion
for low Hct and found to have temp to 100.2 O2 Sats of 90% [**Female First Name (un) **]
which only improved to 94% on 2 L so she was given 125mg of
solumedrol for COPD flare vs PNA.
Past Medical History:
1. SCLCA (stage IIIA) hx-found to have lung mass on CXR after
syncopal episode in [**2-17**], trqnsbronchial bx revealed SCLCA and
she started taxol/carboplatin induction with rad tx in [**3-18**]
followed by gemcitibine with RUL resection in [**7-20**]. CA found to
recur in [**6-19**] and pt started on Iressa. Mass not responding well
to Iressa so she was changed to toxotere on [**8-28**]
2. hypothyroidism
3. TAH
4. ?RML stenting
5. COPD/Bronchitis
6. T4 compression fx and chronic back pain
Social History:
quit smoking 1 yr ago, smoked 1 ppd for 60 years agono EtOH, or
IVDAlives with husband
Family History:
noncontributory
Physical Exam:
PE-T 98.0 HR 88 BP 133/70 RR 22 O2 sat 96% 2l
HEENT-PERRL, arcus senilis, neck supple, 8cm elevated JVP,
pharynx clear, no ant or post cerv lymphad
Hrt- tachy RR nS1S2 but difficult to assess murmur due to coarse
BS
Lungs-diffuse crackles on right, mild diffuse end expiratory
wheeze, no dullness at bases
Abdomen-soft, NT, ND no organomegaly, normoactive BS
Extrem-trace edema to mid shin bilat, 2+ dp and rad pulses
Neuro-A and Ox3, strength not assessed
Pertinent Results:
[**2164-9-11**] 09:35AM GRAN CT-6830
[**2164-9-11**] 09:35AM WBC-7.7 RBC-2.63* HGB-8.7* HCT-27.6* MCV-105*
MCH-33.3* MCHC-31.7 RDW-14.9
[**2164-9-14**] 06:50AM BLOOD WBC-11.8* RBC-4.23 Hgb-13.4 Hct-40.2
MCV-95 MCH-31.7 MCHC-33.4 RDW-18.3* Plt Ct-430
[**2164-9-14**] 06:50AM BLOOD Glucose-92 UreaN-20 Creat-0.7 Na-139
K-4.1 Cl-104 HCO3-23 AnGap-16
[**9-13**] CXR Right lower lobe pneumonia.
Small right pleural effusion.
The right hilar mass is also increased in size in the interval.
[**9-14**] Chest CT-hilar mass increased in size with compression of
rt mainstem bronchus. RLL consolidation
Brief Hospital Course:
1. PNA-CXR on admission showed RLL PNA and she continued to have
productive cough and wheeze with elevated WBC. WBC thought to be
falsely elevated due to steroid use. All culture data except for
initial sputum cx was negative. Initial sputum gram stain with
GPC in pairs suggestive of staph or strep and culture showing
oral flora with sparse Pseudomonas. Pt initially on
Ceftazadime/azithromycin/flagyl then weaned to Levoflox/flagy
for partial pseudomonas coverage on, and postobstructive PNA and
completed 14 day regimen although flagyl dced on day 5 for
possiblity of lowering the seizure threshold and clindamycin
added on day #8. Pt wheeze continued on PE although she has a hx
of obstructive pulmonary disease so was treated with stress dose
IV solumedrol 60mg intially which was titrated up to 6mg
dexamethasone IV q6 hours per neuro after bleeding brain
metastasis found. Pt has partially obstructing lesion of rt main
stem bronchus which appeared larger on repeat chest CT and may
be cause of wheeze, although held on interventional pulomary at
this time. Pt had video swallow to rule out aspiration which was
negative, but S and S recommeded having meds in applesauce and
swallowing twice with all food consistencies. She was continued
on standing MDI's of fluticasone and combivent with albuterol
nebulizer treatments prn.
2. NSCLCA-Held taxotere therapy since pt was acutely ill. Hct
remained stable so we discontinued her outpatient procrit.
Bleeding in brain initially thought to be embolic although MRI
was more suggestive of bleeding metastasis. Kept all options
open so Neuro/Onc consulted and made plan for stereotactic
radioablation and have pt seen in tumor clinic. [**Telephone/Fax (1) 1844**].
Fusion MRI obtained per Neuro/Onc.
3. Change in mental status- Nature of course of mental status
change felt to be due to seizure per neuro and not hemmorhagic
stroke. Pt has no focal neurologic exam findings except for mild
left eye and mouth droop at rest and cont hyprereflexic patellar
and achilles on left, but no loss of strength. Pt initially on
Phenytoin for seizure prophylaxis which had been switched [**9-24**]
to Keppra now titraed up to 1500mg [**Hospital1 **].
4. Thrombocytopenia-Initial fall in platelets thought to be due
to platelet clumping and repeat sample in citrate tube suggests
pseudothrombocytopenia. HIT ab sent and held on all heparin use.
Continued to do platelet checks in citrate tube wtih stable
levels.
4. HTN-BP stable and pt started on metoprolol 12.5 [**Hospital1 **] in [**Hospital Unit Name 153**]
for unclear reason so changed back her outpatient Zestril 5mg qd
when transferred back to floor. Pt remains hypertensive with
stable creatinine so titrated up Zestril to 10mg qd.
5. Back pain-Pt with known t4 compression fracture which
coincides with her area of pain. Fracture not thought to be
malignant. Hydrocodone changed to standing oxycontin now
titrated up to 20mg q12 and oxycodone prn for breakthrough.
6. Depression-Pt mood improved and continued on outpatient
Celexa dose.
7. Hypothyroidism-Cont on outpatient dose levothyroxine
8.Oral thrush-due to high dose steroids. Cont to treat with
nystatin swish and swallow initially but changed to oral
fluconazole.
9. FEN-House diet, cont megace to improve appetite, replete
lytes
10. Px- Pneumoboots, PPI, on agressive bowel regimen
12. Code-DNR/DNI
Medications on Admission:
MVI, Ca-Vit D, Levoxyl 75 mcg qd, Albuterol MDI, Fluticasone
MDI, Megase 10mg qam, Procrit 40,000 u q wk, Zestril 2.5mg qd,
Motrin 200mg [**Hospital1 **], Hydrocodone 200mg PO q4-6h, Celexa 40mg
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 tabs* Refills:*2*
2. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed.
Disp:*3 vials* Refills:*0*
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*3 vials* Refills:*2*
5. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
QPM (once a day (in the evening)).
Disp:*60 Tablet(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
Disp:*60 neb* Refills:*2*
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
12. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2*
13. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for back pain.
Disp:*90 Tablet(s)* Refills:*0*
14. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*500 ML(s)* Refills:*0*
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
18. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
Disp:*120 Tablet(s)* Refills:*2*
19. Insulin Regular Human Injection
20. Megace Oral 40 mg/mL Suspension Sig: Ten (10) ml PO once a
day.
Disp:*300 ml* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
RLL pneumonia
Left parietal brain metastasis
Complex seizure
Discharge Condition:
Stable on 2L nasal canula oxygen
Discharge Instructions:
If you experience any worsening shortness of breath, fever,
chills, cough, loss of consciousness or seizure you should call
your doctor and if he/she is not available you should proceed to
the nearest emergency room.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-9-18**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-9-18**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-9-18**] 12:00
ICD9 Codes: 2875, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4392
} | Medical Text: Admission Date: [**2193-3-28**] Discharge Date: [**2193-3-31**]
Date of Birth: [**2128-2-21**] Sex: F
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 19908**]
Chief Complaint:
right renal colic, chills
Major Surgical or Invasive Procedure:
cystoscopy, placement of right ureteral stent [**2193-3-28**]
History of Present Illness:
65F with h/o nephrolithiasis presents with renal colic. She
awoke
this morning at 2AM with right flank pain, chills, and nausea.
No
dysuria, hematuria, fevers. In the ED, her nausea and pain are
controlled well with analgesics and antiemetics. Cr 1.0, WBC 17
with N81, UA suggestive of infection. CT scan without contrast
today identifies an obstructing 5mm right distal ureteral stone
with perinephric fat stranding.
Past Medical History:
PAST MEDICAL HISTORY:
CHF
Status post ureteral stent lithotripsy
in [**2186**].
Multiple sclerosis.
Spastic colon/IBS.
Osteoporosis.
GERD.
Glaucoma.
Social History:
No EtOH, no tobacco currently (50PY history)
Family History:
FAMILY HISTORY: Mother has history of macular degeneration.
Father has history of emphysema and prostate cancer.
Physical Exam:
Afebrile
NAD
LCTA bilaterally, diminished at bases
Abd S/NT/ND
urine clear
Brief Hospital Course:
The patient was seen and assessed in the ED by the Urology
service. Following persistent hypotension to SBP 80s, continued
chills and leukocytosis, the decision was made to place a
ureteral stent given CT findings of obstructive stone. She had
received iv levofloxacin, ceftriaxone. The patient was taken
to the OR and underwent cystoscopy and right ureteral stent
placement. The patient was placed on Ampicillin/Gentamicin both
peri- and post-operatively. She was taken to the ICU
post-operatively for observation, and did transiently require
use of a cardiac pressor (neo) to maintain SBPs>80. Over the
course of POD1, she was weaned from pressor dependence and began
to autodiurese.
The remainder of her course was unremarkable. Her leukocytosis
improved and she remained afebrile for the rest of her
hospitalization. The Foley catheter was removed and the patient
voided spontaneously. She had no significant pain complaints.
She was ambulating and tolerating a regular diet.
Medications on Admission:
Includes folate, prevacid, vit B12, occuvite. Glaucoma.
Discharge Medications:
1. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
Discharge Disposition:
Home
Discharge Diagnosis:
right obstructing renal stone with urosepsis
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
1-2 weeks with Dr. [**Last Name (STitle) 9125**] for management of your stone
ICD9 Codes: 0389, 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4393
} | Medical Text: Admission Date: [**2167-10-22**] Discharge Date: [**2167-11-6**]
Date of Birth: [**2099-10-27**] Sex: F
Service: SURGERY
Allergies:
Zosyn / Quinolones / Penicillins
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Unresponsive and seizing
Major Surgical or Invasive Procedure:
Subtotal colectomy
Endotracheal intubation
End-ileostomy
Splenectomy
Dobhoff feeding tube
Foley catheter
Orogastric tube
History of Present Illness:
67 year old female with mild retardation was transferred from
[**Hospital6 **] after being found lying down on her
bathroom floor at her nursing facility seizing and unresponsive.
Approximately two days prior to this event, she was noted to
have aspiration pneumonia, shortness of breath and chest
tightness and bilateral upper and lower extremity stasis
dermatitis and scabies. Vitals signs at the time of her arrival
to [**Hospital3 **] showed a hypotensive, bradycardic patient who
was tachypneic. Patient was transferred to the [**Hospital1 18**] ED where
she was intubated prior to arrival, appeared septic and still
found to be hypotensive with a SBP in the 50-60s. Her abdomen
was tense, greatly distended and tympanic.
Past Medical History:
Mild mental retardation
Atrial fibrillation
Hypertension
Congestive heart failure
Post-traumatic stress disorder
h/o Right calf deep venous thrombosis
s/p Pulmonary embolus
s/p IVC filter placed
h/o Endometrial cancer
s/p TAH/BSO
Social History:
Lives in [**Hospital3 2558**] (a long-term care facility)
Has a brother, [**Name (NI) **] [**Name (NI) **].
Family History:
Non-contributory
Physical Exam:
On addmision to [**Hospital1 18**] patient's physical exam was as follows:
Vitals: T=34.6 C, BP=67/37, P=61, R=18, SpO2=100% on CMV
(VT=400cc, RR=14, FiO2=100%, PEEP 5)
Gen: intubated, sedated, in acute distress
HEENT: NC/AT, PERRL
CVS: RRR
Pulm: coarse bilaterally
Abd: greatly distended, tympanic, no BS
Rectal/Anoscopy: mucosa wnl, no ulcers
Skin: scaly, dry
Ext: no edema
Pertinent Results:
WBC-33.3* RBC-2.73* HGB-6.2* HCT-25.0* MCV-92 MCH-22.7*
MCHC-24.7* RDW-21.2* PLT COUNT-442*
PT-21.5* PTT-36.5* INR(PT)-2.9
GLUCOSE-227* UREA N-55* CREAT-1.5* SODIUM-146* POTASSIUM-4.9
CHLORIDE-122* TOTAL CO2-11* ANION GAP-18
CORTISOL-32.9*
CRP-1.15*
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**2167-10-22**] 6:30 PM
1. Free intraperitoneal air and distended gas-filled colon.
Although no bowel wall defect can be seen, the source of the
free air is likely colonic.
2. Large hiatal hernia.
Brief Hospital Course:
Ms. [**Known lastname **] was taken to the OR the evening of her arrival to
[**Hospital1 18**] for an exploratory laparotomy. Intra-operatively, she was
found to have a pan-ischemic colon with evidence of perforation
midway along the transverse colon. At that point she underwent
a subtotal colectomy and end-ileostomy. She also underwent a
splenectomy for a capsule tear as an intra-operative
complication. For details of the procedure, please see
operative note.
Post-operatively, she was transferred to the SICU for monitoring
where she was agressively fluid resuscitated with crystalloid
and blood products and given pressors. She was also maintained
on IV antiobiotics and treated for her scabies. She was slow to
become responsive and a head CT was done on POD #1 but was
within normal. Her mental status slowly improved to near
baseline by POD#7
On POD#2, her hemodynamic status improved and she had no further
pressor requirement. On POD#2, total parenteral nutrition was
started. Her bowel function slowly returned and she started
tube feeds on POD#5. ON POD#8, she was doing well and was
extubated, a Dobhoff feeding tube was placed and all antibiotics
were stopped. She was then transferred out of the SICU on
POD#10.
Follow-up CT done on [**2167-10-31**] for an elevated WBC showed no
identifiable fever source, but, a small amount of free fluid
within the abdomen and bilateral pleural effusions and lower
lobe atelectasis.
On [**2167-11-3**], for concerns of aspiration, a bedside swallowing
evaluation was done as was a video swallow the following day.
Results showed mild to moderation aspiration and no cough
reflex. However, recommendations were for pureed solids and
nectar-thickened liquids with one-to-one assistance. She
continued to have difficulty with adequate blood glucose control
and was maintained on a stringent insulin sliding scale.
On [**2167-11-6**], she was doing well, eating with assistance and
mvoing from her bed to the chair with assistance. She was
transferred to [**Hospital3 **] facility on [**2167-11-6**]. She
is asked to follow-up with Dr. [**Last Name (STitle) 5182**] on [**2167-11-17**] in the
morning.
Medications on Admission:
Zyprexa 10 PO QD
Docusate sodium 100 PO BID
Lopressor 50 PO BID
Coumadin
Iron sulfate 325 PO QD
Fluoxetine 20 PO QD
Lasix 40 PO QD
Protonix 40 PO QD
MVI
Discharge Medications:
1. Urea 10 % Lotion Sig: One (1) Appl Topical ASDIR (AS
DIRECTED).
Disp:*1 1* Refills:*2*
2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Sertraline HCl 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2*
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Hydromorphone 0.5-2 mg IV Q4-6H:PRN
9. Hydralazine HCl 10 mg IV Q6H:PRN
for sbp > 160
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Perforated, necrotic colon
Sepsis
Hypovolemia
Blood loss anemia
Respiratory failure
Hypertension
Hypernatremia
Atrial fibrillation
Congestive heart failure
Thrombocytopenia
Diabetes mellitus
Bilateral pleural effusions
Dysphagia/aspiration
Scabies
Discharge Condition:
Good
Discharge Instructions:
You may restart any home medications you were taking prior to
your hospitalization.
You may shower.
You may ambulate with assistance.
You may eat only pureed solids and nectar thickened liquids with
supervision/assistance.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. SURGICAL SPECIALTIES CC-3 (NHB)
Where: SURGICAL SPECIALTIES CC-3 (NHB) Date/Time:[**2167-11-17**] 9:15
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
ICD9 Codes: 4280, 2765, 5185, 2875, 2851, 0389, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4394
} | Medical Text: Admission Date: [**2113-3-10**] Discharge Date: [**2113-4-10**]
Date of Birth: [**2077-9-28**] Sex: F
Service: SURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Cholelithiasis, duodenal perforation
Major Surgical or Invasive Procedure:
[**2113-3-10**]: ERCP
.
[**2113-3-16**]: Successful CT-guided percutaneous drainage catheter
placement into the right perinephric space
.
[**2113-3-21**]:
1. Wide incision and drainage of retroperitoneal
abscess/infection/hematoma.
2. [**Location (un) **] patch of potential duodenal perforation region with
drainage.
3. Antecolic isoperistaltic side-to-side gastrojejunostomy.
History of Present Illness:
35F with a h/o active IV drug abuse who presented to an OSH ED
c/o jaundice and abdominal pain on [**2113-3-6**], found to have and
ultimately transferred to the [**Hospital1 18**] [**2113-3-10**] for ERCP. Ms.
[**Last Name (un) 110632**] reports noticing RUQ pain intermittently for the
past three months, but it had not become bad enough for her to
seek medical attention. When she also developed jaundice
associated
with generalized malaise and myalgias, she presented to the
[**Hospital3 **] ED, where she was found to have elevated LFTS (TB
9.6, DB 6.6, alb 3.6, AST 638, ALT 640, AP 615, and WBC 13.6),
and cholelithiasis without ductal dilation on ultrasound.
Hepatitis C titer was positive. She was admitted for further
work-up.
When MRCP on [**1-/2030**] revealed cholelithiasis, possible
cholecystitis, and cystic duct stones without CBD or IHD
dilation, she was transferred to [**Hospital1 18**] on [**2113-3-10**] for ERCP.
ERCP revealed a laceration of the major papilla suggestive of
recent stone passage, and stones were noted in the lower CBD
with an impacted stone at the ampulla. Sphincterotomy and stone
extraction were performed, but subsequent cholangiography
revealed constrast extravasation suggesting perforation. Two
biliary stents and an NGT were placed, and arrangement for
direct admission to the West 2A Surgery service was made.
Past Medical History:
PMH: Cholelithiasis, hepatitis C, IV drug abuse, anxiety,
depression, chronic low back pain, migraines
PSH: Tubal ligation
Social History:
Unemployed and currently homeless, though she stays frequently
with her ex-husband. Two children: ages 3 and 5. +tobacco use,
1PPD currently. Denies ETOH. Using heroin, marijuana
regularly, most recently Saturday prior to her
admission to the OSH on Monday.
Family History:
Mother and sister with symptomatic cholelithiasis requiring CCY.
Father died in [**2107**] from MI, mother, alive, with alcoholic
cirrhoisis.
Physical Exam:
On Admission:
Vitals: 98.9 79 127/55 22 99% RA
GEN: A&O, markedly jaundiced, uncomfortable
HEENT: + scleral icterus, mucus membranes dry, NGT in place,
very
poor dentition.
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: +diffuse TTP, no guard or rebound, soft, nondistended, no
palpable masses
SKIN: Marked jaundice, multiple tattoos
Ext: No LE edema, LE warm and well perfused
On Discharge:
VS; 98.6, 92, 126/76, 14, 98% RA
GEN: NAD, AAO x 3
CV: RRR
RESP: Diminished breath sounds on right base, left cta
ABD: Midline abdominal incision open to air with steri strips
and c/d/i. RLQ JP drain to bulb suction with stopcock for
flushing/aspirating.
EXTR: Warm, no c/c/e
Pertinent Results:
[**2113-4-10**] 06:35AM BLOOD WBC-12.3* RBC-4.10* Hgb-11.6* Hct-38.3
MCV-93 MCH-28.2 MCHC-30.2* RDW-13.6 Plt Ct-433
[**2113-4-8**] 08:10AM BLOOD Neuts-78.7* Lymphs-14.7* Monos-3.9
Eos-2.1 Baso-0.6
[**2113-4-10**] 06:35AM BLOOD Glucose-90 UreaN-10 Creat-1.5* Na-137
K-4.0 Cl-94* HCO3-28 AnGap-19
[**2113-4-7**] 06:10AM BLOOD Calcium-8.2* Phos-4.4 Mg-1.8
[**2113-4-6**] 8:31 am PERITONEAL FLUID
GRAM STAIN (Final [**2113-4-6**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
Reported to and read back by DR. [**Last Name (STitle) **] [**Name (STitle) **] #[**Numeric Identifier 11536**]
[**2113-4-7**] 10:46AM.
YEAST. SPARSE GROWTH.
Fluconazole Susceptibility testing requested by DR.
[**Last Name (STitle) **] [**Name (STitle) **]
#[**Numeric Identifier 11536**] [**2113-4-7**]. SENSITIVE TO Fluconazole.
sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
This test has not been FDA approved but has been
verified
following Clinical and Laboratory Standards Institute
guidelines
by [**Hospital1 69**] Clinical
Microbiology
Laboratory..
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.
ID PERFORMED ON CORRESPONDING ROUTINE CULTURE.
[**2113-3-15**] 8:19 am BLOOD CULTURE Source: Line-left picc 1 OF
2.
**FINAL REPORT [**2113-3-21**]**
Blood Culture, Routine (Final [**2113-3-21**]):
STAPHYLOCOCCUS EPIDERMIDIS. FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final [**2113-3-16**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by DR [**First Name (STitle) **] [**Doctor Last Name **] 2PM [**2113-3-16**].
[**2113-3-12**] CT ABD:
IMPRESSION:
1. Large amount of intraperitoneal and retroperitoneal free air.
A large
amount of fluid in the right anterior and posterior pararenal
spaces tracking down to the lower quadrant of the abdomen. No
obvious leak of contrast to identify the site of perforation. If
needed a delayed non-contrast CT abdomen can be obtained to
assess for a delayed leak.
2. Small amount of pneumomediastinum.
3. A small simple right pleural effusion with right basilar
atelectasis.
[**2113-3-16**] CT ABD:
IMPRESSION:
1. Decreased but persistent large intraperitoneal and
retroperitoneal free
air. A large amount of fluid in the right retroperitoneum is
seen with
anterior displacement of the right kidney. No rim-enhancing
fluid collection is seen.
2. Decreased pneumomediastinum.
3. Bilateral pleural effusions with adjacent atelectasis as
described above.
[**2113-3-20**] CT ABD:
IMPRESSION:
1. Improvement in right lower lobe consolidation and decrease in
right
pleural effusion.
2. Slight decrease in fluid component of right perinephric
collection at site of Drain. Extensive multiloculated
phlegmonous change with no significant large fluid component to
target for drainage.
3. No new collections are identified.
4. Persistent extensive free intra-abdominal air with multiple
pockets of air surrounding the second part of duodenum, likely
at site of duodenal
perforation.
[**2113-3-29**] CT ABD:
IMPRESSION:
1. Decrease in size of loculated gas-fluid collections with four
drains in
place. There are small pockets of loculated collections that may
not be
adequately drained. Significant resolution of intra-abdominal
free air.
2. Right hydronephrosis likely from obstruction of ureter due to
surrounding inflammation.
3. Slight improvement in right lower lobe consolidation;
however, slight
increase in right pleural effusion.
[**2113-3-31**] RENAL US:
FINDINGS:
1. There is stable mild hydronephrosis in the right kidney.
Adjacent to the lower pole, is a partially imaged complex fluid
collection containing a drain. The right kidney measures
approximately 14 cm.
2. The left kidney measures approximately 14.2 cm. There is no
hydronephrosis, renal lesion or nephrolithiasis.
3. The bladder is minimally distended limiting evaluation and
grossly
unremarkable.
[**2113-4-6**] CT ABD:
IMPRESSION:
1. Limited study due to lack of intravenous and oral contrast
demonstrates an interval decrease in the phlegmonous collection
in the right perinephric space now measuring 8.0 x 3.0 cm with a
drain in place. Multiple adjacent collections with air and fluid
are again noted and appear relatively stable to minimally
decreased in size. Three of the previously visualized drains
have since been removed.
2. Continued mild right hydronephrosis.
3. Resolution of right pleural effusion. Right lower lobe
opactiy has
decreased in size.
4. Two common bile duct stents are in place with pneumobilia.
5. 2-mm non-obstructive left renal stone.
Brief Hospital Course:
The patient was admitted to the General Surgical Service with
duodenal perforation status post ERCP. The patient was made NPO
with NGT, started on IV fluids and IV Zosyn, and Dilaudid PCA
for pain control. CT scan on HD # 2 demonstrated large amount of
fluid in the right anterior and posterior pararenal spaces
tracking down to the lower quadrant of the abdomen and large
amount of free air. Nutritional consult was called for TPN
recommendations and PICC line was placed. The patient continued
to spike low grade fever and her blood cultures were positive
for STAPHYLOCOCCUS EPIDERMIDIS, Vancomycin Iv was added on HD #
6. Repeat abdominal CT demonstrated decreased but persistent
large intraperitoneal and retroperitoneal free air with a large
amount of fluid in the right retroperitoneum is seen with
anterior displacement of the right kidney. The patient continued
to spike fever and IR drainage of the right retroperitoneal
fluid collection was ordered. The patient underwent CT-guided
percutaneous drainage catheter placement into the right
perinephric space on HD # 6 and fluid was sent for cultures. The
patient's diet was advanced as tolerated on POD # 8, and was
well tolerated. The cultures were positive for [**Female First Name (un) 564**] Albicans
and IV Fluconazole was added. Despite antibiotics treatment
patient continued to spike fever and her abdominal pain was
continued to be significantly high requiring large amount of IV
Dilaudid, Ativan and Ketorolac to manage it, patient's WBC also
continued to increased (16->38).Repeat abdominal CT scan on HD #
10 revealed slight decrease in fluid component of right
perinephric collection, extensive multi loculated phlegmonous
change with no significant large fluid component to target for
drainage and persistent extensive free intra-abdominal air with
multiple pockets of air surrounding the second part of
duodenum. The decision was made to take the patient in OR for
washout.
On [**2112-3-20**], the patient underwent wide incision and drainage of
retroperitoneal
abscess/infection/hematoma, [**Location (un) **] patch of potential duodenal
perforation region
with drainage and antecolic isoperistaltic side-to-side
gastrojejunostomy and JP drains placement x 4, which went well
without complication (reader referred to the Operative Note for
details). Intraoperatively patient received 2 units of pRBC, she
was extubated post op and was transferred in ICU for
observation. On POD # 2, patient received 2 units of pRBC for
HCT 23.4, her post transfusion Hct was 28.3. The patient was
transferred to the floor on POD # 3, NPO on TPN and IV fluids,
and Dilaudid PCA for pain control. The patient was continued to
have low grade fever and she was continued on IV Vancomycin,
Zosyn and Fluconazole. The patient was hydrodynamically stable.
Neuro: The patient is an active Heroin user. Her pain was
controlled with Dilaudid PCA and she had high requirements for
pain medication. When tolerating oral intake, the patient was
transitioned to oral Dilaudid and Chronic Pain Service was
consulted. The patient's pain medications was weaned to [**1-14**] gm
of Dilaudid PO Q4H and patient instructed to continue wean off
her pain medications in home.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: The patient was started on TPN on admission. Her diet was
advanced to clears on HD # 6 and to regular on HD # 8. The
patient was made NPO prior surgery and TPN was continued. Diet
was advanced to clears on POD # 5 and to regular on POD # 9, TPN
was weaned off and d/c/d on POD # 8. The patient was able to
tolerate regular diet prior discharge. Electrolytes were
routinely followed, and repleted when necessary.
Renal/GU: The patient's Cre/BUN were monitored routinely, on HD
# 21 (POD # 10) her Cre increased to 1.9. During hospitalization
patient underwent several abdominal CT scans with contrast, she
received IV Vancomycin x 14 days, and she received IV Toradol
for pain control. The combination of these factors and
inflammatory respond from fluid collection, which lead to mild
right kidney hydronephrosis contributed to patient's acute renal
injury. Urology and Renal were called for consult and their
recommendations were followed. The kidney function started to
improve on POD # 16, and returned to 1.5 prior discharge. The
patient continued to urinate without any difficulties and her
electrolyte balance was generally within normal limits. The
patient will required to have a follow up Renal US to
re-evaluate her hydronephrosis in 6 months as outpatient.
ID: The patient had a positive blood cultures on admission with
STAPHYLOCOCCUS EPIDERMIDIS, she was treated with IV Vancomycin
for 14 days. Surveillance blood cultures were negative. Intra
abdominal fluid was positive for [**Female First Name (un) 564**] and patient was started
on IV Fluconazole for 14 days also. After discontinue of IV
antibiotics, the patient continued to spike low grade fever and
her increased on POD # 15. Blood and urine cultures were
negative, intra abdominal cultures were positive with [**Female First Name (un) 564**].
The patient was restarted on PO Fluconazole and Augmentin. WBC
and fevers subsided after abx was started. She will continue on
PO Abx for 10 days after discharge. She was discharged with one
JP left within biggest fluid collection, she will follow up with
Dr. [**Last Name (STitle) 468**] in 2 weeks with Ct scan to evaluate her fluid
collection and possible d/c JP drain.
Hematology: The patient's complete blood count was examined
routinely; she received total 6 units of pRBC during
hospitalization. Her Hct was stable prior discharge and no
further transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Xanax 1''', Fioricet PRN, oxycodone 10 mg qid
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 2
weeks.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0*
2. acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR (AS
DIRECTED).
Disp:*1 tube* Refills:*0*
3. alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
7. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
8. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0*
10. Xanax 1 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for anxiety.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. Choledocholithiasis
2. Doudenal perforation s/p ERCP
3. Infected right perinephric fluid collection
4. Right hydronephrosis
5. Acute kidney injury
6. Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for treatment
of duodenal perforation s/p ERCP. Your condition continuing to
improve and are now safe to return home to complete your
recovery with the following instructions:
*You will need to repeat Renal Ultrasound six months after
discharge. Please follow up with Dr. [**Last Name (STitle) **] (PCP) to schedule this
test.
*Please resume all regular home medications , unless
specifically advised not to take a particular medication. Also,
please take any new medications as prescribed.
*Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-20**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
*Avoid driving or operating heavy machinery while taking pain
medications.
*Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
JP Drain Care:
*Flush and aspirate drain with 10 cc of NS daily.
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 1 week after discharge to
check you kidney function test.
Follow up with Dr. [**Last Name (STitle) **] (PCP) in 6 month with Renal Ultrasound
to follow up on your right kidney hydronephrosis and left kidney
2-mm non-obstructive left renal stone.
.
Department: RADIOLOGY
When: MONDAY [**2113-4-24**] at 9:15 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
.
Department: SURGICAL SPECIALTIES
When: MONDAY [**2113-4-24**] at 10:45 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2113-4-10**]
ICD9 Codes: 5845, 7907, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4395
} | Medical Text: Admission Date: [**2173-4-19**] Discharge Date: [**2173-4-23**]
Date of Birth: [**2123-5-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion and worsening chest pain
Major Surgical or Invasive Procedure:
CABGx4 ([**4-19**])
History of Present Illness:
Patient with known CAD s/p MI and stent to LAD [**11-1**] now with
worsening dyspnea on exertion and chest pain. Had +ETT then
referred for repeat cardiac catheterization which revealed 3VD
then referred for CABG.
Past Medical History:
s/p CABG x4 (LIMA-LAD, SVG-OM, SVG-RCA, SVG-PDA)MVRepair(#28 CE
Physio ring)[**4-19**]
PMH: CAD,MI, DM2, Kidney stones, HTN, ^chol, Lumbar disc [**Doctor First Name **]
x3, Appy
Social History:
Married, lives with wife and children.
Works in sales
Denies tobbacco
No ETOH since [**2171**]
Family History:
noncontributory
Physical Exam:
Admission
VS HR 98 BP 100/60 RR 16
Gen NAD
Neuro Grossly intact
Chest CTA Bilat
Heart RRR
Abdm soft, NT/+BS
Ext warm trace edema bilat, L knee tender with limited ROM/+
swelling-no erythema. no varicosities
Discharge
VS 99.9 T 100/71 HR 99 RR 18 94% RA sat
Pertinent Results:
[**2173-4-19**] 04:12PM GLUCOSE-90 NA+-133* K+-3.9
[**2173-4-19**] 03:57PM UREA N-26* CREAT-0.9 CHLORIDE-111* TOTAL
CO2-23
[**2173-4-19**] 03:57PM WBC-14.2* RBC-3.41*# HGB-10.7*# HCT-30.5*#
MCV-89 MCH-31.3 MCHC-35.0 RDW-12.6
[**2173-4-19**] 03:57PM PLT COUNT-141*
[**2173-4-19**] 03:57PM PT-14.1* PTT-61.4* INR(PT)-1.2*
[**2173-4-19**] 01:55PM GLUCOSE-142* LACTATE-3.3* NA+-132* K+-4.4
CL--108
[**2173-4-23**] 05:10AM BLOOD WBC-8.1 RBC-3.19* Hgb-10.1* Hct-29.0*
MCV-91 MCH-31.6 MCHC-34.7 RDW-13.4 Plt Ct-178
[**2173-4-23**] 05:10AM BLOOD Plt Ct-178
[**2173-4-23**] 05:10AM BLOOD Glucose-128* UreaN-20 Creat-1.0 Na-135
K-4.5 Cl-97 HCO3-29 AnGap-14
RADIOLOGY Final Report
CHEST (PA & LAT) [**2173-4-21**] 12:24 PM
CHEST (PA & LAT)
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
49 year old man s/p cabg and ct removal
REASON FOR THIS EXAMINATION:
r/o ptx
HISTORY: Status post CABG with chest tube removal.
FINDINGS: In comparison with the study of [**4-19**], there has been
removal of the various tubes including the left chest tube. No
evidence of pneumothorax. Mild residual atelectatic changes are
seen at the bases, especially on the left.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: WED [**2173-4-21**] 4:12 PM
Conclusions
PRE-BYPASS:
1. The left atrium is normal in size.
2. A patent foramen ovale is present.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is moderate
regional left ventricular systolic dysfunction of septal wall
from the mid-papillary segments to the apex. Overall left
ventricular systolic function is mildly depressed (LVEF= 40-45
%).
4. The right ventricular cavity is mildly dilated with normal
free wall contractility.
5. There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. With
provactive maneuvers (Trendelenberg and phenylephrine infusion),
a mildly eccentric, posteriorly directed jet of Moderate to
severe (3+) mitral regurgitation is seen, with noted posterior
leaflet (P1 and P2) restriction. The mitral regurgitation vena
contracta is >=0.7cm.
7. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and wasAV
paced.
1. A well-seated mitral annuloplasty ring is seen with normal
leaflet motion and gradients (mean gradient = 1.5 mmHg, MVA by
PHT 3.2 cm2). There is no valvular systolic anterior motion
([**Male First Name (un) **]). Trivial mitral regurgitation is seen.
2. Regional and global left ventricular systolic function are
mildly depressed LVEF 45-50%, there is improvement of wall
motion of the apical segments.
3. Right ventricular systolic function is normal.
4. Aortic contours are intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2173-4-19**] 16:41
?????? [**2168**] CareGroup IS
Brief Hospital Course:
Patient was a direct admission to the operating room on [**4-19**]
where he had a coronary artery bypass, please see OR report for
details. In summary he had a CABGx4 with LIMA-LAD, SVG-RCA,
SVG-OM, SVG-PDA. He tolerated the operation well and was
transferred from the OR to the CVICU in stable condition. He did
well in the immediate post-op period, his anesthesia was
reversed, he was weaned from the ventilator and extubated. He
remained hemodynamically stable and on POD1 was transferred from
the ICU to the step down floor for continued care. On POD2 his
chest tubes and epicardial wires were removed. He was gently
diuresed toward his perop weight. The remainder of his post
operative course was uneventful and on POD #4 he was discharged
home with visiting nurses.
Pt. is to make all postop appts. as per discharge instructions.
Medications on Admission:
ASA 81'
Plavix 75'
Lopressor 50"
Lisinopril 20'
Coreg 12.5"
Zocor 40'
Percocet prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking percocet;may stop when off narcotics.
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
s/p CABG x4(LIMA-LAD,SVG-OM,SVG-RCA,SVG-PDA)[**4-19**]
PMH: CAD s/p stent/LAD, HTN, DM2, Back surgery
MI, renal calculi,elev. chol.
Discharge Condition:
stable
Discharge Instructions:
Shower daily and pat incisions dry.No bathing or swimming.
Take all medications as prescribed.
Call for any fever greater than 100.5,, redness or drainage from
wounds.
No driving for one month.
No lotions, creams or powders on any incision.
Followup Instructions:
wound clinic in 2 weeks
Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Drs. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14522**] [**Name5 (PTitle) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 77640**] in 2 weeks
Completed by:[**2173-4-23**]
ICD9 Codes: 4240, 9971, 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4396
} | Medical Text: Admission Date: [**2177-3-5**] Discharge Date: [**2177-3-19**]
Date of Birth: [**2107-2-25**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Patient is a 69-year-old male
with past medical history of hypertension,
hypercholesterolemia, who presented to an outside hospital
with chest pain. The patient was at home on the evening of
admission and took a cough medication and felt chest
tightness, shortness of breath, and pain to the neck and
shoulders, which was dull in nature, no nausea, but did
experience diaphoresis. Patient called EMS after taking an
aspirin which gave him mild improvement, but then
subsequently worsened. EMS gave him another aspirin.
The patient was afebrile with a blood pressure of 170/100.
Transferred to the outside hospital where he was afebrile
with vital signs stable. Electrocardiogram showed an acute
myocardial infarction. The patient was transferred to the
[**Hospital1 69**], where he had repeat
electrocardiogram which showed Q waves in II, III, and aVF,
and leads V3 and V5. Bedside echocardiogram was performed
showed anterior and apical wall hypokinesis, ejection
fraction of 30%, normal RV function, no pericardial
effusions. Chest was clear. Heart was regular, rate, and
rhythm.
PAST MEDICAL HISTORY:
1. The patient underwent cardiac catheterization on [**2177-3-6**].
2. Hypertension x30 years.
3. Hypercholesterolemia on a statin.
4. Benign prostatic hypertrophy.
5. Gout.
6. Osteoarthritis.
MEDICATIONS:
1. Cardizem 120 mg q day.
2. Allopurinol.
3. Aspirin 81 mg which the patient stopped taking four weeks
prior.
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: Quit smoking 45 years prior and used
occasional alcohol.
On admission, electrolytes were within normal limits except
for a potassium which is mildly decreased at 3.5 mg. The
patient had a white count of 9.6, hematocrit 46 and platelets
of 226. The patient underwent a cardiac catheterization
which showed severe three vessel disease with 90% stenosis
proximally with thrombus noted in the left anterior
descending artery, 90% proximal stenosis of D1, and a 94%
stenotic LCX, abnormal left ventricular systolic function,
and severe hypokinesis of the inferior wall, and reduced left
ventricular ejection fraction of 40%, elevated resting rate
and left heart filling pressures.
Pulmonary consult was obtained for a patient having a cough
with occasional production of green sputum. By pulmonary
consult, there are no symptoms to suggest pneumonia,
bronchitis, and was put on Zithromax x5 day course.
The patient underwent a CABG x4 with a LIMA to the left
anterior descending artery, saphenous vein graft to the
posterior descending artery, saphenous vein graft to the OM,
and saphenous vein graft to the diagonal, and mitral valve
repair, a #28 mm [**Doctor Last Name 405**] annuloplasty band. Patient
tolerated the procedure without complications and was
extubated on postoperative day #1, who continued to have
respiratory issues with desaturations down to the 80's with
activity.
The patient had aggressive chest physiotherapy. The patient
had vigorous coughing which caused concern for his sternal
incision. He was instructed to be more attentive to that,
and as such improved his situation. Patient also received
albuterol and ipratropium bromide nebulizers which also
helped to improve the situation. Patient was transferred to
the floor on postoperative day #7, who continued to do well,
and by postoperative day #9, was felt to be ready to be
discharged to [**Location (un) **] Transitional Care Unit.
FO[**Last Name (STitle) **]P INSTRUCTIONS: Patient will be following up with
Dr. [**Last Name (Prefixes) **] in four weeks, Dr. [**Last Name (STitle) 3142**], his PCP [**Last Name (NamePattern4) **] [**12-26**]
weeks and his cardiologist in [**1-27**] weeks.
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg [**Hospital1 **].
2. Lasix 20 mg [**Hospital1 **] x7 days.
3. Potassium chloride 20 mEq [**Hospital1 **] x7 days.
4. Colace 100 mg [**Hospital1 **].
5. Aspirin 325 mg q day.
6. Tylenol 650 mg po q4h prn.
7. Ibuprofen 400 mg q6h prn.
8. Percocet 1-2 tablets po q4-6h prn.
9. Albuterol nebulizer one hour q4h.
10. Ipratropium Bromide one nebulizer q6h prn.
11. Allopurinol 50 mg q day.
12. Zantac 150 mg [**Hospital1 **].
DISCHARGE STATUS: Discharged to rehabilitation facility.
DIAGNOSIS: Status post coronary artery bypass graft x4, and
mitral valve repair.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2177-3-19**] 09:08
T: [**2177-3-19**] 09:13
JOB#: [**Job Number 49273**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4397
} | Medical Text: Admission Date: [**2187-4-17**] Discharge Date: [**2187-5-1**]
Date of Birth: [**2143-6-24**] Sex: M
Service: Surgery, Blue Team
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 53-year-old
Caucasian male with no significant past medical history who
was transferred to this institution from the [**Hospital3 3583**]
for treatment of necrotizing fasciitis of the right thigh.
The patient presented to his primary care physician
approximately three weeks ago for right thigh swelling. He
was treated with a 10-day course of antibiotics without
relief. The patient returned to his primary care physician
following this course and was admitted for an
enlarged/fluctuant right thigh mass along with new onset
diabetes with a fasting blood sugar of 500.
A computed tomography scan was done at the outside hospital
which showed a large amount of fluid in the posterior thigh.
The General Surgery Service was consulted, and the patient
went to the operating room where 4 liters of purulent
material was found along with a suspicion for necrotizing
fasciitis. There was no suspected source as the patient had
not had any injuries or lines placed. The wound was packed
with a wet dressing, and the patient was subsequently
transferred to the [**Hospital1 69**] for
treatment.
When the patient first presented, an ultrasound was done at
the outside hospital which did not show evidence of clot in
the deep veins. Cultures were obtained during the time of
his debridement which grew oxacillin-sensitive Staphylococcus
aureus.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: The patient had open
reduction/internal fixation of the left ankle approximately
10 years ago.
MEDICATIONS ON ADMISSION: The patient takes no medications
at home.
MEDICATIONS ON TRANSFER:
1. Ativan 0.5 mg to 1 mg by mouth q.6h. as needed.
2. Timentin 3 grams intravenously q.4h.
3. Regular insulin sliding-scale.
4. Morphine 2 mg to 4 mg intravenously q.2h. as needed.
5. Percocet 5/325-mg tablets one to two tablets by mouth
q.4-6h. as needed.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
his temperature was 98.9 degrees Fahrenheit, his pulse was
85, his blood pressure was 135/75, his respiratory rate was
18, and his oxygen saturation was 99% on room air. In
general, the patient was a pleasant Caucasian male who
appeared his stated age and was in no apparent distress. The
oropharynx was clear with moist mucous membranes. The neck
was supple and without lymphadenopathy or jugular venous
distention. The lungs were clear to auscultation
bilaterally. The abdomen was soft, nontender, and
nondistended. There were normal active bowel sounds, and no
palpable masses. The heart was regular in rate and rhythm.
The rectal tone was normal and without masses or fecal occult
blood. The right lower extremity demonstrated an approximate
10-cm X 4-cm incision on the posterior aspect of the thigh.
It was packed with a moist gauze dressing and had good
granulation tissue. A Penrose drain exited the skin
approximately 4 cm proximal to the wound. The sural,
saphenous, deep peroneal, and superficial peroneal nerves
were intact to light touch. The popliteal, dorsalis pedis,
and posterior tibialis pulses were 2+. The knee extensors,
knee flexors, gastroc-soleus, anterior tibial, and extensor
hallucis longus muscles were [**5-16**].
PERTINENT LABORATORY VALUES ON PRESENTATION: At the time of
admission, the patient's white blood cell count was 14.3, his
hematocrit was 31.4, and his platelet count was 328. His INR
was 1.1. The creatinine was 0.6, with a potassium of 4.6,
and blood sugar of 388.
PERTINENT RADIOLOGY/IMAGING: None.
BRIEF SUMMARY OF HOSPITAL COURSE: After being transferred to
the [**Hospital1 69**], the patient was
evaluated by the Surgical Service and was admitted to the
Intensive Care Unit for blood sugar control.
The [**Last Name (un) **] Diabetes Service was consulted, and an insulin
drip was initiated. The patient's initial antibiotic cover
included Zosyn and Flagyl. His pain was controlled with a
morphine patient-controlled analgesia pump. The wound was
initially cared for via wet-to-dry dressing changes twice per
day. He remained on an insulin drip and was initiated on
long-acting antidiabetic medication along with a Humalog
sliding-scale on hospital day two. At this time, the patient
was deemed stable without acidosis and was transferred to the
regular hospital floor.
On hospital day three, the patient underwent irrigation and
debridement of the right thigh wound. The estimated blood
loss for this procedure was approximately 25 cc. A Hemovac
dressing was placed intraoperatively. At this time, it was
noted that there was no further spread of infection, and the
wound appeared clean and to be healing well with good
granulation tissue.
The patient's blood sugars remained stable throughout his
stay. He received diabetic teaching by the [**Last Name (un) **] Service
and was treated with Glargine and Humalog with excellent
results.
On hospital day eight, after the culture results were
received from the patient's primary care physician indicating
the presence of methicillin-sensitive Staphylococcus aureus
from the initial operative wound culture, the patient was
started on oral dicloxacillin. He remained afebrile
throughout the duration of his stay.
On hospital day nine, the patient returned to the operating
room under the care of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Plastic Surgery
where the Hemovac dressing was removed and a split-thickness
skin graft was applied. The donor tissue was taken from the
proximal anterior right thigh. Following the application of
the skin graft, a Hemovac dressing was reapplied.
Postoperatively, the patient remained nonweightbearing with
elevation of the right lower extremity to [**Last Name (NamePattern1) **] with graft
take. The donor site was cared for using Xeroform and dry
gauze as needed. The recipient site remained with a Hemovac
in place for five days. This device was removed on [**2187-4-30**]. The recipient site was then treated with Xeroform, dry
gauze, and a circumferential Kerlix dressing.
He was discharged to home with a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **]
with wound care and blood sugar management on [**2187-5-1**].
The patient was to finish three additional days of oral
dicloxacillin to complete a total of a 10-day course.
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: The patient was discharged to home with a
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with wound care.
DISCHARGE DISPOSITION:
1. The patient was to have his split-thickness skin graft
site change daily.
2. The patient was instructed to keep his right lower
extremity elevated while in bed.
DISCHARGE DIAGNOSES:
1. New onset diabetes mellitus.
2. Fasciitis of the right lower extremity.
3. Status post irrigation and debridement of a right lower
extremity wound.
4. Status post Hemovac placement.
5. Status post split-thickness skin graft.
MEDICATIONS ON DISCHARGE:
1. Dicloxacillin 500 mg by mouth q.6h. (times three days).
2. Percocet 5/325-mg tablets one to two tablets by mouth
q.4-6h. as needed (for pain).
3. Colace 100 mg by mouth twice per day.
4. Humalog insulin sliding-scale (as directed).
5. Glargine insulin 48 units subcutaneously at hour of
sleep.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] from the Department of General Surgery in
approximately 7 to 10 days for staple removal.
2. The patient was also instructed to follow up with his
primary care physician in [**Name9 (PRE) 3320**] as soon as possible
following discharge.
3. The patient was to be following up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
from the Department of Plastic Surgery in approximately one
week to assess his right lower extremity wound.
4. The patient was also to follow up with the [**Last Name (un) **]
Diabetes Center as needed for blood sugar management.
5. The patient was instructed to follow up sooner if he
developed fevers of greater than 101.5 degrees Fahrenheit,
numbness, weakness, or swelling in his right lower extremity.
6. The patient was instructed to follow up sooner if he had
any questions or concerns.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 26023**]
MEDQUIST36
D: [**2187-5-1**] 18:04
T: [**2187-5-1**] 18:17
JOB#: [**Job Number 55045**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4398
} | Medical Text: Admission Date: [**2119-11-22**] Discharge Date: [**2119-12-4**]
Date of Birth: [**2078-8-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain.
Major Surgical or Invasive Procedure:
s/p CABGx6(LIMA->LAD, SVG->Diag, OM1, OM2, AM, dRCA)/MV
repair(26mm ring) [**2119-11-29**]
History of Present Illness:
Mr. [**Known lastname 39685**] is a 41yo man with h/o hyperlipidemia who first
noticed chest pain with exertion in [**Month (only) 216**] while walking. This
was a pressure on both sides of his chest, no N/V, radiates to
necka nd occasionally ot both arms, accompanied by SOB lasting
for about 20m and then resolved with rest. No diaphoresis. In
the last month or two he has had a few similar episodes of chest
pain all with exertion. Resolves with rest. In the last week or
two he has noticed this chest pain with accompanied DOE while
walking and pushing a cart down a [**Doctor Last Name **] or while walking up one
flight of stairs, also resolved with rest. He had been seen by
his PCP, [**Name10 (NameIs) 1023**] checked his cholesterol and found that his total
fell from 320 to 255 on lipitor. He recommended an exercise
stress test which was performed today as an outpt at [**Hospital 5871**]
Hospital. He is a nonsmoker, has a FH of MI in his father and
uncle in their 50s, has hyperlipidemia as mentioned, and is
obese no h/o HTN.
.
The patient walked for 4 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol with chest
discomfort and reportedly 1.8mm of ST depression for which the
stress test was stopped and he was sent to the ER. His chest
pain stopped with rest prior to arrival in the ER. In the ED at
[**Hospital 5871**] Hospital, he was given ASA 162, Plavix 600mg, lopressor
50mg, lovenox 100mg sq, lipitor 80mg po, aggrastat drip was
started, ativan 1mg. He was also given NTG, although he said
that the CP had resolved prior to receiving this. EKG there was
found ot have Q waves inferiorly in III and F but no ST changes.
His troponin I was 1.43 with a normal CK of 169 (MB not done).
He was transferred to [**Hospital1 18**] for catheterization. He is currently
CP free and has no dyspnea.
.
ROS: he denies N/V/C/D, no dizziness or HA, no cough, no
numbness/tingling, states he has had throat pain since eating
french fries 2 weeks ago at [**Doctor First Name 11492**], no BRBPR or black stool, no
hematuria or dysuria.
Past Medical History:
Hyperlipidemia
Obesity
Social History:
Lives with wife at home. Nonsmoker, rare Etoh, no other
recreational drugs.
Family History:
Father died at age 59 of MI, uncle MI at age 60, paternal
grandfather MI in his 60s.
Physical Exam:
VS 98.7, 89, 115/70, 20, 95% Ra
Gen: NAD, pleasant, conversant
HEENT: PERRLA, no OP injection, MMM
Neck: no JVD, no LAD, supple, full
Cor: s1s2, no r/g/m, RRR
Pulm: CTAB
Abd: soft, obese, NT, +BS, no HSM
Ext: no c/c/e, WWP, 2+ PT pulses bilaterally
Neuro: grossly nl motor and sensory exam
Skin: no rashes noted
Pertinent Results:
[**2119-11-22**] 07:00PM GLUCOSE-100 UREA N-11 CREAT-0.9 SODIUM-142
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-15
[**2119-11-22**] 07:00PM WBC-9.1 RBC-4.74 HGB-15.1 HCT-41.2 MCV-87
MCH-31.8 MCHC-36.6* RDW-12.8
[**2119-11-22**] 07:00PM PT-12.9 PTT-30.4 INR(PT)-1.1
[**2119-11-22**] 07:00PM CK-MB-4
[**2119-11-22**] 07:00PM cTropnT-0.34*
[**2119-11-22**] 07:00PM CK(CPK)-150
.
CXR; No evidence of acute cardiopulmonary process.
.
Stress test: 4:01 of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol, 5.8 mets. HR from
104-133. BP 124/84 to 144/84, pt developed Chest discomfort and
by report 1.8mm ST depressions (unclear which leads, as not
recorded)
.
EKG: NSR at 90, occ PVCs, nl axis, nl intervals, Q in III and F,
no ST changes. No prior EKGs on file. Unchanged from [**Location (un) 5871**] ER.
[**2119-12-4**] 06:35AM BLOOD WBC-8.1 RBC-3.22* Hgb-10.0* Hct-28.2*
MCV-88 MCH-31.1 MCHC-35.6* RDW-13.8 Plt Ct-292
[**2119-12-4**] 06:35AM BLOOD Plt Ct-292
[**2119-12-4**] 06:35AM BLOOD Glucose-101 UreaN-14 Creat-1.0 Na-135
K-4.9 Cl-99 HCO3-26 AnGap-15
Brief Hospital Course:
Cardiac Catheterization on [**2119-11-23**] showed no MR, LVEF 48%, LAD
80% mid, long 60% mid to distal, 70% second diagonal, LCx 99%
OM1, 99% OM2, & RCA 100% mid, 90% acute marginal branch. He was
referred for CABG.
Echo showed 2+ MR, He received a panorex and dental consult. He
underwent extraction of 7 infected teeth on [**2119-11-27**].
On [**11-29**] he underwent a CABG x 6 and mitral valve repair. He was
transferred to the SICU in critical but stable condition. He
awoke neurologically intact and was extubated that same day. His
vasoactive drips were weaned and he was transferred to the floor
on POD #3. He was pancultured for a temperature of 101.9. He was
transfused 1 unit packed cells for a hct of 24. He did well
postoperatively and was ready fo discharge home on [**2119-12-4**].
Medications on Admission:
ASA 325mg po qday
Lipitor 5mg po qday
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10
days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company **]
Discharge Diagnosis:
CAD
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temps.>101.5, sternal drainage.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 1250**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks.
Completed by:[**2119-12-5**]
ICD9 Codes: 4240, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4399
} | Medical Text: Admission Date: [**2129-4-3**] Discharge Date: [**2129-4-11**]
Date of Birth: [**2052-12-2**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: A 78-year-old female with
history of atrial fibrillation, diabetes, and history of
stroke was transferred from [**Hospital 1474**] Hospital to [**Hospital1 18**] CCU in
cardiogenic shock. At home, the patient was found to be
unresponsive with vomitus on her pillow. She was brought to
[**Hospital 1474**] Hospital, where she was found to be in atrial
fibrillation at 150 beats per minute. Initially she was
normotensive, but became hypotensive with systolic blood
pressures to the 60s. At that time, she was successfully d-c
cardioverted into sinus rhythm in the 80s. She remained
hypotensive and was therefore intubated for airway protection
and started on dopamine.
In addition, she was placed on Neo-Synephrine drip,
dobutamine drip, and nesiritide drip. Prior admission to
[**Hospital1 18**], she was on dobutamine 2.5 mcg/kg/minute and 30
mcg/minute of Neo-Synephrine. On those medications, her CVP
was 10, pulmonary artery pressure of 46/15, wedge of 14, and
cardiac output 3.5, and cardiac index 2.0, and SVR of 2514.
She had a myocardial infarction with troponin I 13.8 and a peak
CPK of 822. She had an echocardiogram that was preliminary
read as an EF of 30%, apical hypokinesis, mild MR, TR, and
PR. Prior to her transfer, she had a temperature max of
101.6, and was started on ceftriaxone, azithromycin, and
Flagyl for presumed aspiration pneumonia. Her platelets were
noted to decrease from admission from 148 to 90 prior to
discharge while on Lovenox. This occurred over a two-day
period.
Patient arrived at [**Hospital1 18**] intubated, unalert, with heart rate
irregular with a wide complex on telemetry, MAP of 50s-60s on
Neo-Synephrine and dobutamine. She was started on an
amiodarone, given 5 mg of Lopressor, and a heart rate
decreased to the 80s.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Last Name (NamePattern1) 17526**]
MEDQUIST36
D: [**2129-4-11**] 12:00
T: [**2129-4-11**] 12:32
JOB#: [**Job Number 54707**]
ICD9 Codes: 4280, 5849, 5070, 2875 |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.